23 February 2018

Before HM Senior Coroner for Somerset Tony Williams
Wells Town Hall, Market Pl, Wells BA5 2RB
Opens 26 February. Listed for 10 days.

Robin Richards, 33, was a resident of a Tracscare run care home at Highbridge Court in Somerset. He died on 3 July 2015, after he was found hanging in the care home. Robin was highly vulnerable with multiple needs arising from his mental health and other conditions, including Asperger’s and ADHD. Within weeks of his death a Care Quality Commission (CQC) inspection found the home was unsafe.

Robin’s placement at the recently-opened Highbridge Court home was arranged by Somerset Partnership NHS Foundation Trust. He had a history of mental ill health and had been sectioned three times in the final 2 years of his life.

On 17 February 2015, the period before his death, Robin was detained under the Mental Health Act (section 2) to the Holford Ward in Taunton, before being transferred to the Rydon Ward as an informal patient.   

On 15 June he was transferred from the Rydon Ward, to Highbridge Court care home. Just over a week later (29 June) he was found hanging by staff of the care home.  He was transferred to Weston General Hospital and was pronounced dead on the 3 July 2015.

Just weeks after Robin’s death the CQC conducted an unannounced inspection of Highbridge Court. The report of this inspection rated the safety and leadership of the care home as inadequate, and all other aspects as requiring improvement. Special measures were imposed as the CQC identified that residents at the home remained at serious risk of harm.  You can read the report here.

Following a 2 and a half year wait, Robin’s family look to this inquest to address their many questions and concerns surrounding his death including:

  • whether this was a suitable placement for someone with Asperger’s and other complex needs;
  • the management of his transfer from hospital;
  • communication between the various agencies involved;
  • engagement and communication with his family particularly around the management of his risk and safety.

Robin’s family said: We have many deep-seated concerns and questions in relation to the care and treatment of Robin. We are hoping for a thorough and robust inquiry, which ensures accountability. We hope that the inquest can bring the answers and the justice that Robin deserves. The loss we continue to suffer is immeasurable”.

Deborah Coles, director of INQUEST said: “We are seeing a growing number of disturbing deaths in which safeguarding protections and the suitability of mental health care to those with Autism and Asperger’s is under the spotlight. The fact that the CQC had to intervene with special measures so soon after Robin’s death raises the further question of how the facility was assessed and monitored before the publicly funded placement of vulnerable individuals took place.”


For further information, please contact Lucy McKay on 020 7263 1111 or here.

INQUEST has been working with the family of Robin Richards since his death.  The family is represented by INQUEST Lawyers Group members Clare Evans of McMillan Williams solicitors and Rachel Barrett of Cloisters Chambers.

Interested Persons at the inquest include: Somerset Partnership NHS Foundation Trust, Somerset County Council, Tracscare Ltd, and the CQC.