A jury has found there was a “lack of safety” among staff after a 24-year-old man escaped from hospital and later died.

Christopher Nmaeka Arima-Egwuatu, an inpatient at The Discovery House in Lincoln, was found dead at a property on Woad Farm Road in Boston, Lincolnshire, on 12 May 2023.

Mr. Arima-Egwuatu, who was diagnosed with autism spectrum disorder and paranoid schizophrenia, fled to Boston on May 11, 2023, during an organized trip to attend a football match.

He died a day later as a result of taking heroin and cocaine.

A summary was read by district coroner Jayne Wilkes on the final day of the four-day inquest at the Myle Cross Center in Lincoln.

Mr Arima-Egwuatu first escaped on April 27 last year, while he was on hospital grounds on unaccompanied leave.

He returned to the ward that evening after spending nearly £300 on drugs.

Coroner Wilkes said Mr Arima-Egwuatu was described by clinicians as “extremely vulnerable” and a “model patient” in the community.

On May 11, Mr Arima-Egwuatu attended an event held at Lincoln City’s home ground with chaperoned permission.

The court heard he made his way to the unlocked door before sitting down and leaving in the second half before running away again.

The inquest heard that occupational therapist Richard McGuiness, who accompanied Mr Arima-Egwuatu to the match, was “surprised at how quickly Chris moved” and “gave no explanation” as to why he did not shout at him to get back.

Ms Wilkes said Mr Arima-Egwuatu took a taxi to a property on Woad Farm Road in Boston and purchased heroin and cocaine, which he shared with others and obtained for himself.

The inquest heard that others at the property “heard him snoring” on the morning of May 12 but he was found dead in the evening and emergency services were called.

Paramedics arrived and he was pronounced dead just before midnight.

Mr Arima-Egwuatu was reported to Lincolnshire Police as a missing person by a mental health nurse from Lincolnshire Partnership Foundation Trust (LPFT) on the afternoon of 11 May.

The jury concluded there was a “lack of protection demonstrated by occupational therapists” at the Lincoln City ground.

He added that “no attempt was made to dissuade Chris from leaving.”

Additional findings included information provided to Lincolnshire Police by the hospital after Mr Arima-Egwuatu fled, having been deemed “outdated and inaccurate”.

It also concluded that Mr Arima-Egwuatu’s mother, Julia Farmer, “was not informed” that she had been granted companion leave and that “the responsible clinician failed to review the decision to grant companion leave”.

Coroner Wilkes said consultant psychiatrist Jaswant Singh said he “took into account Chris’ remorse and his assurance that it would not happen again” after he first ran away on April 27.

Despite this, Coroner Wilkes said he was “aware of Chris’ wishes” and accepted that he “had no contact with Julia Farmer”, who had repeatedly asked to speak to him.

LPFT has been contacted for comment.