Episode 4: Missing Chris

Warning, this is a true crime podcast and is not suitable for all audiences. Please use discretion. This episode contains references to suicide. Please, take extra care whilst listening. This is episode three of a ten-part series. If you haven't listened to the first two episodes, please go back to the beginning so you can follow along. If you have a child, or have a child in your family or close friendship group, then I'm sure that one of your biggest fears would be that they became ill. Until I started this podcast, my fears always focused on the physical health, cancer, meningitis, car accidents. All worries and scenarios that intrusively came into my mind in my most paranoid moments. So why have I never thought about what I'd do? If my child's mental health was to deteriorate to the point where I needed round the clock support for them, where I needed help to keep my child alive? In today's episode we will hear from a mother, a loving, caring and incredible mother, who handed her son over to the services that were meant to protect him and keep him alive. But instead, he ended up dead. I'm Naomi Channel and this is investigating Essex dying to be saved. The 2000 deaths being investigated in the Lampard inquiry represent people from all walks of life. Old, young, white, black, male and female. And some of those people were living with other ailments or disabilities. 19-year-old Christopher Noter was the son of Julia Hopper. Chris was a mixed-racial man and he had autism. He was loved dearly by his family and he also had two brothers. Christopher's story is incredibly hard to listen to, but it's one that needs to be heard. He's Christopher's mother, Julia. Julia, am I correct in thinking that Christopher was your first born? Yeah, he was the eldest and he was the main daughter of my brother. My brother killed himself when he was 19 and my brother was called Chris. And we didn't know what hit us because we loved him so much. Oh, Chris was Julia's first born. She had a feeling that something was different about her son from a very young age. When Christopher was born, it became quite a far and quite early on when he was about sort of two-ish two and a half, but he was different. He screamed a lot. He was very, very hard work, but he was stunningly beautiful. When he was serene, he was serene, but he was extremely high maintenance. He got diagnosed with autism and an IQ of 58. So a very classic autism. I now diagnosed as autistic. I always knew I was, but it wasn't important to have that label until just before the inquest. When I wanted to stand with my community and try to prevent these deaths, bringing Christopher up was very acutely aware of the risk of loss, a lot of people don't realise it. I often think about the McCanns, and I feel so sorry for them because I don't think anything else has gone wrong in their world. And they took what they thought was a minor risk and they didn't see the harm. I always saw the harm in everything because we didn't have that luxury of never having lost anyone. So he was washed up with great hair and love. He had two younger brothers, there were approximately two years between all of them. And we've so much love and energy into all of them. And we didn't particularly demand support from the state. Only when Christopher was at school, we moved heaven and earth to support him within our family and to support his brothers who are also autistic. But they didn't have learning disability like Christopher, they're quite bright, still complex and still with need. Christopher used to love watching fireworks on a Saturday night. It was the only time he could really better let me touch him. And we would sit in the dark on the windowsill and watch the fireworks from Peter Pan's at about eight o'clock at night. And we would just scream as the fireworks exploded and we'd hug each other. Or if we were on a rollercoaster, then I could touch him if we were risking our lives on a rollercoaster or all swinging round. And he was so stunningly beautiful and innocent. In a study undertaken in 2022, it showed that 58% of people detained in mental health hospitals were autistic. Another study showed that autistic children are 28 times more likely to attempt suicide than those without autism. Chris loved his grandmother. And when his grandmother got ill, his mental health declined. When mum became well with a very cancer and I looked after her here for two years during her illness. The challenges of his autism were high enough and we were really smart and we thought we would be different to other people. We get through and we'd be the smart family. We wouldn't need these services. And the mum died. And we did everything textbook flowers everywhere, smiles, everything. Dinner was still on the table. There wasn't no theatrics. But still losing her and sadly my two aunts within very thought space of time all from from cancer. And they were the people who would turn up at his birthday parties or school concerts. They would turn up with outrageous big bags of gifts on his birthday Christmas. And they loved him. He loved them. And he had everything. Then all of a sudden all three of them were dead and there was just me and his brothers. And he said he was okay. But within three months he was going into year 11, which is a tough year. I was within three months on the way to school. He had tried to jump from the multi-story car park with no warning. Chris had tried to take his own life by jumping from a multi-story car park on his way to school. He had shown no signs that he had planned to do this. Thankfully on this occasion he was saved. But his mental health continued to spiral. None. Absolutely none. The first thing I got was a phone call to say that he'd been saved and to take him to A&E and children's mental health. We're going to set him two weeks later but they actually cancelled the appointment and Christopher developed down a rexia and was cutting his arms and legs. And we had no access to anything. His target weight was £1. Julia I'm so sorry you must have been just beside yourself to have a target weight of £1 shows that there's clearly a very serious distortion in his mind and that he would have needed instant urgent care. But I've read in my notes here that he didn't receive care straight away. Is that correct? And I also read that your other son's mental health was seriously declining at the same time and I wondered if he got any care. I tried to get access to services for them both but was told that because they were autistic that was nothing on offer and I stupidly tell him to say I qualified as a lawyer before I had Chris and her. I stupidly challenged this discriminatory lack of access to life-saving services and for that all hell rained down on me like you wouldn't believe. So I made complaints, I said, with holding access to these services, it's really dangerous and it's discriminatory. Lots of groups of these people from different ages start to meet together in rooms in secret without you. Plotting, putting together narratives that resemble you, most of them have never met you and they're covering where one street had diagnosed both of the boys and in both cases those diagnoses were doubted by people who were not what is some trained or competent. Both were to be de-diagnosed, it was madness. Julia was petrified that she was going to lose her sons to mental health if she didn't get the boys help quickly. She knew it was beyond her own capabilities. Her sons had autism and serious declining mental health. She found strength in Melanie Lehigh and she continued to fight for help for her sons. She knew about Matthew's campaign, she knew that Melanie had lost her own son to mental health and she was scared that she was going to end up in the same position. So a campaign was Melanie, we supported her in any way we could, we pushed the petition, we knew it was life or death, we weren't helping her, we were helping ourselves. We knew it could be us. She had lost Matthew. I could really see that in my own children and in the children I advocated for five years down the line, it had better be gravestones. But then during the COVID pandemic, Chris's mental health became much worse. And Ben Christopher's sons had come acutely on well again after a couple of years of us walking on eggshells and scuffled in his life because COVID kicks in and he becomes psychotic and then my beautiful son Christopher, ricochets in and out of mental health services. And the clinicians refused in the main to even speak to me to allow me to attend a single meeting. On the rare occasions when I can get hold of them, I'm pleading for his life, I'm saying, I know you pointed to his children really soon. I've advocated for other young people before, you've discharged them too soon without anything and they've nearly died in the community. I know Christopher lost my brother, I know Christopher is a higher risk and I know although they knew as well that they didn't tell me what he told them. I know that I could lose Christopher here and that you won't understand, please work with me, please believe me. Everybody was disowning him, they were also confronting me and and tried to frighten me out. On the rare occasions we spoke over Zoom, they were saying things like you want your son locked up, don't you? As if the problem was me and I was saying, no, I want my son to survive this. I know him very, very well. I want him to be alive and I will insist on whatever that takes. But they would do things like discharge him and he would win me from McDonald's. When he miles away high as a kite, he'd been discharged, he'd got his hand on some drugs. And he attempted to kill himself a number of times as he ricocheted and now with mental health so he would have been discharged, he would have taken an overdose within an hour of discharge. Then they'd taken him in again and they'd put him out again. They wouldn't speak to me, but it transpired that they were well aware he was going to die. In the day before he did die, they were all saying between them in their internal emails, God forbid is a lie quote. We don't end up in the coroner's court with this one. I've seen the email that Julia is referring to here. It was an internal email between mental health staff and she's right. One of the doctors wrote, "God forbid we don't end up in the coroner's court with this one." Because it takes up a whole afternoon of your time. But to me, in the brief taps we had on Zoom, there's nothing wrong with him. You need to cut the apron strings. And if you don't want him home, because I would say, "I'm refusing to have him home because he's a noise suicidal. I know he isn't. He doesn't know he isn't." And they'd say, "If you refuse to have him home, we can declare him homeless and he can go." That's not what I mean. He needs to be in a place of safety. Eventually, the mental health services did find Chris a place to live. They told her that it was a one-to-one facility with support and that he wouldn't be allowed to go out at night. But the truth was that it was a shared house with assistance. It had previously been a mental health rehabilitation unit with one-to-one assistance, but it had since been downgraded. It soon became clear to Julia that this was not going to be the best place for him to live, and he frequently ran away. There were multiple suicide attempts. A week before he died, he slipped out at breakfast time and he walked the mile to that bridge and a member of the public found him and saved him, gave him a cigarette, gave him a hug, and drove him back to this place. And he sat outside in the car and he said, "I don't feel right, so who are the ambulance and ambulance? Tanks for my son, took my son, took him, I think about a few days, a baby has charged it again." Julia, why do you think that Chris kept getting discharged? Because it seems like, you know, he's ricocheting back and forth, and he seems to be getting very temporary care, but no long-term plan, and it also seems that you are not being listened to. What, why do you think that is? I read in some notes that you said that the autism that both you and Chris had, you felt like that played a part in how the staff treated you. Is that correct? It's worth, I think, for our autistic people, because our registered hire, we are not understood, we are hated, we are treated like scum. The psychiatrist said, according to evidence at the inquest, the reason that I didn't want to formally affect my son was because his benefits were popping up, my household income. You know, we are more autonomous, we don't have feelings, but under earnings and pens, the only interest I had in my son was money, a couple of quid. Chris had a voice like many of us do, and his way of coping was by using cannabis. The really difficult thing is, Christopher's well-being, saying from being out and about now. He's out and about with the five of us in his back pocket, and there were people offering him cannabis, and we didn't know, and then he really got quite hooked on it, and cannabis doesn't help. I didn't smoke it, I've never bought it, but I wouldn't have it in that house. Couldn't look him up, because if I looked him up, he would be suicidal. Chris was suicidal. I asked Julia if it was okay to talk about the day that Chris died. She had a powerful response to this request. It's really important for me to be able to say, because I want people to see it through my eyes, having been hyper vigilant, and the best way to describe it is for both the entire life, less alone during the time of crisis. It is like, certainly in the last few weeks, it is, when you realise, no one has to your back, no one has to his back. They want him dead. You're the only thing in the way. If your love for him is superhuman, but your body isn't, And at some point you're going to screw up. So Christopher was supposedly in a place of safety and I read them the right act and they were going to make sure he didn't walk out and there was picking them up from there every day. I reasoned. They'll have him at night, they had two night stuff. I could sleep. Then first thing in the morning, I pick him up every single day. I keep him with me like glue. And that's how we proceeded a couple of weeks. On the day that Chris died, Julia had an important document that she needed to fill out. And in a crawl twist of irony, it was a document that was relating to the care of her youngest son in regards to his mental health. It was timely, so she had to get it done that day. Christopher had therapy that morning booked for between 11 and 12, so that meant I could sit here in this room, going through that drawer, printed it out, quickly go through it with a red pen, was it factually correct or bumps through it, and Christopher would be in therapy, and therapy was finished at 12, and I would be outside in the car at 11.45, taking note answers right outside in the car, walking the front door like a hawk. By sat here at my desk going through the document, and I've got a phone call from Christopher's friend, saying, think it was about 11 o'clock, 10, 30, 11, I'm seeing on social media that someone has dealt with from the bridge. And I'm telling you, I just know with complete certainty of Chris. Chris had been due to have therapy on the morning of his death, but the appointment had been cancelled, and Julia had not been told. Because of that, Chris was left on his own. Julia says if she had known, she would have driven to be with him straight away. It was then that he went to the Queen's Way Bridge in South End Essex, where he jumped to his death. Below him was a busy jaw carriageway that had a constant flow of traffic. Chris died instantly. It's not 3am, you know, it's 10, 30, 11 in the morning, there are people out and about on the streets they're walking, and actually, there were people who were there, and they got people with him when he died. Someone ran to a nearby food bank and said, there's a young man on the bridge, and I don't like the look of it, and he's pacing up and down. Please will you come, and the people from the food bank came, and they had a quick tap with him, and they said, you were right, and he said, yeah, yeah, yeah, yeah, yeah, I'm just just sort of chilling, or whatever, and they said, you're not going to do anything stupid are you? No. And they left him on the bridge, and they walked away, it's a very big bridge, maybe 40 feet away, and they turned, and over he went. The police came, they were quite sweet. I decided, having remembered my own brother's death, he fell himself in the head in the 1990s, when he was 19, and I was sitting with him while we were abroad, that I was not going to scream, I wasn't going to give myself a luxury of collapsing and screaming, had people all around me, I had two children, I had my father who'd already lost his son and his wife, I wasn't going to be screaming, it was just numb. The loss of Chris was felt throughout the community, in newspaper headlines, he was described as a much loved teenager, and it was very clear that he was. Many people left flowers on the bridge, and people wrote tributes to Chris on Facebook and other social media sites, but I also couldn't help but notice the reaction from the community, under a Facebook post by the Facebook group, your south end. The post reads, "Emotional tributes are being paid to a sweet, kind and charming young man who died last week, after falling into the Queen's way underpass in south end." Chris Noter aged 19, tragically died after falling from a footbridge onto the road below. Chris had autism, epilepsy, learning disabilities, and he suffered from crippling anxiety, resulting in mental health problems. His family have claimed he died, after being let down by support services. I read through the comments underneath the post, and I was shocked at just how many linked Chris's death and experiences with local mental health services, with their own. As a parent of two special needs children, I can absolutely see how the failings in children's services to provide adequate support packages is why they become adults with significant mental health issues. If more was done to fund and support these vulnerable children, they may not feel so hopeless they see no way out but to take their own lives. I am currently living this nightmare with my son, several attempts made on his life with no help from anyone, four stays in mental units, and then released to do it all over again. Mental health in this country is disgusting, I feel gutted for the family and the poor young man, no one should suffer like this. Chris This is absolutely heart-breaking. My 16-year-old daughter is suffering from severe mental health issues and is being sidelined terribly by mental health units. Something needs to be done to help our younger generation and also help and assist their families as soon as possible before someone else ends their lives like this. So sad. I hope an inquest will be opened so that all the agencies and services involved with Chris can learn from their mistakes and change how they support young people with autism as well as mental health difficulties. I'm absolutely sobbing for your loss and heartbreak. It's just devastating how they are treated, especially once classed as an adult, so relatable for our son too, although he is still with us thankfully for now. Julia I just wanted to ask you here, when Chris was taken to hospital after his other suicide attempts and the other times that you know he called for help, why was he ever allowed to leave? Was he discharged or did he discharge himself? The amount of suicide attempts prior to his death is just. You couldn't get any more of a red flag that something is so very wrong and that he needs to be in a secure and controlled environment with mental health care and I'm just so sorry that he wasn't and I feel so angry for you. Could you just explain how he managed to keep getting discharged and what that process was? They have some of this claim of the sign and it's called something like this charge against medical advice, only the telling mom's, he's fine, he's low risk, more can damage low risk. Even their own hundred emails they're saying was definitely gonna die. They discharged them anyway but they asked them to sign this dodgy quasi legal form saying I've been discharged against medical advice and if I die it's not this doctor's fault. Hold on to them, hold on to those forms signed. I'm going to come back to these forms in a few minutes when we talk about the inquest. Julia did not want her son's death to be in vain so she held a memorial at a local park advocating for change. When Christopher died one of the things we did immediately was saying please don't want this death to be swept onto the carpet and anybody who feels like it can be come to the park in a week's time and I don't care if nobody turns up, I'll be there. But hundreds of people turned up strangers so you had ruiners from the 1950s and 60s with microphone, singing songs, we had people walk their cars, people we didn't know, people were losing his name, hundreds of people turned up and they were all not breaking because the toll of a public death and we get used to so many public deaths, the toll of a public death out in the open, you're driving your car, you're driving back from work, the road is blocked, what's gone on, all you've seen it or a friend of a friend saw it, the trauma around the town was fast. but also he was very well known and so many young people were absolutely devastated, they all came, they all said they were going through similar and they couldn't get any help, but to have hundreds of people at the park standing up saying actually no well we won't let this be swept onto the carpet, it's unacceptable and we don't want it to happen again and it shouldn't that has happened first time around, that was incredible so yes the support of the public when they were aware was happened although it feels like our stories are siloed and then the change that needs to happen the impact is hidden. Julia didn't get to say goodbye to her son and due to the nature of his death she wasn't able to touch him in the chapel of Rist I'm very similar to Melanie's situation a few days after he died I was called, I think it was after the post-mortem the police came and took me there to quite a formally identified him, I was only able to see him, he had a blanket up to his neck and he had been made to look absolutely beautiful and he looked like he was just asleep, clearly he was very very badly injured, he had gone from a very hard night his beautiful body had been destroyed, it was very hard for the police woman that was there with me, I'm not going to start screaming and sobbing, I'm not, I didn't want people to have to deal with the host members as one, but I was only able to look at Christopher through a very small and a size of a cable map or glass window into a glass window, a very tiny one into the room where he was, I couldn't touch him, I couldn't touch him, I couldn't, I couldn't even touch him, because Chris died in 2020 his funeral had covid restrictions, just 10 people were allowed to be there, all wearing masks and all had to stay five feet apart, Julia said there was no comfort to be had, at the inquest many disturbing things came to light, I need to mention that the inquest started on the 20th of September 2020, but it had to be adjourned, after it was discovered that e-putt had failed to hand over thousands of pages of documents and emails between clinicians and healthcare professionals that discussed Chris's care, they hadn't given them to the independent investigators assigned to Chris's inquest, when they were eventually handed over it became clear why they'd been withheld, the investigators said that what they read on those emails was both unprofessional and inappropriate, the coroner said that in other inquests involving staff who had worked within e-putt, the emails that were inappropriate and unprofessional had been discovered there too, in one email from Dr. Carla Villa, one of the consultant psychiatrists who was part of the team that was supposed to be caring for Chris, wrote to her colleagues, quote, fans have failed too many times in the last few weeks, Chris can't keep himself safe, we are not able to help him remain safe either, God forbid we're going to end up in the coroner's court with this one, in her evidence at the inquest Dr. Villa told the coroner there were no contingency plans in place to make Chris's needs in the community, there were also emails from staff that were talking about Julia and the investigators and the coroner agreed that they, quote, made inappropriate judgments about her with little or no understanding of the complexities of the home environment that she was managing. The coroner also found that the placement at Hart House, the accommodation that Chris had been staying in, was a rushed decision that didn't have the right level of staff with the right experience to look after his needs. On the 29th of June 2020, he was given a form called an irregular discharge against medical advice form. These essentially are forms that patients can use to discharge themselves from hospital care, whilst acknowledging that the medical advice is to stay in for further treatment. But the coroner cited that it was a cause of concern that a young man, like Chris, with such vulnerabilities, would be permitted to sign one and make that decision for himself. But on his discharge summary, a member of staff had written that Chris, quote, had a low risk of self-arm or suicide. Chris had recorded attempted suicide attempts before, and it was almost incomprehensible that this sentence was written on his form. The coroner described this as the result of a breakdown in communication. Ultimately, the coroner ruled that multiple failings in his care contributed to Chris's death. They were. The lack of autism-focused approach to the assessment of Chris's mental health and his care planning. A failure to give significant consideration to detaining Chris under the Section 3 of the Mental Health Act. This was in light of the need for rapid readmission, following Chris's previous failed hospital discharges, his very high risk behaviour in the community, and the fact that less restrictive options were recognised as being insignificant to maintain his safety. In adequate assessment of Chris's capacity, insufficient consideration of the views and concerns of Chris's family, including the lack of involvement from Chris's mother in the capacity assessments. Inappropriate and unprofessional judgments, being made about Chris's mother with a little or no understanding of the complexities of the home environment she was managing, leading to the inappropriately expedited placements of Chris at Hearthouse that possibly contributed to his death. And staff underestimating the concerns detailed by his mental healthcare community team. The trust issued an apology expressing their quote since the apologies for the inadequate standard of care provided to Chris. They confirmed that they would look into their recommendations and implement them. These changes, as reported by E putt in the inquest, would include an adaption to the system of processing complaints and concerns raised by families and carers of patients to ensure that they are documented and escalated when necessary. New autism training for staff, appropriate to their role, and regular reviews of patients who are admitted within 28 days of discharge from hospital. But just months after this inquest, Darian Bankwala, a 22-year-old was discharged from E putt mental health services at Rotchford Hospital, four months prior to his death on 27 December 2020. Darian had learning difficulties and autistic traits, which an inquest heard were never properly investigated or diagnosed. And Darian was Chris' friend. It concluded with the coroner ruling that three agencies working together had contributed together towards Christopher's death. And that, I think, is the absolute crux of why it is so important that the terms of reference for this inquiry are not properly. The coroner had clearly seen so many of these deaths, the same people coming in for their little half hour. He'd seen it so many times. Everyone's had enough. Everyone is physically sick and damaged. Here's another young person, beautiful young person, here's another, here's another, here's a young mother, here's a grandmother. It's a death factory. The loss of Chris greatly impacted the local community. I want to draw your attention to something Julia told me she discovered after Chris had died. And that was that he'd had two [BLANK_AUDIO] previous failed suicide attempts whilst under the trust's care that she'd never been told about. At Christopher's inquest, coroner Sean Horstid said that there were significant concerns about the fundamental misunderstanding of the vulnerability of those suffering with autism spectrum disorder. I wanted to look into this, and according to the National Autistic Society, people with autism can mask their true feelings to better fit in with those around them. This means that whilst they might seem okay on the outside, inside the reality is quite different. The NHS, especially mental health professionals, should have knowledge of this, especially a 70% of autistic people also live with mental health conditions. Chris's death is part of the Lampard inquiry investigation. Julia continues to fight for Chris and for change, because she has two other sons, who both live with autism and mental health concerns, and she wants to keep them alive. I want to thank Julia for sharing Chris's story. I have no idea where she gets the strength from, but I know that I'll never forget Chris. Next time, we're going to hear from another family who also needs justice. But this time, it wasn't their child that ended up dead after going into an Essex mental health unit. The next episode is out and available to listen to now. I'm Naomi Channel, and this is Investigating Essex, dying to be saved. Thank you. [BLANK_AUDIO]