Learning Disability Today
Supporting professionals working in learning disability and autism services

Failings in care contributed to death of young autistic man with a learning disability

A coroner has concluded that failings in care by Essex Partnership University NHS Foundation Trust (EPUT) contributed to the death of young autistic man, who also had a learning disability.

19-year-old Chris Nota died on 8 July 2020 after falling from a height in Southend. At the time of Chris’ death, he was under the care of EPUT.

Now, the Area Coroner for Essex, Sean Horstead, has concluded that “some basic elements of care management and treatment were missed” by EPUT, and this contributed to his death.

An increased risk of suicidality in autistic people and people with learning disabilities

As well as being autistic and having a learning disability, Chris also had epilepsy and experienced mental health problems.

Chris began to struggle at the beginning of 2020, and went missing on 6 April 2020. He was found sitting on the edge of a bridge, and was detained under the Mental Health Act and admitted to hospital.

In the three months prior to Chris’ death, he spent just 13 days in the community, with the rest of his time spent in mental health wards or in A and E.

While Mr Horstead said there was insufficient evidence that Chris had taken his own life, he said there were various factors that contributed to his death. One of these factors was a lack of understanding by EPUT about the increased risk of suicidality in autistic people and people with learning disabilities.

Mr Horstead says the fact that Chris’ autism did not feature in any of his risk assessments meant he did not have an appropriately targeted safety plan.

The community care team felt unable to keep Chris safe

Similarly, the coroner found that Essex mental health services did not adopt an autism-focused approach when assessing Chris’ mental health and creating his care plan. In doing so, they failed to make reasonable adjustments for Chris and did not adequately consider how Chris’ autism impacted his communication and presentation.

He also concluded that EPUT did not sufficiently consider detaining Chris under the Mental Health Act in the days before his death. Given Chris’ history of very high-risk behaviour in the community, Chris should have had a formal capacity assessment, rather than being allowed to discharge himself from Basildon Mental Health Assessment Unit on 29 June 2020, he said.

The coroner also expressed concern that Chris’ mother, Julia Hopper, was not involved in capacity assessments or listened to when she raised concerns about the services ability to keep Chris safe. He said she was an “underemployed resource from the outset”.

The inquest also revealed that members of the community support team felt they were unable to keep Chris safe, yet these staff members did not share their concern for Chris’ safety with other clinicians or Chris’ family.

Essex mental health services say they have put measures in place to improve care

Ms Hopper now wants an inquiry into Essex NHS mental health services. She told the BBC: “While the ruling was definitive, it is our terror that it will not make any difference in practice and we need a statutory public inquiry into Essex mental health services to look deeper at it and identify what is needed.

“I can’t get my son back but if we get the inquiry, we can help prevent future deaths.”

EPUT said it “fully accepts” the coroner’s findings and “have put in place a number of measures to improve the care [they] provide for people who have autism or a learning disability.”

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