Inquest into former Bristol and Bath rugby union star Nick Köster's death takes place in Norfolk
The South-African born player moved to Norwich after his rugby career ended
Last updated 2nd Oct 2024
An inquest into the death of a former Bristol and Bath rugby union player living in Norfolk has taken place.
34-year-old Nick Köster took his own life whilst getting treatment at a mental health clinic in Attleborough in July 2023.
The South-African born player moved to Norwich after his rugby career ended in 2018, and had been admitted to the Priory Hospital a month before his death.
Coroner Samantha Goward told the court that Nick died by suicide, and the action was deliberate - but the intent and motivation of the decision is unknown, and it's not clear if mental health played a part.
When the inquest was opened earlier this year, the court heard Nick had initially been referred to the Norfolk and Suffolk NHS Foundation Trust (NSFT) but turned to private treatment after struggling to see a doctor.
He then spent time at two hospitals, beginning in Chelmsford, before moving to Attleborough's Priory Hospital.
He was due to be discharged from the facility a day after he died.
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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.
"Tragic passing"
At the time of Nick's death, Bristol Bears released a statement saying: "Bristol Bears is devastated to hear of the tragic passing of hugely popular former player Nick Koster at the age of 34.
"The South African-born back row played 62 times for the club between 2013 and 2017, making a remarkable impact on and off the field during his five seasons with Bristol.
"In 2017, Koster was shortlisted for Community Player of the Season for his incredible work with the club’s Community Foundation, giving up hours of his own time to a number of programmes and initiatives with young people in the city.
"Our thoughts, prayers and love are with Nick’s wife Jeannie and his two young children."
Meanwhile, Bath Rugby said: "Bath Rugby is deeply saddened to learn of the passing of former player Nick Koster.
"Nick, 34, joined the club in 2012, making 11 appearances in Blue, Black and White.
"Everyone at Bath Rugby would like to extend their heartfelt sympathies to Nick's family, friends and teammates.
"He will be sorely missed and will always remain part of the Bath Rugby family."