Chris Nota, 19, died on 8 July 2020 after falling from a bridge shortly after discharging himself from a residential placement at Hart House, in Southend, where he was receiving mental health care, Essex coroner’s court was told.
The inquest, held between 3 and 9 January, heard that Chris, who was diagnosed with autism and learning disabilities, died following a cycle of repeated admissions to A&E and mental health wards over the preceding months. In intermittent discharge periods, he was frequently found to be engaging in high-risk behaviours, and more than once was found on a bridge.
At the time of his death, he was under the care of mental health services at Essex Partnership University NHS Foundation Trust (EPUT).
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