A lack of understanding around autism by mental health staff contributed to the death of a teenager from Essex, a coroner has concluded.
Chis Nota, from Southend-on-Sea, fell from a bridge less than a month after he was discharged from a mental health unit.
The 19-year-old, who was autistic, had been under the care of the Essex Partnership University NHS Foundation Trust in Basildon and Southend before he died in July 2020.
At his inquest in Chelmsford, the coroner recorded a narrative conclusion and said there had been missed opportunities to prevent the tragedy.
The coroner said the increased vulnerability of people with autism had not been recognised by the majority of staff caring for Mr Nota.
He added numerous chances to prevent his death were missed due to inappropriate assessments and a lack of communication.
The inquest also heard how repeated concerns from his mother Julia Hopper had been ignored.
"I'm feeling no emotions at the moment at all because this situation goes beyond emotion," said Ms Hopper.
"The level of trauma that we have suffered during Christopher's illness and death and its aftermath is so extreme, it's impossible to feel, to have the luxury of feeling emotions.
"I know a lot about autism and mental health, but I was not able to effectively voice what I knew.
"I had to watch it from the point of view of being a mental health campaigner who was aware that there are a very high number of deaths in Essex.
"It wasn't even shocking. We just had to live it, knowing what had gone before. Knowing of the string of cases that had gone before, where young autistic people were being lost."
Ms Hopper is now calling for a statutory public enquiry into mental health services in Essex.
It is a call that is being echoed by other campaigners including Melanie Leahy whose son Matthew died while he was a patient at the Linden Centre in Chelmsford.
"There's no accountability," said Ms Leahy. "We end this inquest now with recommendations, we've got a whole list of recommendations going back years. They don't work.
"Unless we have people in under oath to see what's been going wrong, defibrillate the system and make the changes necessary, we will see no change other than death toll."
The coroner said the evidence presented did not meet the required standard of proof of whether Mr Nota had settled on the intention to end his life when he fell over the railings.
He delivered a narrative conclusion detailing all the missed opportunities to prevent his death.
Paul Scott, Chief Executive of Essex Partnership University NHS Foundation Trust, said: “I would like to express my deepest condolences to Chris’s family and loved ones, who remain in our thoughts following their loss.
“We are dedicated to helping people in their time of need and the death of anyone who has been in our care is devastating.
“We fully accept the coroner’s findings and have put in place a number of measures to improve the care we provide for people who have autism or a learning disability.”
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