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An investigation into the death of an autistic woman who was killed after being hit by a truck revealed numerous failures in her care in a private residence.
The coroner described the death of Colette McCulloch, 35, in 2016 as a "preventable tragedy".
"In 2014, an badessment by Colette revealed that she did not have the ability to protect herself and that she was very vulnerable," said Martin Oldham, deputy coroner of Bedfordshire, on Thursday.
"The lack of a mental health badessment and the inadequate Milton Park diet left her at liberty the day she died too long. No one will ever know how she arrived on the A1, but it is there that she died. "
At the time of McCulloch's death, she was placed under the responsibility of Pathway House, a nursing home that is part of the privately run Milton Park Therapy Campus near Bedford. The campus, which took the name Lakeside in January 2018, was recently deemed insufficient by the Care Quality Commission.
McCulloch was placed at Pathway House, outside of his region, by Susbad Partnership NHS Trust. Four of his parents' applications regarding a McCulloch badessment under the Mental Health Act were rejected by the local licensed Mental Health Professionals Service, jointly managed by the Bedford Borough Council, the council of Central Bedfordshire and the trust of the East London NHS Foundation.
McCulloch's parents, Andy and Amanda McCulloch, said, "We believe that Colette's death was predictable and preventable. She had had a very risky behavior for months before her death, but she was left to herself without any support, structure or activity at Pathway House.
"We have repeatedly raised our concerns but these have fallen repeatedly in the ears of a deaf person. The "person-centered treatment" announced by Milton Park in his pamphlet is certainly not what Colette received. We feel disappointed by all those who were supposed to take care of her and protect her. "
They added: "It is crucial that the failures in Colette's care are not neglected. It is essential that systems and personnel are not allowed to repeat the same mistakes. "
A spokesperson for Pathway House said, "Following Colette's death in July 2016, we conducted a thorough internal investigation and, working closely with our local authorities and health partners, we modified our joint work processes to prevent such an event from happening again. . "
The NHS Foundation of East London said: "After Colette's death in 2016, independent and internal investigations were conducted to understand how and where the NHS and other agencies had not provided Colette with care and support she needed. We listened, learned and made changes to improve the way we provide services following this tragic incident. "
Deborah Coles, director of the charity Enquest, said, "Colette's death was predictable and preventable due to flagrant failures in basic protection and a series of missed opportunities.
"Colette's investigation has raised serious concerns about the treatment of women with mental disorders and autism and the need for specialized services for women. Urgent action is now required to better monitor and monitor private providers of mental health services and a review of services provided to women with multiple needs. "
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