Chris was born at the tail end of 2000 on 30 December. He was a restless baby, he didn’t sleep for long and he didn’t like loud noises, instead preferring peace and quiet. He was very much loved, and the eldest of three boys. His parents separated when he was 7. Chris lived at home with his mum and his two brothers.

He excelled at being a big brother. When he was about 8 one of his younger brother’s called the fire brigade, so he could see a fire engine. They duly arrived and before they left they asked to check the house. Chris leapt in front of his brother’s bedroom door, announcing ‘You’ll have to go through me first, you’re not taking my brother to jail’. When he let them in, they found his younger brother pretending to snore. Chris adored his brothers and would do anything for them.

Chris was part of a close knit, large family who adored him. Chris’s Gogo (grandmother) and his aunts would adore all of his school concerts and events. He’d stop off at their houses on the way back from high school to raid their fridges and freezers. Which would be full of his favourite things. His signature dish was tortillas with pasta sauce and grated cheese, which he’d proudly cook, in the microwave. He also liked jam tarts, cereal, yoghurt, ice cream and chicken wraps. His diet was mostly party food. Chris lived for parties and spending time with his friends.

He loved football and went to local matches with his friends from school. He supported Chelsea and Southend United. If his friends played football in their school lunch hour, Chris would place a chair in the middle of the pitch where he’d sit reading The Highway Code. His friends accepted that, and played around him. Chris had a great group of friends who loved him, as he loved them.

Chris also loved to travel, he liked trains and planes. He especially enjoyed visiting family members in Portugal and New York. Chris was from Southend on Sea, Essex. His family describe him as a beautiful soul 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 was autistic, and at 16 he was diagnosed with epilepsy, which his mum believes was brought on by stress and his mental ill health.

Chris attended mainstream school, until his depression and anxiety stopped him attending. His family say it sometimes felt as if the world was the wrong shape for Chris. The death of his much loved Gogo in 2016 contributed to further deterioration in his mental health.

Chris found the covid lockdown really hard. The restrictions imposed in March 2020 made it very difficult for Chris to cope, as he was isolated from his support network, his friends, that meant so much to him. On 6 April 2020 Chris 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 2020.

Chris 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. He was taken to hospital after he was found having a fit in the street. Safeguarding concerns were raised about the suitability of Hart House but Chris was discharged back there on 19 June 2020.

Chris’s mum, Julia, describes how desperate they were for support. “We worshipped him but knew he was at lethal risk in the community” She was told that Hart House would be a place of safety for Chris. 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, on 8 July 2020. He was just 19.

Coroner’s conclusion

Coroner Sean Horstead found that Chris died from injuries following his fall on 8 July 2020. He found that “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:

a) The lack of autism-focused approach to the assessment of Chris’s mental health and his care planning, including:

1. Insufficient consideration of the impact of Chris’s autism on his presentation and communication, leading to inappropriate decisions being made about his mental health care and treatment
2. A lack of understanding of the increased risk of suicidality in those with autism, which did not feature in any of his risk assessments and meant he did not have an appropriately targeted safety plan
3. A failure to make reasonable adjustments to account for Chris’s autism
4. A lack of understanding as to how learning disability/autism-informed input could be provided on the issue of Chris’s substance use

b) A failure to give sufficient consideration to detaining Chris under Section 3 of the Mental Health Act (MHA) 1983, in light of the need for rapid re-admission following Chris’s previous failed hospital discharges; his very high-risk behaviour in the community; and the fact that less restrictive options (i.e., community treatment and continued placement at Hart House) were recognised as being insufficient to maintain his safety from at least 16 June 2020. Absent a formal assessment of capacity the decision to allow Chris to discharge himself from the Basildon Mental Health Assessment Unit on 29 June 2020, without all avenues which could have kept him safe on the ward being explored was flawed.

c) Inadequate assessments of Chris’s capacity, including:

1. Poorly documented and confusing mental capacity assessments, which did not adequately set out the salient information for each decision separately, and did not explicitly consider Chris ‘masking’ or his executive functioning
2. The lack of any autism specialist input into assessments of Chris’s mental capacity, and a lack of leadership and peer review from any consultant-level practitioner with appropriate expertise to support Chris’s care co-ordinator and the professionals assessing his capacity, was a significant failure leading to assessments being undertaken by professionals who were insufficiently experienced in understanding the impact of autism on Chris’s presentation, particularly in relation to his substance misuse

d) Insufficient consideration of the views and concerns of Chris’s family, including the lack of involvement of Chris’s mother in the capacity assessments (alongside her express concerns  about the inadequacy of the assessments of Chris’s capacity and her concerns regarding the ability of Hart House staff to keep Chris safe) possibly contributed to the death

e) Inappropriate and unprofessional judgements being made about Chris’s mother with little or no understanding of the complexities of the home environment that she was managing, leading to the inappropriately expedited placement of Chris at Hart House possibly contributed to the death

f) A serious failure to include, in terms, the level of concern about Chris’s safety expressed in emails exchanged by the ESTEP team, including most particularly those of the 29^th June 2020, in contemporaneous entries in Chris’s medical records or in assessments of his risk, led other clinical staff (and staff at Hart House) to underestimate the risks that Chris was presenting with, and the degree of concern held by staff in his community team. The failure to communicate the nature and extent of the very grave concerns held by the community team beyond that team including to the Consultant Psychiatrist prior to the flawed discharge from the assessment Unit on the 29^th June, the staff at Hart House, Chris’s mother or those attending the Professionals’ Meeting on the 7^th July 2020 was a significant failure.