Inquest into the death of Tom Parsons finds a lost opportunity by doctors treating him at East Surrey Hospital materially contributed to the development of blood clots which caused his death

Tom, from East Grinstead in West Sussex, had diagnoses of autism, epilepsy and a learning disability. He died on 8 July 2024 at St George’s Hospital in London as a result of blood clots impacting his bowel. 

Concluding the inquest on Tuesday 12 May 2026 at Surrey Coroner’s Court, HM Assistant Coroner, Dr Karen Henderson found that:  

• There were lost opportunities to administer Tom’s blood thinning medication
• Tom was not given the blood thinning medication for 14 consecutive days, with no risk assessments carried out during that time
• Tom had multiple risk factors including not having the blood thinning medication, being immobile, having a recent diagnosis of Covid-19 during his admission, and a raised BMI, all of which materially contributed to the development of the pulmonary embolism
• The coroner will, as a result of Tom’s inquest, be writing a Prevention of Future Deaths report to highlight Tom’s case and the need for joining up physical and mental health care in such cases. It is understood this report will be sent to the Secretary of State for Health & Social care, NHS England, the Parliamentary and Health Services Ombudsman, the Minister for Women & Equalities, and the Integrated Care Board for Surrey & Sussex. 

Tom, who lived in supported accommodation and volunteered at a local steam railway, had previously been treated at East Surrey Hospital (part of Surrey and Sussex Healthcare NHS Trust) after suffering a deterioration in his mental health, which was out of character.  

He was subsequently detained under the Mental Health Act and prescribed antipsychotic drugs. During his time at East Surrey Hospital, Tom contracted COVID and developed a pulmonary embolism. On 2 July, he was transferred to St George’s Hospital for emergency surgery but, sadly, six days later he died as a result of the blood clots. 

Tom was prescribed a standard blood thinning medication called Enoxaparin on his admission to East Surrey Hospital. Tom had various other risk factors that increased his risk of clotting, including his weight, his lack of mobility during hospitalisation, prescription of antipsychotic drugs, and infection with Covid but, despite this, there was a period of two weeks, from 17 to 30 June 2024, when East Surrey Hospital did not administer any blood thinning medication. 

The inquest, which began on 4 June 2025 and resumed on Tuesday 31 March 2026, heard evidence from three of the doctors who treated Tom: Dr Ben Mearns and Dr Patrick Morgan, from East Surrey Hospital (part of Surrey and Sussex Healthcare NHS Trust), and Dr Hilary Foster, a consultant psychiatrist from Surrey and Borders Partnership NHS Trust. Evidence was also head from Dr Muhammad Sardar, a consultant in general and geriatric medicine. 

Dr Ben Mearns, a consultant physician in acute and elderly medicine at East Surrey Hospital, told the inquest that he recognised the effect of failing to give Tom the prescribed Enoxaparin put Tom’s life in danger. The family’s view is that, if this medication had been administered appropriately, Tom may have survived.  The coroner found that the failure to administer the blood thinning medication, together with his multiple risk factors, materially contributed to the development of Tom’s pulmonary embolism. 

Tom’s family are represented by solicitors Sarah Westoby and Tiffany Bucknall at law firm Leigh Day and barrister Paul Clark of Garden Court Chambers and were supported by the charity INQUEST during the legal process. 

Speaking after the inquest, Tom’s mother, Kim Parsons said: 

“We are so proud of Tom and of everything he achieved in his lifetime. From spending time with his beloved brothers to his many volunteering roles, including at the Bluebell steam railway, Tom was passionate in everything he did. 

“Tom adored the Bluebell Railway and achieved so much during his time there - becoming a highly respected member of the team and winning an award for the most committed person in the locomotive department.  

“After he died, staff at Bluebell Railway wrote two obituaries for Tom which summed up how much he was loved and appreciated in that role. Growing up was hard for Tom in so many ways, but he really found his calling there. He was a young man with a lot to offer and had only just found his niche in life. His confidence grew and he was relishing in his sense of achievement and belonging. 

“Throughout his life, due to his autism, epilepsy and learning disabilities, our family had to fight for Tom from beginning to end, and it was no different during his final stay in hospital. We were ready to work with staff in any way we could to ensure Tom received the right care and treatment. Yet, we feel that our voices were not heard by some of the medical staff and our concerns were not acted upon.  

“We strongly believe that the family and carers’ role when a person with autism is hospitalised is invaluable. We did not know that staff had not been administering the blood thinning medication for such a long period, and we were not told how important this medication was for protecting Tom’s life. If we had known, we would have been able to work with staff and with Tom to help him receive the medication that we now know he so desperately needed.  

“Tom’s death at St George’s Hospital was a great shock to our family; we remain devastated by what happened and are still struggling to come to terms with it. That is why we are so determined to ensure that lessons are learned from what happened to Tom so that no other family has to experience the grief and pain that we have endured.” 

The family’s solicitor Sarah Westoby said: 

“The evidence heard at Tom’s inquest has raised important issues around the role that families and carers play in supporting patients in hospital, particularly those with autism or learning disabilities, and those experiencing mental health crises. The coroner’s conclusions include criticism of the care Tom received, noting that the risks for Tom were heightened and not receiving appropriate medication was one of the factors which materially contributed to his death. 

“The coroner’s conclusions are welcomed, and we look forward to hearing the response to the prevention of future deaths report. It became clear during this inquest that the Trust did not have effective systems in place to record or escalate when prescribed medications were not administered, which led to repeated missed opportunities to administer life-saving medication to Tom, and to involve his family in this process. 

“In 2016, the tragic death of Oliver McGowan led to the development of mandatory training on learning disability and autism being implemented across the NHS which underscores the importance of listening to families.  In spite of this, the circumstances of Tom’s death show a similar lack of understanding of how to care for people with learning disabilities and autism and limited joined-up thinking across different disciplines within the hospital. We hope that such training will be prioritised in the future, in this hospital and others across the country. 

“Throughout the inquest process, Tom’s family have shown enormous strength and resilience in spite of their grief, and their focus has always been on trying to prevent similar mistakes happening again. We hope that this inquest process and the findings and conclusions of the coroner today has enabled the trust to reflect on their practices, to ensure that no other family has to go through what Tom’s has. We look forward to hearing the responses to the important Prevention of Future Deaths report”.

Farah Alblooshi, caseworker at INQUEST, said:

“Tom’s parents are loving, devoted parents who understood their son’s needs better than anyone, yet their insight was excluded from key decisions about his care. They were forced to advocate for Tom throughout his life, and now they are fighting for answers in his death. 

“This pattern is echoed across almost all bereaved families we support, especially where the person was autistic or had complex care needs: parental and familial expertise is routinely dismissed, even when it is critical to safe and effective care. 

Those entrusted with caring for others must stop sidelining families’ expertise and recognise it as vital to preventing further harm.”