A jury concluded that Jessie Eastland Seares died as a result of misadventure when she tied a ligature around her neck while at Mill View Hospital in Hove.
The 19-year-old was found by staff during an hourly observation in the early hours of May 17, 2022.
Despite a doctor and paramedics performing CPR Jessie, from Saltdean, was pronounced dead at the scene.
The jury said there were systemic failures in health and social care.
Senior coroner Penelope Schofield said provision to support autistic people in the community was lacking nationally and she “feared” more lives could be lost.
She said “changes need to be made”.
The inquest at the Leonardo Hotel in Stroudley Road, Brighton, heard Jessie was autistic and had a history of complex physical and mental health issues and self-harm.
She had been diagnosed with dyspraxia, Ehlers Danlos Syndrome, ADHD (attention deficit hyperactivity disorder), sensory processing disorder, depression and anxiety, and disordered eating.
Jessie had been detained at the Caburn ward, a unit for people with acute mental health issues which forms part of the Sussex Partnership Foundation Trust, under Section 3 of the Mental Health Act since March 4.
Shortly before her death Jessie had been living in temporary, emergency supported accommodation, but then was admitted to the Royal Sussex County Hospital for physical issues, weeks before she was admitted to the Caburn ward.
Prior to her death, Jessie’s parents Katherine Eastland and Andy Seares repeatedly raised concerns about the care she received in the community, the suitability of placing her at Mill View and the care she received there.
There was disagreement between Jessie’s parents and services over the level of personal care Jessie needed.
Ms Eastland said during the inquest that herself and Mr Seares had to help Jessie with tasks including bathing.
Jessie Eastland Seares (Image: Submitted)
“If we didn’t do it who would?” she said.
She said Jessie felt that staff “did not care for her”.
Under the care of East Sussex County Council and Children and Adolescent Mental Health Services (CAMHS), Jessie had been an inpatient in various hospital and care settings in the community, from January 2017.
She was transferred to adult mental health and social care services when she turned 18 in December 2020.
The inquest heard East Sussex County Council had struggled to find a suitable permanent placement for Jessie to meet her needs.
It was heard the local authority had approached 30 providers but to no avail.
Ms Schofield said: “East Sussex County Council tried over 30 providers but they could only patch together temporary accommodation with agency staff.
“I fear there wasn’t much they could do.”
Jessie’s parent said they felt they were “never able to get the right support” for their daughter.
Ms Eastland described her daughter, who had a “passion” for animals, as “creative and artistic”.
A spokesman for Sussex Health and Care Partnership said: “We offer our sincere condolences to the family and friends of Jessie Eastland-Seares.
“We continue our ongoing commitment to do all we can to support patients and service users with autism and other complex needs.
“We acknowledge there are challenges across the health and care system in finding the most appropriate support for people with highly complex mental and physical health needs, including learning disabilities and autism.
“We continue to work together to improve access to specialist, bespoke care packages for people in Sussex whose needs are best met in the community.”
An East Sussex County Council spokesman said: “We would like to extend our condolences to Jessica’s family and friends.
“We accept the view of the jury in this inquest, and we continue to work with partners to identify lessons to be learnt and implement changes that will improve the way we support young adults with complex needs.”
Ms Schofield said she would be writing a prevention of future deaths report, which coroners issue when they want organisations to take action to prevent repeat failures.
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