8 September 2022

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

Chris Nota, 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 now open to examine the circumstances, and consider any systemic issues in the Essex Partnership University NHS Foundation Trust (EPUT) which may have contributed to Chris’ 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 airplanes.

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 s136 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.



For further information, interview requests and to note your interest, please contact Jodie Anderson on [email protected]  

The family are represented by INQUEST Lawyers Group members Rachel Harger of Bindmans Solicitors and Tom Stoate of Doughty Street Chambers. The family are supported by INQUEST caseworker Jodie Anderson.

Other Interested persons represented are Essex Partnership University NHS Trust (EPUT, Hart House, Mid & South Essex NHS Partnership Trust (MSEPT), Southend Borough Council and Southend Safe-Guarding Partnership Adults.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

Deaths in Essex mental healthcare

See the Essex Mental Health Independent Inquiry website and INQUEST’s response to the latest update, March 2022. Also see the petition for an alternative Statutory Public Inquiry, made by bereaved families.

Darian Bankwala was 22 years old when he was discharged from EPUT mental health services at Rochford Hospital four months prior to his death on 27 December 2020. Darian had learning difficulties and some autistic traits which an inquest heard were never properly investigated or diagnosed. Media release.

Bethany Lilley was 28 when she died whilst an informal patient on Thorpe Ward at Basildon Mental Health Unit on the evening of Wednesday 16 January 2019. The inquest in March concluded that her death was contributed to by neglect due to a plethora of failings by Essex University Partnership Trust. Media release.

Other relevant cases: Deaths of people in the care of Essex mental health services, November 2020

INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Our specialist casework includes death in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question, such as the deaths and wider issues around Hillsborough and Grenfell Tower. Our policy, parliamentary, campaigning and media work is grounded in the day to day experience of working with bereaved people.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.