09 Jan 23

Multiple significant failures in care by EPUT contributed to the death of Chris Nota, a remarkable young man with autism and learning difficulties

The inquest touching upon the death of Christopher Samson Nota, known to his family as Chris, concluded that multiple significant failures in his care contributed to his death.

Chris’s family were represented by Tom Stoate of Doughty Street Chambers’ Inquests and Public Inquiries Team, instructed by Rachel Harger and Khariya Ali of Bindmans LLP and supported by INQUEST.

Chris, 19, had an autism diagnosis, learning disability, epilepsy and experienced mental ill health. His family describe him as a beautiful soul, a streak of light who was full of love, laughter and gentleness. He had been under the care of Essex mental health services when he died on 8 July 2020, after falling from a height in Southend.

At the start of 2020, Chris found it increasingly difficult to cope, turning to cannabis for relief. On 6 April 2020 he was reported missing by his family and later that day he was found sitting on the edge of a bridge. He was detained briefly in hospital (under section 136 of the Mental Health Act), but he was discharged the following day. In the following 11 weeks, Chris spent only 13 days in the community. The remainder of that period was taken up by repeated failed discharges from hospitalisations in A&E and on mental health wards.

In a highly critical narrative conclusion, the Area Coroner for Essex, Sean Horstead, found that “some basic elements of care management and treatment were missed” in Chris’s case, and that his death was contributed to by the following issues:

The lack of autism-focused approach to the assessment of Chris’s mental health and his care planning, including:

- Insufficient consideration of the impact of Chris’s autism on his presentation and communication, leading to inappropriate decisions being made about his mental health care and treatment;

- A lack of understanding of the increased risk of suicidality in those with autism, which did not feature in any of his risk assessments and meant he did not have an appropriately targeted safety plan;

- A failure to make reasonable adjustments to account for Chris’s autism;

- A lack of understanding as to how learning disability/autism-informed input could be provided on the issue of Chris’s substance use;
A failure to give sufficient consideration to detaining Chris under Section 3 of the Mental Health Act (MHA) 1983, in light of the need for rapid re-admission following Chris’s previous failed hospital discharges; his very high-risk behaviour in the community; and the fact that less restrictive options (i.e., community treatment and continued placement at Hart House in Southend-on-Sea) were recognised as being insufficient to maintain his safety from at least 16 June 2020. Absent a formal assessment of capacity the decision to allow Chris to discharge himself from the Basildon Mental Health Assessment Unit on 29 June 2020, without all avenues which could have kept him safe on the ward being explored was flawed.
Inadequate assessments of Chris’s capacity, including:

- Poorly documented and confusing mental capacity assessments, which did not adequately set out the salient information for each decision separately, and did not explicitly consider Chris ‘masking’ or his executive functioning;

- The lack of any autism specialist input into assessments of Chris’s mental capacity, and a lack of leadership and peer review from any consultant-level practitioner with appropriate expertise to support Chris’s care co-ordinator and the professionals assessing his capacity, was a significant failure leading to assessments being undertaken by professionals who were insufficiently experienced in understanding the impact of autism on Chris’s presentation, particularly in relation to his substance misuse;
Insufficient consideration of the views and concerns of Chris’s family, including the lack of involvement of Chris’s mother in the capacity assessments (alongside her express concerns about the inadequacy of the assessments of Chris’s capacity and her concerns regarding the ability of Hart House staff to keep Chris safe) possibly contributed to the death;
Inappropriate and unprofessional judgements being made about Chris’s mother with little or no understanding of the complexities of the home environment that she was managing, leading to the inappropriately expedited placement of Chris at Hart House possibly contributed to the death;
A serious failure to include, in terms, the level of concern about Chris’s safety expressed in emails exchanged by the ESTEP team, including most particularly those of the 29 June 2020, in contemporaneous entries in Chris’s medical records or in assessments of his risk, led other clinical staff (and staff at Hart House) to underestimate the risks that Chris was presenting with, and the degree of concern held by staff in his community team. The failure to communicate the nature and extent of the very grave concerns held by the community team beyond that team including to the Consultant Psychiatrist prior to the flawed discharge from the assessment Unit on the 29 June 2020, the staff at Hart House, Chris’s mother or those attending the Professionals’ Meeting on the 7 July 2020 was a significant failure.