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30 September 2022

Chris Nota: key evidence not provided to independent investigators causes delay to inquest concluding

5 mins

Before HM Coroner Sean Horstead
Essex Coroner’s Court, Seax House
Scheduled 12 – 30 September 2022

The inquest into the death of 19-year-old Chris Nota at Chelmsford Coroner’s Court, which was expected to conclude on 30 September 2022, has today been adjourned to January 2023 as a result of a failure by Essex Partnership University NHS Foundation Trust (EPUT) to provide thousands of pages of potentially key correspondence between clinicians to independent investigators.

Chris, a young man with diagnosed autism and learning disabilities, had been under the care of Essex mental health services when he died on 8 July 2020, after falling from a height in Southend. The inquest into his death has been examining the adequacy of the care and support he received.

After Chris’ death and in light of concerns raised by his mother, Julia Hopper, EPUT commissioned Niche Health and Social Care Consulting to undertake a full internal investigation.

According to the NHS England Serious Incident Framework, such reports are carried out following: ‘events in health care where the potential for learning is so great, or the consequences to patients, residents, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive response.’

After 13 days of evidence, the inquest was forced to abruptly adjourn after it became clear that the independent Niche investigators (including an independent Consultant Psychiatrist and Consultant Mental Health Nurse) had not seen key correspondence between clinicians about Chris, including an email from Dr Carla Villa (Consultant Psychiatrist in the Essex Support and Treatment for Early Psychosis (ESTEP) team) to colleagues on 29 June 2020 – some eight days before Chris’ death – stating: ‘Plans have failed too many times in the last few weeks, [Chris] can’t keep himself safe, we are not able to help him remain safe either… It will be [us] (God forbid) going to the Coroner’s court…’. Chris’ mother had by that point raised numerous concerns about Chris’ discharge back into community accommodation. 

Lynnbritt Gale, EPUT’s Director of Community Delivery, who was today called to court to provide an urgent explanation about EPUT’s disclosure process, stated that Niche should have been provided with full access to the emails in this case, and offered a ‘humble apology both to the court and to the family for the inconvenience, upset and delay that this omission has caused’. Ms Gale also stated that she would have expected clinicians to bring all relevant evidence to the attention of the internal investigators when being interviewed.

HM Area Coroner for Essex, Sean Horstead, made clear that this was not the first case involving EPUT in which disclosure failures had arisen. In voicing his ‘concern and disappointment’ that documents, the relevance of which should have been ‘barn door obvious’ to EPUT, had not been disclosed in its investigation, Mr Horstead said: ‘The fact that an Article 2 inquest a long time in the planning, subject to pre-inquest review after pre-inquest review, has now not been able to conclude is beyond disappointing’.

The inquest will now resume on 4-6 January 2023, when the Coroner will hear the evidence of the Niche authors and provide his own conclusions.

Julia Hopper, Chris’ mother, said:

After three weeks of relentless and distressing evidence, we hoped to have some resolution this week. Sadly, that wasn’t to be. Two days before Chris’ inquest was due to conclude, another bombshell was dropped. I am shocked and distressed by the developments and delay. The impact of this process on both my body and my mind is devastating but I have no choice but to keep going and seek justice for Chris. I truly believe that this inquest has been doing its best to get to the truth of why Chris had to die, but these delays show that only a full independent statutory public inquiry into deaths under EPUT will suffice to address the wider problems in the Trust.

Jodie Anderson, senior caseworker at INQUEST, said:

INQUEST has been campaigning for a national statutory public inquiry into the state of mental health care in this country. It is quite clear that this is now a necessity. The failures by EPUT to disclose key evidence raise deeply concerning questions about candour. If this government is truly committed to improving mental health care for vulnerable people like Chris, it must act now and commission a robust inquiry, and implement recommendations urgently.

Rachel Harger, solicitor at Bindmans LLP who is representing Chris’ family, said:

EPUT is currently subject to the Essex Mental Health Inquiry, but that is non-statutory. These delays in Chris’ inquest show that there is a wider cultural failure of candour and transparency which should now be the subject of a full statutory public inquiry, with powers to compel evidence and witnesses.

Chris’ family are represented by Rachel Harger of Bindmans LLP, with the assistance of trainee solicitor Khariya Ali, and Tom Stoate of Doughty Street Chambers. The family are supported by INQUEST caseworker Jodie Anderson.

Read our previous press release on this matter here

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