A patient who hanged themselves outside A&E had attempted to do so twice inside the department on the same day they were discharged from hospital, an inquest heard.

Matty Sheldrick was discovered outside the Royal Sussex County Hospital in Brighton less than two hours after leaving the hospital following a mental health assessment on November 4, 2022.

Matty, who had autism and ADHD, died 17 days later after spending more than a fortnight in intensive care.

The 29-year-old, who lived in Hove, had previously spent more than three weeks in the emergency department in September as there were no mental health beds available.

It was heard at the inquest in Horsham on Tuesday that Matty had made ligatures twice in the hospital on the day they left the department.

Mental health nurse Kat Nicolaou-Scott, who was involved in Matty’s care during both hospitalisations in September and November, said she called The Haven, a dedicated, mental health crisis assessment facility at Mill View Hospital in Hove, when she started her shift on the morning of November 4 to secure Matty a referral there for an extended period of assessment.

Read more: Patient who took their life outside A&E was left without personal support for months

When she went to see Matty to discuss this she heard Matty had tried to hang themself in the toilet.

Ms Nicolaou-Scott later returned and heard Matty had tried to hang themselves again.

Ms Nicolaou-Scott returned with Dr Lisa Page to discuss options with Matty.

It was heard Matty felt going home was “not an option”.

The nurse said she was concerned the atmosphere of the short stay ward was escalating Matty’s feelings and was causing Matty greater distress.

After she found out Matty had attempted to ligature themselves Ms Nicolaus-Scott contacted the Havens to inform them of this.

The Haven said they would not have accepted Matty’s referral had they known as the attempts increased Matty’s risk and would not be manageable at the Havens.

Ms Nicolaou-Scott returned with Dr Page to reassess Matty at 5pm and heard there had been an alleged incident where a staff member said Matty had assaulted them when they tried to stop Matty banging their head.

The nurse said she remembered Matty being “very agitated” and tried to get through the doors of the short stay ward.

Dr Page decided to do a recommendation for Matty to be detained under the mental health act.

Later, Matty was assessed again.

“I was told Matty had been calm, having engaged and was not detainable and was going to go home with crisis home support,” said Ms Nicolaou-Scott.

A discharge plan was agreed, the court heard. As Matty was “calm” they would go home with arranged visits from the crisis home resolution service.

Due to the lateness of the day, Matty agreed to stay overnight and would leave in the morning.

But just after 9pm Ms Nicolaou-Scott got a call from nurse Sam Hill saying Matty would not sign a discharge against medical advice form.

She said she was not concerned by this as a discharge plan had been agreed and Matty was free to leave.

“My belief was that Matty had decided to go ahead with the discharge plan that night rather than the morning,” she said.

She said there was nothing to indicate anything had changed since Matty’s last assessment.

Matty left the emergency department just after 9pm. At 10.45pm Matty was found less than 30 metres from the hospital.

The inquest continues.