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

The inquest into the death of 19-year-old Chris Nota at Chelmsford Coroner’s Court, which was expected to conclude on 30 September 2022, has today been adjourned to January 2023 as a result of a failure by Essex Partnership University NHS Foundation Trust (“EPUT”) to provide thousands of pages of potentially key correspondence between clinicians to independent investigators.

Chris, a young man with diagnosed autism and learning disabilities, 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 has been examining the adequacy of the care and support he received.

After Chris’s death and in light of concerns raised by his mother, Julia Hopper, EPUT commissioned Niche Health and Social Care Consulting to undertake a full internal investigation.

According to the NHS England Serious Incident Framework, such reports are carried out following: “events in health care where the potential for learning is so great, or the consequences to patients, residents, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive response.”

After 13 days of evidence, the inquest was forced to abruptly adjourn after it became clear that the independent Niche investigators (including an independent consultant psychiatrist and  consultant mental health nurse) had not seen key correspondence between clinicians about Chris, including an email from Dr Carla Villa (Consultant Psychiatrist in the Essex Support and Treatment for Early Psychosis (ESTEP) team) to colleagues on 29 June 2020  - some eight days before Chris’s death – stating: “Plans have failed too many times in the last few weeks, [Chris] can’t keep himself safe, we are not able to help him remain safe either… It will be [us] (God forbid) going to the Coroner’s court…”. Chris’s mother had by that point raised numerous concerns about Chris’s discharge back into community accommodation. 

Lynnbritt Gale, EPUT’s Director of Community Delivery, who was today called to court to provide an urgent explanation about EPUT’s disclosure process, stated that Niche should have been provided with full access to the emails in this case, and offered a “humble apology both to the court and to the family for the inconvenience, upset and delay that this omission has caused”. MS Gale also stated that she would have expected clinicians to bring all relevant evidence to the attention of the internal investigators when being interviewed.

HM Area Coroner for Essex, Sean Horstead, made clear that this was not the first case involving EPUT in which disclosure failures had arisen. In voicing his “concern and disappointment” that documents, the relevance of which should have been “barn door obvious” to EPUT, had not been disclosed in its investigation, Mr Horstead said: “The fact that an Article 2 inquest a long time in the planning, subject to pre-inquest review after pre-inquest review, has now not been able to conclude is beyond disappointing”.

The inquest will now resume on 4-6 January 2023, when the Coroner will hear the evidence of the Niche authors and provide his own conclusions.

Julia Hopper, Chris’ mother, said After three weeks of relentless and distressing evidence, we hoped to have some resolution this week. Sadly that wasn’t to be. Two days before Chris’ inquest was due to conclude another bombshell was dropped. I am shocked and distressed by the developments and delay. The impact of this process on both my body and my mind is devastating but I have no choice but to keep going and seek justice for Chris. I truly believe that this inquest has been doing its best to get to the truth of why Chris had to die, but these delays show that only a full independent statutory public inquiry into deaths under EPUT will suffice to address the wider problems in the Trust.”

Nyarumba Nota, Chris' father, said "I am shocked and very disappointed by what has unfolded. My priority at this stage is to protect the integrity of the proceedings, after three weeks of evidence, in the hope we can seek some justice for Chris. I hope no other family has to go through this ever again.”

Rachel Harger of Bindmans LLP, representing Chris’ family, said: “EPUT is currently subject to the Essex Mental Health Inquiry, but that is non-statutory. These delays in Chris’s inquest show that there is a wider cultural failure of candour and transparency which should now be the subject of a full statutory public inquiry, with powers to compel evidence and witnesses.”

Jodie Anderson, Senior Caseworker at INQUEST, said: “INQUEST has been campaigning for a national statutory public inquiry into the state of mental health care in this country. It is quite clear that this is now a necessity. The failures by EPUT to disclose key evidence raise deeply concerning questions about candour. If this Government is truly committed to improving mental health care for vulnerable people like Chris, it must act NOW and commission a robust inquiry and implement recommendations urgently.”

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 and Khariya Ali of Bindmans LLP 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.