A trans person who was found hanged outside a hospital emergency department was left for months without personal support when they moved counties because councils could not decide who was responsible, an inquest heard.
Matty Sheldrick was discovered outside the Royal Sussex County Hospital in Brighton less than two hours after being discharged following a mental health assessment on November 4, 2022.
Matty died 17 days later after spending over a fortnight in intensive care.
The 29-year-old, who lived in Hove and had autism and ADHD, had previously spent more than three weeks in the emergency department in September as there were no mental health beds available.
After this stay in hospital Matty was “desperate” to avoid A&E.
Read more: Trans man 'felt dismissed, ignored and lied to by hospital staff' before his death
Family raised concerns that the “actions and inactions” of University Hospitals Sussex NHS Foundation Trust, which runs the hospital, and Sussex Partnership NHS Foundation Trust, which runs mental health liaison services, contributed to Matty's death.
Resuming the inquest on Monday in Horsham, senior coroner Penelope Schofield heard issues with housing and a lack of concrete support for Matty’s personal needs and mental health caused Matty to rapidly decline in the months leading up to the second hospitalisation in November.
The court heard there had been issues transferring Matty’s personal support from Surrey Council to Brighton and Hove City Council when Matty moved to Hove in November 2021.
Matty needed a personal assistant who could help with practical activities such as shopping, cleaning and engaging in social activities as well as being an advocate for Matty.
It was not until February 2022 that the transfer was confirmed and it was not until the end of May that Matty got a personal assistant.
Gray Hutchins, chief executive of the Clare Project charity, which supported Matty, said this long wait resulted in Matty’s wellbeing to “deteriorate” and said there was a “disconnect” between the local authorities in Surrey and Brighton.
Gray also said there was a lack of support while Matty waited for the transfer to be completed.
“I think the transfer of care was a huge issue,” Gray said.
“It was unclear whose responsibility it was.
“There was a lack of responsibility being taken.
“It felt like people were pointing fingers as to who was responsible for helping Matty.
“It caused Matty a lot of stress.
“It made them feel quite isolated.
“Matty really struggled with practical activities.”
Daniel Francis, acting operations manager at Brighton and Hove City Council, admitted the transfer “could have been managed much better”.
It was heard emails from Matty’s GP and the Clare Project flagging to the council Matty’s deteriorating mental health during the wait for the transfer were not added to Matty’s profile.
Mr Francis agreed the emails should have prompted further investigation into Matty’s mental health needs.
It was heard Matty felt overwhelmed during this time and these feelings were further exacerbated with issues with Matty's accommodation.
Matty was living in an annexe in the garden of a house in Hove.
The landlord and neighbouring house had dogs and both animals would bark loudly, keeping Matty awake.
It was heard Matty would hyperfocus on the noise and could not sleep in anticipation of the dogs barking.
It was heard Matty did not feel able to approach the landlord about this, something a personal assistant would have been able to help with.
Gray said there were positive moments during the summer when Matty would come on walks organised by the Clare Project but that as the summer went on it became clear Matty needed mental health support.
The inquest previously heard Matty had suffered from anxiety and depression since 2013.
Matty eventually stopped taking part in the walks and was self-harming.
Gray said a lack of concrete long-term mental health support made Matty feel disbelieved and that the lack of urgency and acknowledgement made Matty feel like this reflected on them as a person.
In September, Gray said Matty came into the Clare Project looking “profoundly different in how well they looked”.
It was then that Matty was hospitalised.
After being discharged, Matty was getting visits from the crisis home resolution service to help with practical activities.
Gray said this was more “disruptive” than helpful because the person who came was different each day and would only be there for a short period of time.
Gray said this was very unsettling.
It was also heard that Matty was regularly visiting Mill View Hospital in Hove for one-on-one sessions with the crisis team in October 2022.
In November, Gray said Matty realised there was a need for a higher level of intervention to keep them alive and that it was a big step for Matty to reach out for help.
“I didn’t feel they were safe to be at home alone at this point,” said Gray.
Lily Bond, who was Matty’s social worker from the end of August until Matty's death said she felt Matty had a sense “there was nowhere for them to go”.
She felt there was not enough support for autistic people.
Asked whether she thought Matty accessed suitable mental health support, Ms Bond said “sometimes they did, a lot of the time they didn’t”.
The inquest continues.
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