Before HM Senior Coroner Veronica Hamilton-Deely
Brighton and Hove City Coroner’s Court
Wednesday 8 January 2020

Luke Blackhurst was 24 years old when he died in his room in supported accommodation run by YMCA in Brighton. He was found over a day after he died, despite his mother raising concerns with staff and requesting a welfare check as she was unable to make contact. The inquest into his death concluded with the coroner returning a short form conclusion of misadventure, and highlighting Luke’s high functioning autism in childhood as a contributory factor.

Luke had long standing diagnosis of Autism, Attention Deficit Hyperactivity Disorder (ADHD) and Obsessive-Compulsive Disorder (OCD). He had complex social care needs and specific communication difficulties. His family described him as being a truly unique person, a great analytical thinker and problem solver with interests in IT and music.

The inquest heard that in March 2018, Luke had moved from William Colliers House, YMCA supported accommodation which operates within a higher band level of support needs, to Fred Emery Court with the aim of moving further towards independent living. YMCA staff told the inquest that Luke was considered to be an extremely polite, co-operative and quiet tenant within the supported housing environment.

Evidence was also heard that on 10 and 11 January there had been an incident where staff had entered Luke’s room and found him intoxicated with a friend in his room. Luke could not be roused. In a letter to Luke dated 11 January, the manager of Fred Emery Court highlighted a concern that “excessive alcohol and/or substance misuse with visitors” resulted in a “high risk that [Luke] could become seriously unwell” in his flat.

Despite an obvious decline in Luke’s wellbeing and identifying this risk to Luke’s health, support staff only issued a tenancy warning to Luke and a recommendation that he re-engaged with alcohol services. No steps were taken to increase the support needs previously in place or to raise safeguarding concerns with adult social services.

On 20 January Luke returned home from a party at 3.20am. In the afternoon of 21 January, Luke’s mother contacted staff at Fred Emery Court because she was concerned that she had been unable to make contact with him which was unusual. She requested for a welfare check to be carried out, as staff had keys to the flat, but staff initially refused to do this.

The coroner found that Luke died sometime on 20 January 2019, with the medical cause of death being bilateral pneumonia caused by aspiration of gastric contents (vomit in his airways) and combined drug use (metabolised to 0.2mg). Despite her concern, and their knowledge of the incident that took 10 days prior, staff did not enter Luke’s flat to check on him until 8.30am on 22 January 2019, 16 hours after his mum had raised the alarm. Upon entering Luke’s flat staff found he had died. The pathologist confirmed at the inquest that Luke’s death could have taken up to 19 hours after Luke vomited and inhaled gastric contents while being asleep or unconscious on his sofa.

Rebecca Blackhurst, mother of Luke said: “Despite the coroner’s findings, I had concerns for Luke’s safety and level of care where he was living at Fred Emery Court. Next of kin concerns regarding a family member’s wellbeing should be taken seriously and there is clearly a need to develop stronger safeguarding processes.

I am really disappointed regarding the lack of understanding regarding Luke’s diagnosis. Training is paramount for staff dealing with people on the autistic spectrum. Luke’s warmth, compassion and love for others will live on. He wouldn’t have hurt a fly. I am grateful for the time I had with him and only wish this could have continued.”

Selen Cavcav, senior caseworker at INQUEST said: “Despite recently identified risks to Luke’s wellbeing and health, and the urgent concerns raised by his mother, support staff at the YMCA failed to promptly respond to fears for his welfare. There is clearly a need to develop safeguarding processes and robust mechanisms to respond to the concerns of next of kin. The inadequate regulation of supported accommodation leaves little room for accountability. It is essential that dangerous practices and procedures in these systems are not only identified but rectified.”


For further information, interview requests and to note your interest, please contact INQUEST Communications Team: 020 7263 1111 or [email protected]; [email protected]

Luke’s family are represented by INQUEST Lawyers Group members Isobel McCarroll of 4 Breams Buildings. The family are supported by INQUEST caseworker Selen Cavcav.

Supported accommodation provided by Brighton and Hove YMCA are not regulated by the CQC. Instead it is self-regulating because it provides support rather than personal care.

Other relevant cases

Jake Humm, 22, died a self-inflicted death in semi-independent accommodation run by YMCA in Brighton in August 2018. Despite the YMCA knowing he was suicidal, he was not checked on and was only found in his room two days after he had died. Read more on the Guardian.

Following Jake Humm’s death, Brighton MP Caroline Lucas said the toll of deaths in sheltered accommodation should be a national scandal, and urged the council to hold an inquiry into the rates of homelessness and suicide in Brighton.

Kieran Lunn, 21, was found dead in his room at a YMCA hostel in Penzance in October 2018. Read more at Cornwall Live.

Stephen-Lee Lanning Goodwin, 19, died in his supported living apartment in Weston-super-Mare in September 2017. His parents told Bristol Live said they would like to campaign to have supported housing regulated.