30 October 2018

Before HM Senior Coroner Tom Osbourne
Milton Keynes Coroner’s Court, Crownhill, Milton Keynes MK8 0AH
Tuesday 23 October - Friday 26 October

On Friday 26 October the inquest concluded into the self-inflicted death of Billie Lord. He died aged 26 after absconding from the Campbell Centre in Milton Keynes, where he was a voluntary inpatient who was de facto detained, on 11 July 2017. He was hit by a train on nearby railway tracks.

The inquest heard that after Billie’s first attempt to leave the Campbell Centre of the 9 July through a window, he was moved from a single room to a dormitory and his observations were increased to 15 minutes.

Billie was diagnosed with autism as a child and had selective mutism. When a member of staff asked him why he tried to leave, he did not respond. It was considered whether the staff made reasonable adjustment for the difficulties in communicating with Billie as a result of his autism, such as asking him to respond by writing instead.

On 11 July Billie tried to abscond again through a window and this time he was successful. Several hours later he made his way to nearby railway tracks where he was hit by a train.

The inquest heard how placing Billie in a shared dormitory would have been an added stressor because of his autism. The Coroner indicated that he would make a Prevention of Future Deaths report recommending that patients in the Campbell Centre ought to be placed in single rooms.

Fay Lord, Billie’s mother said:We were concerned to learn that no one with the right expertise in Autism was involved in Billie’s care planning at the Campbell Centre. We believe that his heightened anxiety at being in an unfamiliar environment, having to interact with strangers and his inability to communicate how he was really feeling, led him to escape.

Whilst the inquest process has provided us with some answers we are still unable to comprehend how Billie was able to escape from a mental health unit when there were eight members of staff on duty. Billie was loved immensely by his family and is deeply missed. Not a single day goes by when we do not think about him.”

Selen Cavcav, caseworker at INQUEST said: “If the families cannot trust the mechanisms which are in place to protect their loved ones in a mental health crisis, who can they trust? The circumstances of Billie’s death clearly show that more could have been done to keep him safe. Proper understanding and training on autism is key to prevent future deaths.



For further information please contact Lucy McKay and Sarah Uncles on 020 7263 1111 or [email protected] [email protected]

The family is represented by INQUEST Lawyers Group members, Fleur Hallett of McMillan Williams Solicitors and Paul Clark of Garden Court Chambers.

The Interested Persons represented in the inquest proceedings include Billie’s family, Central and North West London NHS Foundation Trust and Dr Marchevsky, Consultant Psychiatrist at the Campbell Centre.