Kurtis Ward, of Newmarket Street, Norwich, was discovered dead at his home on July 2, 2022. 

He is believed to have died by suicide.  

A pre-inquest review at Norfolk Coroner’s Court last year heard the full inquest would not proceed until a Safeguarding Adult Review (SAR) had been completed. 

Norfolk Coroner's Court (Image: Newsquest)

Commissioned by the Norfolk Safeguarding Adults Board, the report has now been published and examines his life and death, three weeks before his 22nd birthday.

The independent review found that although numerous agencies had contact with the family, Mr Ward himself was “largely invisible” within the system. 

He lived with complex needs throughout his life, including autism, chronic depression, anxiety with psychotic symptoms and a rare genetic condition known as Familial Adenomatous Polyposis. He also had coeliac disease and underwent major surgery in 2017. 

At home, he shared caring responsibilities for his sibling, who has a rare chromosome disorder and learning disability, and sometimes supported his mother. 

Kurtis Ward died in 2022 and his mother Rachel Spinney is still awaiting his inquest (Image: Newsquest)

Despite these pressures, the review highlights that Kurtis had many interests and ambitions. He loved literature, history and politics, studied American Studies at university, and enjoyed travelling, motorcycling and online gaming with friends. 

However, he experienced persistent mental health difficulties from his early teens.

He had suicidal thoughts for many years and previously attempted to take his own life in 2019. 

The review suggests he often reassured professionals he had no intention of acting on those thoughts.

Investigators believe this may have been linked to the social communication difficulties associated with autism, meaning practitioners may not have fully understood the seriousness of his distress. 

“Douglas [the name given to Mr Ward in the anonymised report] was a young man on the threshold of adulthood,” the report says. 

“To many professionals he appeared happy and optimistic about the future. In reality he lived with significant anxiety and depression, often masking his distress and not wanting to burden others.” 

CARING RESPONSIBILITIES 

A central theme of the review was that services focused on individual family members rather than recognising the combined pressures within the household.

The wider impact on the family, including Mr Ward’s own wellbeing, was not consistently assessed. 

His role as a young carer was identified at age nine and he initially received one-to-one support.

But when funding ended, support moved to group sessions which he found difficult because of his autism.

After he disengaged, there was no follow-up assessment and his caring responsibilities were not explored further during adolescence. 

The review also identified missed opportunities to assess his needs directly.

Although he was eligible for children’s social care assessment at 17 and adult social care assessment at 18, neither took place. 

Investigators also found gaps in understanding autism across services.

Professionals often recorded his diagnosis but did not adapt their approach or explore how it affected his mental health or ability to communicate distress. 

The report also examined his transition into adulthood, including university.

While wellbeing support was available, his Education, Health and Care Plan (EHCP) ceased when he enrolled, meaning the university had no access to earlier assessments unless he disclosed them himself.

Later in 2022, Mr Ward secured an NHS care support apprenticeship, but the four-month gap between the job offer and start date created uncertainty that may have intensified his anxiety. 

Kurtis Ward died in 2022 and his family are still awaiting his inquest (Image: Courtesy of family)

‘HE HAD HOPES AND AMBITIONS’ 

The report concludes that while Mr Ward was known to many professionals, only a small number truly understood his daily lived experience. 

The Norfolk Safeguarding Adults Board says it has already begun implementing learning from the case.  

Recommendations include improving recognition of young carers, adapting suicide-risk assessments for autistic people, strengthening transitions between services and ensuring families with complex needs have a dedicated liaison professional. 

The review concludes: “Douglas had hopes and ambitions – he wanted to travel, learn and make a difference in the world.  

“By learning from his story, agencies must work collaboratively and with curiosity so that no young person remains hidden in plain sight.” 

The full inquest into Mr Ward's death is expected to take place in June. 

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