FAILINGS by medical staff who lacked experience of autism had a bearing on the death of a man who fell from a Southend bridge, an inquest has found.

Chris Nota, 19, died after falling into the Queensway underpass on July 8, 2020, less than a month after he was discharged from a mental health unit on June 9.

The inquest into his death has been heard at Essex Coroner’s Court, in Chelmsford.

During the inquest process, one of the hearings was told how Mr Nota had been under the care of Essex Partnership University NHS Foundation Trust (EPUT) at Hart House, in Southend, before he died.

At the conclusion of the inquest today, coroner Sean Horstead told the court medical staff did not utilise Mr Nota’s mum Julia Hopper for her knowledge of his conditions.

Recording a narrative verdict he found a lack of staff experience around autism had contributed to Chris’ death.

He also told the court there had been inappropriate emails between doctors and medical staff about Chris’ care.

Mr Horstead said: “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.

“Unless otherwise indicated the following matters probably more than minimally contributed to the death: the lack of autism focused approach to the assessment of Chris’s mental health and his care planning.

“The lack of any autism specialist input into the assessments of Chris’ mental capacity and the lack of leadership and peer review from any consultant-level practitioner with appropriate expertise to support Chris’ care co-ordinator and the professionals assessing his capacity, was a significant failure leading to assessments being undertaken by professionals who were in sufficiently experienced in understanding the impact of autism on Chris’ presentation, particularly in relation to his substance misuse.

“Chris was not defined by his learning difficulties but was defined by the love and affection from friends, family and clinicians.”

Paul Scott, Chief Executive of Essex Partnership University NHS Foundation Trust, said: “I would like to express my deepest condolences to Chris’s family and loved ones, who remain in our thoughts following their loss.

“We are dedicated to helping people in their time of need and the death of anyone who has been in our care is devastating.
“We fully accept the coroner’s findings and have put in place a number of measures to improve the care we provide for people who have autism or a learning disability.”