Day two of Nick Köster's inquest at Norfolk Coroner's Court

Ralph Nick Köster, also known as Nick, was being treated at the Norwich Priory Hospital in Attleborough when he went missing on July 11. The former rugby player was found dead in a wooded area later that day.

The hospital says it has reviewed and revised its risk assessment and handover processes in light of the incident.

On the second and final day of the inquest into Mr Köster's death Norfolk Coroner's Court heard that despite the 34-year-old leaving the hospital at 2.30pm, and being expected back within two hours, staff only noticed he was missing between 6pm and 6.40pm.

After searching the ward, staff called the police to report a missing person but were told it "did not appear to be an urgent issue" and to call 101 instead.

Nick Köster was found dead in a nearby wooded area close to Norwich Priory on July 11 (Image: PA)

Mr Köster's wife, Jeannie, arrived at the priory around 7pm and tracked him by using her phone’s location tool revealing his phone was less than a mile away.

However there was a delay in notifying both the police and senior nurses of this due to a handover process happening at the time.

Roughly three hours later Mr Köster was found dead by a member of the public in a wooded area close to the facility.

MISSING HOURS

A statement read out on behalf of Charles Mwangi, an assistant mental health nurse at the priory, said: "I started doing my medication rounds at around 6pm around the ward but could not find Mr Köster.

"After realising he should have been back at 4.30pm I tried searching for him around the ward and then tried to call him but there was no answer.

"At around 7.25pm I called the 999 helpline to report him missing.

"I explained that he had not returned from leave, and in the past had experienced suicidal thoughts, but had appeared well and settled upon leaving.

"I was told by the call handler it did not appear to be an urgent issue and they told me to call 101."

A statement from a member of staff at Norwich Priory said Mr Köster wasn't declared missing until almost two hours after he was due to return from leave (Image: PA)

Mr Mwangi added a different member of staff was placed on hold after calling 101 - which was never answered - before he called 999 again at roughly 7.49pm.

Prior to his death it was heard that Mr Köster had been allowed, accompanied, on leave to the grounds and locally a few times since arriving at the hospital but this was the first time he'd had unescorted leave.

Mr Mwangi added that Mr Köster was also on the lowest level of observation and another member of staff completed a five-point risk assessment prior to him leaving the hospital.

RUGBY STAR

Mr Köster who lived in Chestnut Drive, in Horsford was born in South Africa. He had a career as a professional rugby player and moved to England to play for Bath and Bristol.

The married father-of-two began struggling with his mental health after returning from a work trip to America in 2022. 

He was admitted to the Norwich Priory Hospital in June 2023, just a month before his death.

CORONER'S CONCLUSION

Area coroner, Samantha Goward, ended the inquest by claiming more could have been done during Mr Köster's disappearance.

She said: "Someone should have been responsible for ensuring that if Nick didn’t return at the agreed time immediate attempts to contact him were made.

"Police should have then been contacted immediately once a search of the grounds was made.

"There was a delay in notifying both the police and senior nurses when Mrs Köster was able to identify Nick’s location on her mobile app.

"The handover meeting should have been interrupted to pass this information over to the nurse in charge so immediate action could be taken.

"However it’s not possible to say earlier detection of Mr Köster's failure to return would have led to him being found before his death."

She concluded that Mr Köster "died to a deliberate act but his intent was unknown and his thoughts may have been impaired by his underlying medical condition."

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Area coroner Samantha Goward concluded Mr Köster died to a deliberate act but his intent was unknown (Image: Newsquest)