Former Bristol and Bath rugby player Nick Koster took his own life while on leave from a mental health hospital where he had been voluntarily admitted, an inquest has heard.
The 34-year-old had smiled as he left the facility in Attleborough, Norfolk, on July 11 last year having asked to go shopping, Wednesday’s hearing in Norwich was told.
Mental health nurse Charles Mwangi said there was “no indication at all that he was suicidal or that his mental health had deteriorated”, and that Koster had “said ‘see you in a bit’, smiled and left”.
Koster was found dead hours later after he failed to return by an agreed time of 4.30pm, having left the site at about 2.30pm.
The athlete, who made 62 appearances for Bristol between 2013 and 2017 after joining them following a short stint with Bath, had been an “informal patient” at Priory Hospital Norwich.
Samantha Goward, area coroner for Norfolk, said this meant Koster was able to leave if he wanted to but had an agreed care plan.
Recording a narrative conclusion, she said Koster “died due to a deliberate act but his intent was unknown and his thoughts may have been impaired by his underlying condition”.
He had been living in Norwich and began to struggle with his mental health in March 2023.
The coroner said Koster had contacted his GP and was prescribed antidepressants before two voluntary admissions to mental health facilities the second to Priory Hospital Norwich from June 14, 2023.
She said operations director Koster “wanted to get better” and “complied with his treatment”.
In a statement read to the inquest by the coroner’s officer, mental health nurse Vikramsing Damree said Koster had asked for leave to go to Attleborough town as he had “a few bits and pieces to buy”.
Mr Damree said that Koster “said he had slept well and was looking forward to his discharge the next day”.
The nurse said that he completed a five-point risk assessment and agreed a return time with Koster.
Mr Damree said that he went on a break at 5.50pm and when he returned at 6.30pm he was told Koster had not returned from leave.
He said a 999 call was made to report him missing but the call-handler referred them instead to 101, with a second 999 call made at 7.49pm when the incident was reported.
Healthcare assistant Robin Wilson said Koster’s wife, Jeannie, was able to track the location of Koster’s phone and it indicated it was in countryside between the hospital and Attleborough town.
The coroner said there was no evidence to confirm what Koster did after his last phone call at 3.47pm, to his father.
She said they spoke “about travelling to South Africa he (Koster’s father) could hear traffic in the background, he (Koster) explained he was going to Attleborough to buy snacks”.
Mr Mwangi said that changes have been made since the incident, including that the names of those who leave the site and the time they are due back are now displayed on a board so they can be more easily seen.
The coroner said it was “not possible to say based on the available evidence whether an earlier call to the police would have altered the outcome”, as Koster’s actions after 3.47pm are not known and he had not been due back until 4.30pm.
Koster’s medical cause of death was recorded as hanging and the time his death was officially confirmed was given as 9.11pm.
Koster captained Cambridge University in the 2018 Varsity Match against Oxford, scoring a try, and played in South Africa for Western Province and the Stormers.
He completed an MBA during his rugby career and a master’s degree at Cambridge University shortly after.
The coroner expressed her condolences to family members who attended the hearing.
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