An inquest into the death of a 24-year-old man last year has heard how his mum wasn’t told he was allowed unescorted leave from a secure ward in Lincoln.
A four day hearing in front of a jury in Lincoln was told Chris Arima-Egwauatu was recalled to hospital in January 2023 under the terms of the Mental Health Act after an attempt to take his own life.
He had a diagnosis of autism and schizophrenia and had been detained several times previously under the Mental Health Act.
Described as a ‘fun loving and caring individual,’ Chris was classed as being profoundly vulnerable.
But he absconded on April 27 while out in the grounds of The Fens, Discovery House, on unescorted leave. He returned later that day having spent a large amount of money on drugs, which he took with others. His use of drugs was a known risk factor by the team treating him, and a capacity assessment in March concluded he lacked capacity to understand the danger of drugs.
He spoke to his mum Julia Farmer, of Spalding, on the phone on May 11 and said he was struggling to control his cravings. Later that day he attended a football match as part of a group activity and absconded.
He was found dead in Boston the following day.
The Lincoln inquest, presided over by Area Coroner Jane Wilkes, was told several reports had been given to staff about him planning to abscond.
Evidence also showed that despite Julia contacting the Fens almost immediately after he went missing to tell them a local taxi driver had dropped him off in Boston, the information was not passed to police until the following day.
Within the narrative verdict returned by the inquest jury were a number of causitive failings which included lack of a risk assessment to reinstate unescorted leave on May 3; failure to review the decision in light of Chris planning to leave and a failure to inform his mum that he had been granted unescorted leave.
“Since Chris’ death, the main issue for me is still the lack of communication that I had with the Trust and the police, and the frustration that I provided such vital information within the first 20 minutes of Chris going missing, including where he was, and who he was with.
“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.”
Julia added that she believes Chris would have been found if police had acted on the the information she sent.
Officers had been looking in Lincoln but he was found in Boston, where she said he would probably be.
“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,” said Gemma Vince, of Ison Harrison solicitors.
The Fens is a purpose-built male ward which specialises in rehabilitation for those with complex needs.
It is based within Discovery House, Long Leys Road, Lincoln and is operated by the Lincolnshire Partnership NHS Foundation Trust.
Discovery House also includes the Vales, a high-dependency ward for females.
Chris Higgins, chief transformation officer at the Trust, said in response to the inquest: “Our thoughts continue to be with Christopher’s family and friends.
“We are a learning organisation and when things go wrong, we are determined to learn and take action to improve our standards of care when needed.
“We’ve improved how we work with carers and families, having employed a dedicated Carers Lead into the service, acting as a clear liaison point to ensure families are kept involved and informed about the care of their loved one. We have also reviewed our policies and procedures to ensure they are robust, and provided guidance to staff so that everyone is clear on their roles and responsibilities.
“We will continue to learn and improve our services, so that patients and their families receive the best possible care.”
