An autistic teenager who threw a boy from the Tate Modern’s 10th floor viewing platform had a history of violent behaviour, a report has found.
A serious case review found that Jonty Bravery, then 17, had expressed a desire to hurt people prior to the attack on the six-year-old in 2019.
He also had a personality disorder that had not been diagnosed and this was the explanation for the offence, it found.
The review calls for “critical lessons” to be “translated into action”.
Professionals failed to distinguish between behaviours linked to his autism and callous, premeditated traits, the report says.
Despite previously assaulting police and a restaurant worker, and hitting support staff with a brick, Bravery was not considered a risk to others at the time.
He told supervisors he was going to visit a local shopping centre on August 4 2019.
But instead travelled to the central London art gallery where, after lying in wait, he hurled a young French tourist from the 10th storey viewing platform.
The child survived but suffered life-changing injuries and has undergone round-the-clock treatment.
Bravery, who told horrified onlookers that social services were to blame for the atrocity, is currently serving a 15-year minimum prison term for attempted murder.
The report into Bravery highlights a series of violent incidents in the two years before he struck, as well as other examples of troubling behaviour including putting faeces in his mother’s make-up brushes and threatening to kill members of the public.
But it also concluded that Bravery’s violent behaviour had reduced at the time of the Tate Modern attack, while he was living in a bespoke placement with two-to-one care funded by Hammersmith and Fulham Borough Council and the clinical commissioning group.
The report states: “There was no recent evidence that he (Bravery) presented a risk to other children or adults unknown to him.
“It was in this context that he was progressively given more freedoms, which saw him able to visit central London unaccompanied on the day of the incident.”
But the review also found that, while Bravery’s case was characterised by “appropriate efforts by professionals from across agencies to access assessment and treatment for (him)”, those efforts “were stymied due to the lack of services, placements and provisions that were suitable for his needs as an autistic young person with a co-existing conduct disorder diagnosis”.
It makes seven findings, including a lack of residential treatment options for young people with high-risk behaviours, emerging personality disorder and co-existing autism, and disincentives for support staff to escalate service gaps, creating an unmet need on behalf of the service user.
The report said Bravery was diagnosed with autism at the age of five, but that there was a clear “lack of join-up between different elements of support that were being provided to (Bravery) and his family”, and that he was not known to Children’s Social Care or Child and Adolescent Mental Health Services (CAMHS) until more than a decade later.
Bravery, who was not diagnosed with an anti-social personality disorder until he was arrested for the Tate Modern attack, spent various periods of time being moved from psychiatric intensive care units, specialist residential schools and hotels from the age of 15 as his behaviour became more troubling.
His father told the review he felt “frustrated” at the apparent lack of expertise of private care providers in dealing with his son.
The review said Bravery was taken to hospital twice in May 2016, once for overdosing on tea tree oil and then for purposefully ingesting paint in an art lesson.
His medication was increased and he was treated for two weeks on an inpatient psychiatric unit.
But that unit was said to be an “extremely stressful environment” for someone with autism, as was the psychiatric intensive care unit in northern England where he spent several months – an experience his parents described as “extremely damaging to his wellbeing”.
Bravery was then sent to a residential school, where he attacked a fellow pupil after losing a game of 10-pin bowling – the review stated the injuries “could have been life-threatening”.
The local authority approached “over 60 establishments” to find a suitable alternative for Bravery, but all “either felt that (Bravery) presented a higher risk than they could safely manage, or had no vacancies”, the review found.
He was sent to a specialist children’s home where his brief stay was characterised by “several violent incidents”, including one occasion when he assaulted a member of staff with a brick after being told his poor behaviour at a local leisure centre would be documented on his behaviour report.
A few days later, Bravery assaulted a police officer called to his room amid concerns that he was secreting a brick.
The teenager was later sent to live in a flat in west London but had to move to another facility after assaulting a member of care staff by dragging her along the floor by her hair.
A year before the Tate attack, Bravery called police to his flat, saying he was thinking of killing people, during which he assaulted an officer.
The following month he made two claims to support staff that he wanted to go out in the community “so that he could assault a member of the public and be arrested and put in prison”.
Staff believed he was making these statements to provoke a reaction from the support worker.
The review said: “It is evident that professionals working with (Bravery) at this time did not think he would act on these statements, which were seen as attention-seeking behaviour.
“This was because all of (Bravery’s) actions were viewed as products of his autistic behaviour and there was no consideration of these threats in a context of conduct disorder.”
Five months before the Tate attack, he assaulted a member of staff at Burger King in Brighton after punching his care worker.
The review said: “Unfortunately (Bravery) also had incidents of premeditated instrumental aggression that were not explained by his autism and therefore were unlikely to be resolved through such therapy.
“The fact that these incidents were rare, though could be dangerous, made it easier for them to drift from view.”
It found the “apparent abruptness of the escalation” of Bravery’s situation – such as sending him to a psychiatric hospital at the age of 14 – to be a “striking feature” of his case.
It added: “The mismatch between (Bravery’s) needs and available provision ran through the whole of (his) case.”
The review said Bravery, now 19, needed residential therapeutic solutions that could enable him, as an autistic young person, to engage in a treatment regime for his conduct disorder.
“But such a residential option did not exist,” it added.
“This meant that the legal frameworks available provided limited options for Bravery at the time.”
A psychiatric report in 2018 said Bravery had learnt to use his autism as an excuse to evade responsibility for dangerous behaviour.
Last December, Bravery was jailed for another 14 weeks after admitting attacking Broadmoor Hospital staff on January 29.
He punched nursing assistant Sarah Edwards in the head and face before pulling her hair, after she said she was going to clean his room.
He then bit Maxwell King, a rehabilitation therapist assistant, on his finger after he came to his colleague’s aid.
The Local Safeguarding Children Partnership, who carried out the review, says it is continuing to make improvements across police, health and social care in the delivery and co-ordination of support for autistic children and those with complex high-risk behaviours.