Matty Sheldrick died 17 days after hanging themselves outside the Royal Sussex County Hospital in Brighton less than two hours after leaving A&E on November 4, 2022.
The 29-year-old, who lived in Hove and had autism and ADHD, had suffered with anxiety and depression since 2013.
Matty had moved to Hove in November 2021 to live more independently but an inquest heard a lack of concrete long-term support for their mental health needs and practical needs led to their mental health deteriorating, leading to two stays in hospital.
Matty’s family has raised concerns that the “actions and inactions” of University Hospitals Sussex NHS Foundation Trust, which runs the Royal Sussex, and Sussex Partnership NHS Foundation Trust, which runs mental health liaison services, contributed to Matty’s death.
At the inquest in Horsham on Friday, senior coroner Penelope Schofield heard evidence from Dr Seirra Schaffer who had been involved with Matty’s care in November and a previous three week stay in September.
Dr Schaffer, who was a junior doctor at the time, said she felt her concerns about Matty, who had tried to hang themselves inside the A&E department on November 4 and had become increasingly distressed after police were called following an incident with a health care assistant, were ignored by her seniors.
Dr Schaffer witnessed an incident where a health care assistant tried to stop Matty from banging their head against the wall of the toilet on the afternoon of November 4.
She described how Matty “flailed” their arms and was “distressed”, shouting “get off me”.
She said the health care assistant fell and was knocked by Matty’s “swinging” arms.
Security restrained Matty, who managed to calm themselves back down on the short stay ward, Dr Schaffer said.
Dr Schaffer said Matty was crying and apologised and asked if everyone was ok.
She described her horror at hearing police had been called following the incident.
She said she felt if police came “that would escalate everything” as she knew Matty did not feel comfortable around men.
The inquest heard Matty had been through a “traumatic” experience with police before.
Dr Schaffer expressed these concerns, she said, but was told police would attend.
She said Matty became more and more distressed and seemed like they were “spiralling” when they were later told they would have to be moved to the mental health liaison suite, a room away from the short stay ward where Matty had been staying, as they could no longer stay on the short stay ward following the incident with the health care assistant.
The doctor said Matty pleaded for greater intervention when they were told this and said they did not want to be in the room alone.
This followed a mental health assessment in which it was decided Matty would not be detained under the mental health act.
Due to the lateness of the day, Matty agreed to stay overnight and would leave in the morning.
Dr Schaffer, who said she again tried to raise her concerns about Matty’s increasing distress, said Matty was told allowing them to stay overnight was “generous”.
The court heard in a statement provided by Dr Schaffer that Matty said: “I can’t stay here I will go crazy.
“But if I leave I know I will kill myself.
“If I go home there is no way to stop it.
“I do not have the capacity to keep myself safe.”
Dr Schaffer said she was told Matty had tried to run out of the room but security had detained them and brought them back in.
She claimed Matty was shouted at to “get out” of the ward by a staff member and that she too was shouted at when she tried to intervene.
She said she was worried “about what would happen” when she realised Matty had left the hospital just after 9pm.
At 10.45pm Matty was found less than 30 metres from the hospital.
Dr Schaffer said she was upset “all day” because of what happened.
“It felt like I was watching a slow-motion car crash,” her reflective statement said.
“I was asking for help but no one would listen to stop it.”
Dr Schaffer said she voiced her concerns to those more senior several times during the day but she was told “the decision has been made”.
“It felt like something wrong was happening,” she said.
She said it was probably the worst day of her career.
The inquest will resume on December 9.
