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09 September 2022

Chris Nota: Inquest to examine Essex mental health services care of teenager with autism

3 mins

Chris Nota, aged 19, 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 will open on Monday 12 September 2022, to examine the circumstances, and consider any systemic issues in the Essex Partnership University NHS Foundation Trust (EPUT) which may have contributed to Chris’s death.

Chris was from Southend on Sea, Essex. His family describe him as a beautiful soul, a streak of light who was full of love, laughter and gentleness. They say Chris had ‘an aura of sunshine and innocence’ around him, but in later years clouds too. Chris loved Chelsea Football Club and Southend United, as well as trains and aeroplanes.

Chris had an autism diagnosis, learning disability, epilepsy and experienced mental ill health. His family say it sometimes felt as if the world was the wrong shape for Chris. Chris remained in mainstream school, but faced many challenges, and suffered from depression and anxiety throughout his teens. The death of his much-loved grandmother in 2016 contributed to further deterioration in his mental health.

At the start of 2020, Chris found it increasingly difficult to cope and was turning to cannabis for relief. His behaviour changed and he became more agitated.

On 6 April 2020, he was reported missing by his family, and later that day 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.

Hours after his discharge, Chris was arrested and detained under section 136 of the Mental Health Act, and held in a police cell overnight. He was ultimately admitted to the Cedar mental health ward in Rochford Hospital for assessment and care on 8 April. He remained there for the following weeks, but was able to discharge himself on 26 May.

Just a few days later on 29 May, Chris become unwell following an overdose and he was admitted into Southend Accident and Emergency. The following day he was transferred to Basildon Hospital as an informal patient, where he remained for two weeks. On 15 June, Chris was discharged into residential placement at Hart House. He was able to come and go from the property freely. Just hours after his discharge into Hart House he left the property and was taken to general hospital after he was found fitting in the street.

Safeguarding concerns were raised about the suitability of Hart House, but Chris was discharged back to the property on 19 June 2020. On 27 June, Chris left Hart House again and was found on a nearby bridge by a member of the public who alerted emergency services. Chris was taken to hospital by paramedics, but discharged the following day. Ten days later, Chris was able to leave Hart House again and returned to the same bridge. Emergency services were called, but he ultimately fell and died.

The inquest will examine the issues arising from the care he received. It will begin with a video pen portrait from the family, showing the hearing who Chris was before his death.

Chris’s 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.

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