Thread by @ChrisNInquest

The concluding day of the Article 2 inquest into the death of Christopher Nota, Day 16, will be starting at 2pm

Area Coroner for Essex Mr Sean Horstead is sitting without a jury

This inquest discusses suicide and self-harm

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I report on twitter contemporaneously, and as accurately as I am able.

At times, especially on concluding days, it is simply impossible to catch anything but snippets of dialogue.

I always do my best to share as much with you as I can.

I am attending court remotely.

2/

Usually when reporting, I indicate where I [missed chunks] or I've used [paraphrase].

While reporting today I will use the convention of ... to indicate missed speech, to save me having to take the time to type [missed] because I anticipate it will happen a lot

3/

It goes without saying, my reporting *is not* a full or complete transcript of proceedings, and should not be relied upon as such.

This inquest discusses suicide and self harm.

I will intentionally write [withheld] for some details, in keeping with @samaritans guidance

4/

This is Day 16 of Chris's inquest.

It commenced in September, before adjourning to enable Niche investigators to review email communication between @EPUTNHS clinicians which had not previously been disclosed to them, and produce an addendum report (discussed Wednesday)

5/

5 Interested Persons represented by counsel

Chris's family by @TomStoate of @DoughtyStreet

@EPUTNHS by Briony Ballard of @serjeantsinn

Hart House by Laura Nash of @SJBnews

@SouthendCityC by Alex Denton of @ropewalklaw

Southend CCG, now @MSEssex_ICS by Nageena Khalique KC

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My #OpenJustice reporting is crowdfunded chuffed.org/project/openju… It wld not be possible without those funding and following

I report to provide a degree of scrutiny into an often unseen process, and raise awareness of premature deaths of learning disabled and autistic people

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My reporting from today's conclusion will start shortly.

I'll stop numbering tweets now.

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Coroner introduces himself, welcomes everyone

C: This is concluding element of this inquest. It ran in September, heard evidence over 13 days, was adjourned when an element of disclosure was identified mainly emails to be provided by @EPUTNHS to the authors of the Niche report.

C: A report that EPUT itself had commissioned. That led to an adjournment for effectively three months so authors could review emails disclosed and provide an addendum report, provided just before Christmas, evidence was received by me on Wednesday of this week.

C: That explains the timetable in recent times but this is a tragic death that goes back to 8 July 2020.

I welcome Julia who joins us in court, and Nyarumba who attends from the United States, mother and father. Advocates attend by Teams.

C: Am joined in court by a number of members of the press.

Its my role to sum up the evidence I've heard, having heard 13 days wont be able in any practical sense to sum up all that evidence...

C: my role and function to sum up in this Article 2 inquest the salient elements I need to review, consider and ultimately a conclusion in respect of.

Received helpful submissions yesterday from Mr Stoate of counsel who represents the family.

C: In very large part I accept those submissions and will turn to those at the conclusion of this part of the process.

The starting point for this summing up is a brief chronology takes in relevant and salient immediate elements

C: I'll then go back and highlight those I consider important to conclusions I reach (my paraphrase)

Tragic starting point is 8 July 2020 when, as witnessed by a number of members of the public [withheld]

C: Pathology and toxicology evidence... was no evidence of recent use of cocaine or cannabis in hours immediately prior to death

Police evidence

I must conclude whether I can be satisfied on standard of proof... all conclusions in coroners court...

C: on balance of probabilities, is something more likely than not... an important consideration, in respect of one obvious element, was this a suicide, can I be satisfied was no third party involvement, no hesitation in coming to that conclusion

C: would also need be satisfied that Christopher had a settled intention to end his life... I am not able, on balance of probabilities, to come to that second view as to what Chris's settled intention was.

C: Had been number of occasions back to 2016 when he'd found himself [withheld] on 27 ? June Chris [withheld] and he accounted he did it for the adrenaline rush, the thrill, rather than any intention to take his life....

C: I must before meeting conclusion... I struggle to reach that view [that Chris was settled in intention to take his life] can't say this wasn't a slip or anything other than an accident... for that reason I can not reach a settled view that this was a suicide.

C: Keenly aware for family members and others will be important consideration, so I say it at the outset, when I provide my conclusion in due course, it will be a narrative conclusion.

C: Having raised issue with various lawyers involved, no one has sought to dissuade me from taking that course

C: the most important evidence I heard at the outset of this inquest... the evidence provided by Julia Christopher's mother.

C: She @JuliaCa20602661 provided a lengthy, detailed and if I may say a very helpful statement that set out her concerns with respect to what she considered failed periods of care, and failed discharges from inopatient care.

C: We will turn to elements of those embedded within the review of evidence I conduct shortly. The important starting point is this, Christopher had been diagnosed in childhood by GOSH with childhood autism, prior to 2013

C: In 2013 several types of autism were brought under umbrella of autism spectrum disorder, ASD. Christopher also had a diagnosis of epilepsy.

C: On 6 April Chris was detained in London and taken to a place of safety at Homerton where an assessment of his mental state was undertaken, was documented Chris was agitated and distressed, psychiatrist documented Chris was vulnerable and appeared younger than his age

C: concluded wasn't appropriate to discharge him....

On 7th, this was of course a concern, understandably in my view, for Julia. The staff there having reviewed Christopher took the view he should be discharged.

C: He was subsequently discharged from Homerton and placed in a taxi for a return journey to Essex, much to the consternation and concern of Julia, understandably.

C: on arriving home, swiftly took his leave and left. Following day 8 April 2020, after breaking window and pushing member of public was arrested and taken into custody. Chris was at this age 19yrs 3mths old

C explains his chronology is a summary

Coroner acknowledges his gratitude to the authors of the Niche report and the work they’ve undertaken. I reach my conclusions, in very large part I accept virtually all the matters that they set out in their findings and conclusions.

C: Seems therefore sensible and appropriate to make this clear at this stage, as I go through the chronology I have the benefit of their initial report.

C: At the point that Julia describes as first failed discharge from London, Chris was detained under Section 2 of the Mental Health Act and admitted to Cedar Ward in Rochford under care of Dr Thies Fletchner, consultant psychiatrist.

C: He remained under S2 until 5 May when he agreed to remain as informal patient on Cedar Ward. Care Act Assessment started and he was referred to the ESTEP team.

C: Authors of Niche report were of view, and I agree and adopt that view, that this was appropriate team for him to be under care of and remained so throughout months that followed.

C: Nature and extent to which ESTEP team were appropriately supported with input from other teams is matter I’ll turn to in due course.

26 May Chris was discharged from Cedar Ward and returned to family home.

C: He was provided with 7 days medications and he had at this stage a Care Coordinator identified as Miss Kirsty Lister, but no other arrangements at this time for daily support.

C: Julia refers to this as a second failed discharge.

I have to agree with that view.

This was a discharge that took place absent a CPA care planning meeting, absent the care coordinator and took place in circumstances where Julia, Christopher’s mother had expressed

C: significant concerns, and I put that mildly as to the appropriateness of that course of action.

Dr Thies Fletchner said there was no basis by which Christ at that stage could be detained under the MHA so he was discharged home.

C: Its right to say the response of Christopher to medication he was provided with was a successful response to that first episode of psychosis, I accept this.

C: The evidence from a number of clinicians was while a good response to medication, and good response to first episode of psychosis is obviously welcomed, there is recognised a certain fragility to that.

C: For that reason ESTEP team was and remained the appropriate team to lead in the community. However the discharge home did not go well.

C: Within a short period of time Chris had to be admitted as informal patient to MH assessment unit in Basildon, just 4 days after his discharge from Cedar Ward.

C: Following his admission to Southend Hospital 2 days after his discharge, he’d taken all his medication and used significant amounts of cannabis.

Was documented…. He told staff he wanted to live in his own accommodation.

C: The important consideration I recognise, as we all must, ins the condensed period of time from the admission at the beginning of April through to the death on the 8 July.

C: I pause to say this, it is right and appropriate that one recognises the timing of these events, this three month period, we’ll all remember this was the first months of the covid pandemic.

C: Its sometimes easy to forget with the little distance we have from that period of time now. Only right to recognise, as authors of Niche report do, and I do and have done through proceedings, the challenges the effects of the pandemic had for clinicians involved in care

C: shouldn’t be underestimated. The extent to which face to face consultation was possible, clearly limited, and impacted on a number of other aspects. Important consideration and background to matters that evolved.

C: However, two further elements of covid pandemic need born in mind, firstly as Julia set out in her evidence, the impact of covid and restrictions on Chris, diagnosed with autism and learning disability, were profound and significant.

C: Second, the way in which he could deal with his own emotional reaction to the additional pressures that all were feeling at that time, is of some significance. Not least because of the tender proximity his mother had to him, and his response to those covid pressures.

C: As is made clear and I’ll turn to in due course, by the Niche authors, Julia’s determined, relentless and I emphasise understandable involvement in seeking to secure for her son the best possible care

C: was something that required and I put this in inverted commas ‘management’ by those responsible for the care management and treatment of Chris. There was in view of Niche authors, and in my view, an over emphasis on that managerial dimension.

C: of how to I’ll put it plainly, deal with Christopher’s mother’s vociferous, ferocious and consistent requirements for appropriate treatment as she saw it for her son, rather than, as the Niche authors emphasise and I accept, regarding Julia as an invaluable resource

C: in that process of the care management and treatment of her son.

Whilst Dr Potter for one, consultant psychiatrist member of the Niche team, emphasised how overwhelming the teams may have found some aspects of Julia’s persistence in seeking what she deemed to the the best

C: for her son, I have to say from a professional perspective the better view is that expressed by his colleague Chris Hutchinson, with the specialism in autism, where she emphasised how valuable the resource of the immediate carer actually is.

C: And if front loaded and engaged from the outset is likely to offset, minimise and otherwise limit that which the clinicians, individually and collectively, found overwhelming, to not engage in an appropriate manner with Julia from the outset was in my view a significant

C: shortcoming in the way matters were dealt with.

Not least as I’ve said because her contribution to a number of different features, including capacity assessment, including safeguarding, including risk assessments was a voice which should have been heard

C: and in my view wasn’t heard as plainly and straight forwardly as might have mean.

C: I don’t for second suggest these are easy matters for clinicians to deal with. I find the view had there been a senior clinician with expertise and experience in ASD involved with Julia from an early point in this process then that would have offset a number of difficulties

C: experienced by other clinicians and focused more clearly… Julia, an under deployed resource, in my view from the outset.

C: The other advantage of such an approach, frontloading of senior clinician with requisite experience in ASD would have been, my phrase, to lighten the load, the incredible load placed on Kirsty Lister, care coordinator….

C: If there had been an alternative to that which appears from the evidence to be a considered strategy, one understands why it was adopted as strategy to deploy Kirsty Lister as single point of contact for Julia, so was clarity and conduit,

C: that placed additional weight of responsibility on Kirsty, was inevitably going to overwhelm her.

Authors of Niche report made it clear Ms Lister did feel overwhelmed by all the responsibilities she felt she was carrying

I should pause to say I do consider and find Kirsty had significant support from the other members of the ESTEP team, including Dr Villa, consultant psychiatrist who led that team but didn’t at any point directly meet Chris.

C: Was very great support from Judi Jeavons, experienced and dedicated colleague, fastidious in my view, and the contribution of Richard Weidner to that process.

It wasn’t as if Kirsty was left entirely out on a limb but she did have in my view an unmanageable responsibility.

C: Part of that process was a capacity assessment conducted during course of admission to which I’ve just referred.

Authors of Niche report identified a number of shortcomings with that assessment including aspects of the paperwork and expressions of way in which findings

C: were articulated.

Will turn to that in little more detail in due course.

Conclusion of that was Chris having capacity to make decisions around accommodation, around medication, cannabis use and keeping safe was queried, some 5 to 6 weeks prior to his death.

C: On 12 June 2020 Chris was offered place in Supported Accommodation at Hart House in Southend on Sea. Was discharged from MH Assessment Unit to Hart House.

There is undoubtedly concern expressed on Julia’s part about the suitability of Hart House.

C: That, together with the expressed concerns of Julia that those undertaking capacity assessments were insufficiently knowledgeable or experienced to conduct them appropriately appears to be borne out by the findings of the Niche report, I’ll turn to those shortly.

C: Whether or not Hart House was, as Julia indicated, a sufficiently experienced for keeping unwell and vulnerable people like Chris alive, appears to be unclear.

C: Certainly, by 16 June Chris was admitted to general hospital in Southend on Sea as emergency after he was observed having a seizure.

18 June further mental capacity assessment conducted by Care Coordinator, a SALT Sam Salici and Melika Kay from Local Authority LD Team.

C: Capacity decision, whether Chris had capacity to make decisions about his accommodation, keeping himself safe and drug use… evidence taken….

[missed chunk, sorry]

C: And so in the circumstances, one has sympathy for the burden again on Ms Lister, usual process whereby the documentation following such an assessment would be completed had been significantly disrupted by covid

C: absence of admin staff, lack facility to print out and review documentation.

However, for whatever reasons, upshot is the adequacy of those capacity assessments was not considered to be appropriate and not appropriately recorded.

C: I turn to part 4 of Niche report Mental capacity assessments did not adequately set out the salient information for each decision separately and did not consider masking or executive functioning explicitly

Coroner states that Julia was aware of Chris’s masking and tried raise issue

Niche authors state: We acknowledge that the mental capacity assessments completed by Chris’s care coordinator tried to consider the impact of autism, but she was not experienced in understanding

C: the impact of autism on a patient’s presentation.

This changed the way decisions about Chris’s care were made…

Some of the MCA documentation is confusing as to the accepted conclusion of the assessors.

C: Therefore, the clarity on what statutory framework should have been used for next steps is unclear. Alongside this the assessors did not follow the guidance outlined in the MCA Code of Practice to deal with disagreements about capacity.

C: The teams involved in Chris’s care and treatment were not equipped to manage, and help with, his specific needs. Chris would have benefitted from greater input from people with expertise in working with patients with autism.

And that is a view in which I agree

C: I turn to Sharon Allison’s limited contact with Chris… very limited contact… appears to have reassured a number of clinicians including consultant psychiatrists working in inpatient context

11 June, period preceding capacity assessment on 18 June.

C: Ms Allison conducted what she described in email addressed to vast number of clinicians who by this stage in one way or another had been involved in Chris’s journey through care management and treatment. She said, this, in her email.

C: I did have a short visit with Chris on Monday for about 40mins… describes interaction as reasonable, seemed relaxed, good eye contact…

C: There was no discussion with Christopher at this stage by Ms Allison of his use of cannabis, a marked feature of the concerns that Dr Thies Flechtner of Cedar Ward considered to be significant element of Chris’s presentation.

C: A likely drug induced psychosis saw him being admitted, and that resolution of that first episode was one she appeared confident he’d sustain as long as he stayed away from cannabis and cocaine.

It’s interesting in my view that Ms Allison did not raise the issue of cannabis.

C: And that her short review led her to the conclusion on the basis of, I’ll turn to caveat she introduces, difficult to say about learning disability but he didn’t present as someone with moderate difficulties although was perhaps somewhat naïve…

C: I think him being somewhere where he’s encouraged to be independent… can build relationships with staff is good idea but don’t feel he needs highly specialist placement currently

C: It was clear from evidence of Julia, throughout, was specialist placement, she considered was only appropriate and safe place for Chris.

C: It is important to emphasise, that whilst there were responses from Dr Thies Flechtner and Dr Carr, that on 12 June, day following it was emphasised by Ms Allison:

I’m obviously only going from my 40min conversation, don’t consider myself an expert...

C: there is always more to learn but my feeling was he doesn’t have severe or moderate LD or severe ASD.

Sharon Allison in expressing herself as not an expert should be set in context that her role was consultant clinical psychologist, Head of Aspergers, Autism and LD service.

C: She continued in this email do understand request for up-to-date assessment… cautious if do go down route ensure as robust as possible… family have clear ideas about what his difficulties are so would be helpful to have another perspective as well…

[missing lots]

C: The views expressed by Dr Thies Flechtner preceded that response from Dr Allison, on same day, Dr Carr says ‘thank you Alison, your assessment and clinical impression match my own views’ and Dr TF said very similar clinical impression…

C: do you feel more borderline LD, milder end of ASD… not an expert?

That was query to which Sharon Allison responded, caveating her expertise, always more to learn.

This is email exchange on 12 June, less than a month prior to the tragic death.

C: The nature of the email exchanges that took place with respect to discharge of Chris at and around the 10th, 12th June, must be addressed.

It was at that point, 12 June, Chris was offered place at Hart House and discharged from MH Assessment Unit on that date.

C: The concerns identified in email exchanges I must touch upon.

Because there were concerns expressed by Dr Carla Villa, the consultant leading the ESTEP Team, in email dated 8 June, copying in a large number of other clinicians, including Sam Ball at Southend CCG

C: as then known… was this ‘patients mother said last week not willing for him to be discharged home and will not have him home’

C: That must be set, I find, in context that Julia was not expressing anything other than, had been consistently expressing nothing other than, her inability to safely manage Chris absent an appropriate care package and wraparound care.

C: She was simply unable to keep him safe at home. It is important that is understood.

That is my finding, and that is undoubtedly in my view, no hesitation in finding that’s the basis on which and context within with her not wanting to have Chris home was settled.

C: She was more than happy to have him home with appropriate support.

However in email exchanges, responses from Dr Thies Flechtner and Dr Blaga Carr, that element, the matters I’ve just emphasised appear to be lost.

C: Dr Thies Flechtner was of the view in her email on 8 June

'the mother is not having him home, he must be evicted formally, she’s so far avoided doing so, my understanding is he has benefits and she’s aware that him moving out will have impact on her….

C: The mother will have to make a decision'

The response, same day from other consultant psychiatrist, I’ll turn to later, Dr Carr.

Thanking Dr TF, said discussed in handover if mum doesn’t want Chris at home she should evict him, he can present to council as homeless person…

C: don’t see reason Chris remain in hospital, I’ll talk to mum in morning… although from last conversation she had with member of staff she’s not interested in listening

As found by Niche, I consider that exchange both inappropriate and unprofessional.

C: Reflects views that are inappropriate to be expressed in that way.

The authors of the report, and I agree with them, found they were views formed with little and no understanding of the home environment Julia was managing… do not find it helpful or accurate

C: it does perhaps express frustration in respect to their engagement with Julia and I return to the earlier findings I’ve made in that respect.

C: I have to say this, it’s not the first occasion I have in 2022 come across inappropriate comments of that kind being recorded, albeit a different format, in context of a medical record. These comments didn’t find their way into a medical record.

C: On previous occasions I’ve had cause to find, and have expressed, that disparaging comments on that previous occasion with respect to the patient, are not appropriate.

I repeat that view now.

C: The impact of this is not trivial.

Evidence was heard that the concerns or suggestions of homelessness for this vulnerable young man, who may be a potential event, is something that Sarah Range spoke to in her statement and evidence.

C: She was Head of Adult Mental Health and Principal Social Worker for SBC. In respect of the impact of the mooting of possible homelessness, her statement read as follows… [reads it]

C: Her evidence to inquest was process was rushed, Hart House was swiftly identified in light of potential risk of homelessness as she interpreted it, whether was intention of communication from Dr Thies Flechtner and Dr Carr is another matter.

C: In any event Hart House was identified and it was to Hart House that Chris was discharged, with concerns on the part of Julia.

On 16 June Chris was admitted to general hospital following a seizure.

C: on 18 June mental capacity assessment to which I’ve referred already was conducted

On 19 June, following that assessment, Chris was discharged from hospital back to Hart House. He on his return refused to engage with staff and left building to meet with his friends.

C: Julia’s view when she spoke to Niche investigators was Chris was unable to engage with the untrained support staff.

The nature and extent of assessment undertaken by Hart House was considered in evidence, and I find, was not the most robust of processes.

C: The paperwork in respect of that assessment was not the most comprehensive or complete kind.

There were at this stage, a period, measured in days, of potential confidence about progress. That progress was short lived.

C: The role of Hart House was to ensure principally, compliance with medication, and engage Chris in activities, give a degree of structure to his day.

Extent to which that was achieved is moot.

C: There was a lack of expertise and experience at Hart House with respect to how to manage Chris and his presentation.

Stability lasted just a few days.

Next significant incident involved Chris on 27 June, making his way to [withheld] and [withheld]

C: Admission to mental health assessment unit as informal patient, documented he was ambivalent about living, neither sad or happy

C: The emails which emerged within the ESTEP team are important and significant, because they record, in very clear terms, the clearest of terms, the nature and extent the concerns the ESTEP team, the community team had, with respect to Chris’s presentation

C: 22 June was progress to which I’ve referred, but by 29 concern had been raised. Richard Weidner sent email on 29 June 11:05 to rest of the team… seem be back at square one… back at Basildon MH [withheld]

I am not confident we can keep this young man safe…

C: The response from Dr Villa, the consultant psychiatrist lead fort ESTEp was set out in following terms, just before half past 12 that day

‘I was talking to Richard earlier today… I would agree, that we need a specialist unit to keep him safe, focused on drugs issues

C: possibly similar to ones mum is referring to addressing autism and drug use.

Then in bold, plans have failed too many times in the last few weeks, he can’t keep himself safe, we are not able to help him remain safe either.

C: He is, in bold, our patient, we can… responsibility with us a team and Kirsty as Care Coordinator and myself as consultant who’ll god forbid go to the coroners court hence need go to tertiary panel….

C: Nature and extent of concern there expressed was something in view of authors of Niche report, could and should have found its way into the clinical medical records.

This in my view is a pretty important point.

C: When Helen Clarke, Deputy Manager of Hart House gave evidence, with emotion, she emphasised if she’d been aware that was nature and extent of risk the community team she was working with were expressing and holding, she would have, if I summarise the evidence on this point,

C: she’d have taken Christopher to hospital herself and stayed with him until sorted out.

She was clearly upset that this level and nature of concern and extent hadn’t been shared with her, or her team.

C: The key point in this respect is this, the absence, the authors of Niche report write and I agree and adopt, the absence of the information in Chris’s clinical record, certainly in respect of this aspect I add, would have led staff to underestimate the risks Chris was

C: presenting the degree of concern held by staff in community team. That indeed led, once Niche authors reviewed further emails, led to further recommendation made with respect to engaging those matters.

This is an important consideration in my view.

C: Because that level of concern expressed was not reflected, I find, in the later and ongoing engagement by the ESTEP team members with other clinicians, including the consultant psychiatrist at the assessment unit, where at that time, Chris was an informal patient.

C: And indeed later that day, was permitted to discharge himself.

There is a further email exchange between Mr Weidner and Dr Carr to which I’ll turn shortly

C: the short point I find is this, if that level of concern is held by one group of clinicians, in the community, that they cannot help this young man to keep himself safe, and he cannot keep himself safe, then that self evidently in my view, could, should and must be shared

C: with other clinicians.

At least the starting point, a clinician who is going to assess whether or not its safe and appropriate for this young man to take his own discharge that day.

C: I’ll turn to that email exchange now, in light of email exchange between Mr Weidner and Dr Villa…

[missed chunk]

Taking on basis that expressed request wasn’t seen.

C: I notice is a further response from Mr Weidner, he says do we have an understanding for potential harm around his actions, were no capacity issues in that regard?

[missed chunk]

C: We can do 48hr follow up but wonder if, given overall risks, 7 admissions in short period of time, it would be prudent to consider the crisis home treatment team.

C: The fact Mr Weidner accepted was discharge now taking place and has not, in terms from his evidence or Dr Carr’s evidence, not picked up the phone

C: I’m left trying to reconcile the nature and extent of concerns expressed in morning emails that day, we cant help keep him safe, he cant keep himself safe… with that relatively relaxed view.

Doesn’t appear from records to be any further response from Dr Carr to that query.

C: The MDT meeting on 7 July was attended by Mr Weidner and members of the ESTEP team did not reiterate the level of concern and there was in my view a missed opportunity at that point to reiterate the concerns.

C: That leads me to consider the appropriateness or otherwise of discharge at that stage. I’ll turn to documentary evidence before the findings of Niche report, which I indicate now I accept and adopt

C: Two pieces of evidence, note of ward review conducted on 29 June that has start time on documentation of 16:20 hours and finish time 16:50 hours, present junior doctor, consultant Dr Carr, members of the xxx team and a staff nurse.

[missed it]

C: This document records his self discharge request was granted

During her evidence I took Dr Carr to pro forma document, completed by Yvonne, staff nurse present on ward round.

Titled irregular discharge against medical advice.

C: The explanation from Dr Carr was against advice, its written I hereby give notice I’m discharging myself against the advice of Dr Carr who has explained the consequences of my decisions… [missed it]

C: Struggle to reconcile the medical discharge against the advice of Dr Carr with what I’ve just referred to, his self-discharge request was granted.

It’s not in my view possible to reconcile those and it is a cause for concern.

C: Third is discharge summary, drafted by Dr Odeyo [?], CT3 to Dr Carr, psychiatrist, addressed to Queensway Surgery, mostly replicates content of ward review.

But in terms of risk assessment is recorded low risk for self harm and suicide.

C: Finally, the psychiatric assessment unit discharge letter completed by Dr Carr, in her hand and signed by her, she makes reference there to him testing positive on THC, cannabis on admission, there’s no mention there of cocaine, no signs/symptoms of psychosis, well kempt

C: pleasant and engaging… said [withheld] denies suicidal thoughts/intent, has capacity, not detainable.

Those are the primary documents that inform the view I take, which is this was a flawed discharge.

C: When one combines the level of concern, about which it would appear Dr Carr and her team were aware in terms expressed by Dr Villa and Mr Weidner that very day.

C: It’s difficult to reconcile the contradictions in documentary evidence that in one hand suggest discharge against advice, Dr Carr expressed in her evidence the form doesn’t reflect what is meant by it as far as I could understand her response on this point

C: so why get a vulnerable young man with autism and learning disabilities to sign a form saying he’s discharging himself against the advice of a doctor, when the ward round indicates that his request was granted with a low risk suicide and self harm

C: Whatever breakdown in communication it is significant, with clear view of community team this young man couldn’t keep himself safe, and they couldn’t help keep him safe.

C: Difficult to understand whether decision by Dr Carr was taken on fully informed basis and in my view it appears not to have been.

That is the view that appears to be reflected in the findings of the Niche report with respect to the discharge.

C: They write, decision to discharge Chris was flawed… no evidence was mental capacity assessment at that time.

C: Pause to say even if I accept on balance of probabilities, that Dr Carr hadn’t prior to her ward round or assessment seen that email, well I find she must have seen it after because she sent a further email herself to Mr Weidner.

C: If she hadn’t seen request, in all circumstances, a formal capacity assessment was in my view both sensible and required in all the context of the risks in this case, which had been in my view self evident for a number of week and days culminating in [withheld]

C: Authors of Niche report write emails evidence genuine concerns about Chris’s ability to keep himself safe…. Consequently, he was allowed to leave hospital without all avenues that would have kept him safe on the ward being explored.

C: That’s finding of Niche report that I agree with and find, for the purpose of this inquest.

It was the intention to involve the Young Persons Drug and Alcohol Team in an assessment of Chris, that couldn’t be facilitated prior to his death.

C: The YPDAT weren’t undertaking face to face assessments, but ESTEP were concerned about phone assessment so PPE was offered to facilitate more meaningful assessment but at the time of his death hadn’t taken place

C: Ms Ibbs says was opportunity to detain Chris under Section 3 of MHA at that point.

In view of Ms Hutchinson was sufficient information in the system to detain Christopher under Section 3.

C: Ms Ballard sought clarification on which their conclusions were based that the decision to allow Chris to discharge was flawed

They retained their view, whether or not Dr Carr had seen request for capacity assessment from Mr Weidner.

C: Their clear view was there was enough information and level of concern to consider detention.

C: Niche authors say there were many emails and concerns raised but little action [my paraphrase]

They say, and I agree, if patients can not be kept safe in community there are options to be explored

C: There was a lack of understanding of what was driving Chris’s behaviour, clear in Mr Weidner’s frank and honest emails where its spelt out.

Authors of report found, I accept, that mental disorder under MHA could not have been excluded…

C: consideration would have been appropriate… most specialist inpatient units would require legal framework for detention, MHA or MCA

Authors find difficult understand why options for specialist units weren’t considered under S3 of MHA or Deprivation of Liberty Safeguards

C: Part of the problem identifies with the lack of autism focused approached to care assessment and planning, was availability of others, including Julia, but not limited to Julia

C: staff at college also available, to disentangle extent to which Christopher was able to mask his autism.

Prof Skuse detailed report from 2008 had not been supplanted by any subsequent report. That was the view of Sam Ball, whose evidence was helpful to this inquest.

C: He emphasised that point. Until, this was accepted by clinicians, unless and until a further assessment had been undertaken that could supplant and replace the original diagnosis, then that original diagnosis, of autism and learning disabilities, had to continue.

C: That was subject of great deal of discussion as Niche authors identify, I agree with them, that perhaps occupied unduly the attention of the clinicians.

In the words of Dr Potter meant some basic elements of care management and treatment were missed.

C: The involvement of the EPUT LD team was evidence of Dr Udu, team led in large part by him, set out in his email exchanges to other clinicians, why was felt by him that learning disability placement was not appropriate, and secondly that ESTEP were appropriate team to lead,

C: and fair to say offering to attend joint assessment, joint meeting, joint conference and MDT meetings if and when required.

That offer was there, it was, I accept the proposed course for what would follow.

C: But in the context of the circumstances of the complexity of this presentation, I agree with the evidence of, oral evidence of the authors of the report

C: there really needed to be a more proactive engagement from the EPUT LD services, rather than in a sense reactive offer to attend MDT meetings, to discuss matters and then in due course to attend for a joint assessment.

C: That was, in all the circumstances, insufficient and to that extent, although ESTEP was appropriate team to lead, was a lack of dynamic practice engagement on part of LD senior clinicians, and secondly

C: I emphasise again now, being Dr Allison’s contribution, a 40 min meeting with Chris, there was a conspicuous lack of support to the ESTEP team from the specialist clinicians, in my view an important consideration.

C: There’s all of this, in my view feeds into the nature and extent of risk assessments that were undertaken.

Risk assessments did not, in my view, adequately consider the impact of Chris’s autism and learning difficulties

C: and were not in my view teased out in the course of risk management throughout the period.

There was, in the words, I summarise, of the Niche authors...

C: an absence of an overview or helicopter view of the risks, a longitudinal view of the risks of self-harm and suicide, and too much preoccupation and focus on how Chris presented in the moment in any single assessment.

C: An important consideration, but taken at the expense of that overview of risk, had an appropriate helicopter view of risk been taken and repeated escalating, incredibly risky behaviours, would have been seen in context and perspective thru which risk would be properly assessed

C: By the time of that last admission on 27 June 2020, Chris spent just 13 days in the community over the course of the previous 11 weeks.

The longest period he’d been in the community was a period of 8 days.

C: That is part of the longitudinal assessment of risk and self-harm and suicide, self-harm specifically and some incredibly risky behaviours he was demonstrably engaged in.

C: That inadequacy of risk was in my view, as expressed by the authors of the Niche report, resulted from an underestimation of the extent to which the learning disability and autism impacted upon Chris.

C: A key aspect in the Niche report, I adopt and find, is a complete absence in documentary records that staff were aware of the increased risk for Chris of suicide because of his autism.

C: The authors concluded, and I find, this fact did not feature in any of his risk assessments

[missed chunk]

C: Heard evidence and accept, particularly from the very helpful Ms Hutchinson, that the research indicates its clear studies have identified a significantly increased risk of suicide in autistic people.

C: Whilst no currently validated suicide assessment tools for autistic adults… it is important staff make all attempts possible to create plans tailored to individuals, indications of that have been identified.

C: Ms Hutchinson told me the suicidality risk is increase of 7 to 9 times greater for those suffering** from ASD she identified a number of reasons for that

[** at the end the Coroner corrected his language but I'll leave it in for speed of sharing what was actually said]

C: the burden of diagnosis being one, bullying, which Julia emphasised had been childhood feature throughout large tranches of his schooling, isolation, unmet support needs, levels of social disengagement, isolation and increased risk.

C: Lack of appropriate health care and after care because of the masking and camouflaging that the condition manifests through, or hides itself through, alongside challenges with communication.

C: Which, those of us Ms Hutchinson referred to, as in the neurotypical world, simply don’t appreciate.

Again comes back to the point at which I started, the resource that Chris’s mother represented to understanding this element of Chris’s particular presentation

C: and as a resource to indicate what kind of person centred approach to risk assessment and mitigation would have been at least potentially useful.

C: There is in my view a significant concern arising in this case about a fundamental misunderstanding of the vulnerability of those with ASD, with or without evidence of a learning disability, with respect to suicidal ideation and/or risky behaviour

C: in context of an ambivalence to safety.

Those levels of self-harm and suicidality can, and should be, recognised by clinicians who specialise in ASD, and drawn by them to the attention of other colleagues working with this cohort of vulnerable patients

C: Certainly at time of Chris’s involvement with EPUT I form view, given absence of any documentary record of recognition of increased suicidality in this cohort of patients, that lacuna was there.

C: The extent to which that extends beyond EPUT to other areas more widely is something about which I haven’t heard evidence, but I would be, if I may say, extremely surprised if EPUT were the only place.

C: I don’t want to unfairly focus on EPUT’s shortcomings in this respect because I strongly suspect this may be an issue far more widespread than this coronial jurisdiction.

C: In my view it is, given as Ms Hutchinson emphasised, the nature and scale of emerging and continuing developments of this cohort, of vulnerable people, something that requires urgent attention.

C: I have received some evidence that EPUT recognise and are going to grapple, continue to grapple with this, but at the moment there is a concern arising from circumstances of this case, and the earlier inquest I heard

C: that there’s an insufficient understanding, recognition of, and management with regard to the vulnerability with regards to the suicidality with regards to those who suffer from ASD.

It is time that is changed.

C: I emphasise EPUT will not be alone and not in this respect an outlier. It’s a broader societal question I am, in my own mind, convinced.

I have not exhausted all of the evidence, it would be very clear to those listening in, particularly the advocates involved

C: I have not touched upon the evidence of the CCG, SBC or indeed of Hart House.

I have no particular concerns that inform my finding or conclusion in respect of the care and conduct of those identified interested persons.

C: In my view and I find Hart House was not a venue, with the best will in the world, that was going to be able to accommodate, deal with, manage and control Chris’s risk to himself, at that juncture.

C: I am satisfied by evidence heard from number of SBC witnesses, that this matter falls and fell foursquare within the EPUT jurisdiction, so to speak.

The last matter I touch on is in relation to the CCG.

C: I have made more general comments that I hope, helpfully, beyond EPUT there is a broader issue that needs to be acted upon so that all clinicians, including, up to and including consultant psychiatrists are properly informed so that they can distil down

C: the nature and extent of the increased risk suicidality for those who suffer from ASD.

Before turning to record of inquest, should say whilst one cant say had there not been a discharge, granted discharge whether on 29 June

C: what necessarily would have definitively been the outcome of a MHA assessment, but the fact all reasonably available … hadn’t been exhausted

[didn’t catch, sorry]

C: I want to say this finally before turning to the record of inquest, that I haven’t, and Julia and Nyarumba will no doubt appreciate, gone through in detail all the specific myriad concerns of each which Julia referred to as failed discharges

C: but my finding in respect to his discharges is that I’m driven in the way Julia expressed in her evidence, a sequence of failed discharges, one I consider to be an appropriately fitting description.

C: Thats not withstanding the vast majority of clinicians involved, particularly perhaps ironically in context of what I’ve set out today, particularly the ESTEP clinicians who were doing their level best I consider, within limit of their knowledge and experience, to assist Chris

C: I emphasise that, it’s an important point for me to make clear, not only in relation to Ms Lister, but also Ms Jeavons, Dr Villa and Mr Weidner.

All doing their best within the incredibly challenging context and circumstances

C: it wasn’t for lack of effort, there were reasons I set out, some flaws in their approach, not assisted by a less than dynamic or proactive engagement from other teams.

[missed chunk]

The ESTEP team were left to deal with matters as best they could.

C: In those circumstances I’ll turn next to the record of inquest, the final stage in this process

This is formal document and record. Findings as indicated also part of the public record. So I turn to that document.

Name of the deceased I record as Christopher Sampson Nota

C: Medical cause of death: Multiple injuries

With respect Box 5 [lists particulars, date of death 8 July 2020, usual address his mother’s home address]

Box 3 I’m required record how, when and where, and in what circumstances

C: Christopher Samson Nota died on the 8th July 2020 from multiple injuries sustained when he fell from the Queens Way Overpass, Southend-on-Sea onto the road below.

C: The evidence does not disclose, to the required standard of proof, whether Chris had a settled intention to end his life at the time that he climbed over the railings and subsequently fell.

C: With respect to Box 4, this obviously, I spell it out now, I consider satisfies the requirement under Section 5 – 2

Gratefully assisted by all counsel and particularly assisted by Mr Stoate on behalf of the family’s submissions

C: Those submissions were formed in large parts by the documented findings of the Niche authors, I’ve emphasised throughout I accept virtually all of those findings, so what follows will be familiar not only to Mr Stoate but other representatives of interested persons.

C: There are some differences from those I received in submissions yesterday

Narrative conclusion as follows, unless otherwise indicators the following matters I consider probably more than minimally contributed to death

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

C: (1) 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

C: (2) 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

C: (3) A failure to make reasonable adjustments to account for Chris’s autism

(4) A lack of understanding as to how learning disability/autism-informed input could be provided on the issue of Chris’s substance use

C: b) A failure to give sufficient consideration to detaining Chris under Section 3 of the Mental Health Act, in light of the need for rapid re-admission following Chris’s previous failed hospital discharges, his very high-risk behaviour in the community,

C: and the fact that less restrictive options (i.e. community treatment and continued placement at Hart House) were recognised as being insufficient to maintain his safety from at least 16 June 2020.

C: 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.

C: c) Inadequate assessments of Chris’s capacity, including

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

C: 2) 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

C: 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

C: d) Insufficient consideration of the views and concerns of Chris’s family, including the lack of involvement of Chris’s mother in the capacity assessments

C: 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

C: e) inappropriate and unprofessional judgements being made about Chris’s mother with little or no understanding of the complexities of home environment that she was managing, leading to inappropriately expedited placement of Chris at Hart House possibly contributed to the death

C: f) 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 29th June 2020, in contemporaneous entries in Chris’s medical records or in assessments of his risk

C: led other clinical staff, and the 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.

C: 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 29th June, the staff at Hart House, Chris’s mother or

C: those attending the Professionals’ Meeting on the 7th July 2020 was a significant failing

That concludes the record of inquest.

That concludes virtually all matters for today

C: Closing remarks to the family who have waited, as a lot of families in this jurisdiction, incredibly long periods of time, in the context of the covid pandemic and the aftermath, with the greatest assistance and patience

C: For Nyarumba and Julia and the rest of the family, and Chris’s friends, this process can be absolutely

[cant hear, sound dropping out]

Worst extremes of the grief following this bereavement onwards.

I want to conclude by saying this.

C: Christopher Nota was not, and is not, and never will be defined by his ASD or any learning disability.

He is defined by the love and affection of his family and his friends, and certainly the affection he was held in by many if not all the clinicians I have referred to today

C: He was a remarkable young man and he had strengths and abilities that us in the normal world do not have access to

The vulnerability that goes along with that aspect of his humanity. The vulnerability… and for all those with ASD, must in my view, be appropriately recognised

C: not only by clinicians involved in this case, but all across other jurisdictions in this country.

Unless and until there is a proper and appropriate recognition of significantly increased risk of suicidality in this cohort, then tragic deaths are likely.

C: Thank you to everybody who has attended today. Before I go any further can I please turn to the advocates.

Mr Stoate anything you wish to draw my attention to?

TS: nothing other than to thank you very sincerely on behalf of the family for the diligence, care and hard work you’ve put into a long and difficult inquest, I know family would want to draw that to your attention

C: thank you Mr Stoate very much.

C: Ms Ballard anything before short break and then return to deal with other matters? I’ve received further bundle following yesterday’s hearing, grateful to colleagues for that.

BB: nothing thank you

Nothing from Ms Denton, Ms Nash

C: Ms Khalique?

NK: nothing from me other than to convey our condolences once again to the family

Court adjourned 16:19, will return 16:35 in respect of PFD matters

[I may not report the discussion, just decision if one made, Coroner has indicated he may reserve his decision]

We returned to court a little later than planned.

Coroner decided he’ll pause for 28 days before making his decision on how many Prevention of Future Deaths reports he’ll make

Sounds like he’ll likely be making one to national bodies @NHSEngland and Royal College of Psychiatrists re increased suicidality amongst autistic people.

Not sure about whether any will be required for @EPUTNHS

There will be a 28 day pause before he decides

Coroner thanks those present in court, including representative of an autism charity that has supported Julia who had raised an issue of language with him.

C: I slipped into the error which sometimes happens with relation to committing suicide, a hangover from religious prohibition on that, but I referred to those who suffer from ASD.

That is absolutely inappropriate.

C: The colleague who raised issue with me quite properly, has just returned, she’ll hear me say, I’m grateful for me being corrected. it’s that casual complacency and lack of attention to detail we all have to have a word with ourselves about.

You had it with me. Thank you.

C: I’ve corrected the record and hope members of the press will do so, so that we don’t promulgate that.

Those with ASD suffer the exclusion from others, they don’t suffer the condition themselves.

[Such humility, and so bang on re language, glad it was addressed]

Coroner thanks all barristers who have assisted him over lengthy period of time, with PIRS and lengthy hearing.

Thanks each of witnesses who’ve attended to assist.

C: Whilst it might be felt some fairly robust criticism has been identified I hope an appropriate emphasis on the humanity of virtually all of the clinicians working in the limits they had. Hope that’s passed onto respective clients.

C: thank you very much indeed, subject to issuing PFD, that concludes these proceedings.

Thank you very much, that’s the end of this case.

Court was adjourned at 17:05

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