This is a media release by Ison Harrison, reshared by INQUEST.
Before HM Area Coroner Jayne Wilkes
Lincolnshire Coroners Court
The Myle Cross Centre, 92 Macaulay Drive, Lincoln, LN2 4EL
21 October – 24 October 2024
An inquest has concluded into the death of Christoper Nmaeka Arima–Egwuatu (Chris), a 24-year-old Black man, who died on 12 May 2023 whilst a mental health inpatient at the Fens, Discovery House in Lincoln. He died having absconded whilst on escorted leave.
Chris was a spirited, fun-loving, kind and caring individual. When he was in school Chris was popular, outgoing and confident. He was a much-loved son and brother.
He had a diagnosis of autism and Schizophrenia. He had been detained on numerous occasions throughout his life under the Mental Health Act (MHA).
In November 2022, Chris’ mental health began to deteriorate once more. Following a serious attempt to take his own life in January 2023, he was recalled back into hospital under section 37 of the MHA. In early March 2023, he was transferred to the Fens, Discovery House.
On 27 April 2023, Chris absconded whilst out on hospital grounds on unescorted leave. He returned to the ward himself that evening having spent a large amount of money on drugs, all of which he consumed with associates over the course of that day.
Chris’ use of drugs was a known risk factor by his treating team and a formal capacity assessment on 2 March 2023 concluded that he lacked the capacity to understand the danger of drugs: he had some superficial knowledge of what could go wrong but struggled to relate this to himself. In response to his absconding, his observation care plan was reviewed, and his observations were increased, and he was no longer allowed to leave the hospital.
Over the next few days both Chris and his mother shared information with his treating team that Chris was experiencing strong cravings for drugs and that these were strongest when Chris had been paid.
On 11 May, Chris called his mum and told her he was struggling to control his cravings for drugs as he had been paid. She did not contact the ward as she still believed that his leave had not been reinstated.
Later that day, Chris attended football as part of an organised group activity where he absconded.
Chris was reported to the police as a missing person and was found deceased on 12 May 2023.
Over the course of four days evidence was heard by the Jury from a number of key witnesses from both the mental health ward and the police.
Evidence was heard that several reports were given to staff that Chris had been planning to abscond in the week leading up to his absconsion on 11 May. His psychiatrist gave inconsistent evidence as to what if any further risk assessments were conducted in light of that information and there was no documented evidence that risk had been assessed further.
Evidence was also heard that despite his mum Julia contacting the Fens almost immediately after Chris went missing, to say that she had confirmed with a local taxi driver that Chris had been dropped off in Boston, this information was not passed on to the police until a day later. Nor did the police illicit this information from her during their inquiries.
The jury returned a narrative conclusion which included a questionnaire. A number of causative failings were identified by the jury including.
- The risk assessment relating to the decision to reinstate unescorted leave on 3 May was not adequate and reasonable in all the circumstances.
- A failure by the responsible clinician to review the decision to grant escorted leave in light of information suggesting that Chris was planning to abscond.
- A failure to inform Chris’ mum that Chris had been granted escorted leave on 3rd May.
The jury also found the following significant but non causative failings:
- Communications between the nurse and the OT who was escorting Chris on 11 May on handover was inadequate
- Lack of safeguarding was demonstrated by the OTs at the Lincoln City football ground as no attempt was made to dissuade Chris from leaving the football ground
- Chris’ mum was not contacted by his Responsible Clinician at any point during his last admission despite there being consent to do so by Chris.
A number of Tainton admissions were also found including the failures in communication between LPFT and the police on the 11 May which related to risk assessments, his extreme vulnerability and capacity and that Lincolnshire Police should have been proactive in obtaining information from Chris’ mum who would have had vital information to feed into the missing person investigation.
Julia Farmer, Chris’ mum, said: "Since Chris’ death the main issue for me as and still is the lack of communication that I had with the Trust and the Police and the frustrations that I provided such vital information within the first 20 minutes of Chris going missing including where Chris was and who he was with.
I know the Jury were unable comment on whether that failing would have made a difference to Chris’ death BUT I believe that had the police had the information that I gave them from the outset they would have found him before his death.
I last spoke to Chris at around 2am on 12 May and Chris went missing at around 1.30pm on the 11 May. There was therefore nearly 12 hours where the police could have located Chris had they had and acted on the information that I provided to them.
I just want to thank the staff at the coroner’s court, the coroner and the legal team who made this process a little easier for me.
Chris was my son. He was my pride and joy, my best friend and he always told me I was his best friend. When we argued, he'd send me a message saying come on duck don't let's fall out I need me mam and I need me mate. And today there has never been a moment that I have needed him more."
Gemma Vine, of Ison Harrison Limited, said: “This is a case where Chris’ mum on numerous occasions had vital information that could and should have fed into various decision making around risk assessments for Chris.
Firstly, by the Trust when considering whether his leave should be reinstated and again when they failed to pass on important information that had been given by her to the police when Chris first went missing.
Secondly, by the police in failing to proactively obtain information from his mum as part of the missing person investigation. Which, had they done so they would have known very early on in the investigation that they should be looking in Boston, where he was eventually found, rather than Lincoln.
The lack of engagement with family members is a recurring feature of many deaths and this needs to change as quite often the information that they have is fundamental to understanding the risk that their loved one poses.”
ENDS
NOTES
For further information, interview requests and to note your interest, please contact Leila Hagmann on [email protected].
The family are represented by INQUEST Lawyers Group member Gemma Vine of Ison Harrison Solicitors, Leeds and Counsel Michael Wall, Park Square Chambers.
The family are supported by INQUEST caseworker Jordan Ferdinand-Sargeant.
Other Interested persons represented are Lincolnshire Police and Lincolnshire Partnership NHS Foundation Trust
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
Christopher Arima-egwuatu: Jury Find Failures Following Death Of Autistic Black Man Detained At Lincoln Mental Health Hospital
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This is a media release by Ison Harrison, reshared by INQUEST.
Before HM Area Coroner Jayne Wilkes
Lincolnshire Coroners Court
The Myle Cross Centre, 92 Macaulay Drive, Lincoln, LN2 4EL
21 October – 24 October 2024
An inquest has concluded into the death of Christoper Nmaeka Arima–Egwuatu (Chris), a 24-year-old Black man, who died on 12 May 2023 whilst a mental health inpatient at the Fens, Discovery House in Lincoln. He died having absconded whilst on escorted leave.
Chris was a spirited, fun-loving, kind and caring individual. When he was in school Chris was popular, outgoing and confident. He was a much-loved son and brother.
He had a diagnosis of autism and Schizophrenia. He had been detained on numerous occasions throughout his life under the Mental Health Act (MHA).
In November 2022, Chris’ mental health began to deteriorate once more. Following a serious attempt to take his own life in January 2023, he was recalled back into hospital under section 37 of the MHA. In early March 2023, he was transferred to the Fens, Discovery House.
On 27 April 2023, Chris absconded whilst out on hospital grounds on unescorted leave. He returned to the ward himself that evening having spent a large amount of money on drugs, all of which he consumed with associates over the course of that day.
Chris’ use of drugs was a known risk factor by his treating team and a formal capacity assessment on 2 March 2023 concluded that he lacked the capacity to understand the danger of drugs: he had some superficial knowledge of what could go wrong but struggled to relate this to himself. In response to his absconding, his observation care plan was reviewed, and his observations were increased, and he was no longer allowed to leave the hospital.
Over the next few days both Chris and his mother shared information with his treating team that Chris was experiencing strong cravings for drugs and that these were strongest when Chris had been paid.
On 11 May, Chris called his mum and told her he was struggling to control his cravings for drugs as he had been paid. She did not contact the ward as she still believed that his leave had not been reinstated.
Later that day, Chris attended football as part of an organised group activity where he absconded.
Chris was reported to the police as a missing person and was found deceased on 12 May 2023.
Over the course of four days evidence was heard by the Jury from a number of key witnesses from both the mental health ward and the police.
Evidence was heard that several reports were given to staff that Chris had been planning to abscond in the week leading up to his absconsion on 11 May. His psychiatrist gave inconsistent evidence as to what if any further risk assessments were conducted in light of that information and there was no documented evidence that risk had been assessed further.
Evidence was also heard that despite his mum Julia contacting the Fens almost immediately after Chris went missing, to say that she had confirmed with a local taxi driver that Chris had been dropped off in Boston, this information was not passed on to the police until a day later. Nor did the police illicit this information from her during their inquiries.
The jury returned a narrative conclusion which included a questionnaire. A number of causative failings were identified by the jury including.
The jury also found the following significant but non causative failings:
A number of Tainton admissions were also found including the failures in communication between LPFT and the police on the 11 May which related to risk assessments, his extreme vulnerability and capacity and that Lincolnshire Police should have been proactive in obtaining information from Chris’ mum who would have had vital information to feed into the missing person investigation.
Julia Farmer, Chris’ mum, said: "Since Chris’ death the main issue for me as and still is the lack of communication that I had with the Trust and the Police and the frustrations that I provided such vital information within the first 20 minutes of Chris going missing including where Chris was and who he was with.
I know the Jury were unable comment on whether that failing would have made a difference to Chris’ death BUT I believe that had the police had the information that I gave them from the outset they would have found him before his death.
I last spoke to Chris at around 2am on 12 May and Chris went missing at around 1.30pm on the 11 May. There was therefore nearly 12 hours where the police could have located Chris had they had and acted on the information that I provided to them.
I just want to thank the staff at the coroner’s court, the coroner and the legal team who made this process a little easier for me.
Chris was my son. He was my pride and joy, my best friend and he always told me I was his best friend. When we argued, he'd send me a message saying come on duck don't let's fall out I need me mam and I need me mate. And today there has never been a moment that I have needed him more."
Gemma Vine, of Ison Harrison Limited, said: “This is a case where Chris’ mum on numerous occasions had vital information that could and should have fed into various decision making around risk assessments for Chris.
Firstly, by the Trust when considering whether his leave should be reinstated and again when they failed to pass on important information that had been given by her to the police when Chris first went missing.
Secondly, by the police in failing to proactively obtain information from his mum as part of the missing person investigation. Which, had they done so they would have known very early on in the investigation that they should be looking in Boston, where he was eventually found, rather than Lincoln.
The lack of engagement with family members is a recurring feature of many deaths and this needs to change as quite often the information that they have is fundamental to understanding the risk that their loved one poses.”
ENDS
NOTES
For further information, interview requests and to note your interest, please contact Leila Hagmann on [email protected].
The family are represented by INQUEST Lawyers Group member Gemma Vine of Ison Harrison Solicitors, Leeds and Counsel Michael Wall, Park Square Chambers.
The family are supported by INQUEST caseworker Jordan Ferdinand-Sargeant.
Other Interested persons represented are Lincolnshire Police and Lincolnshire Partnership NHS Foundation Trust
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
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