It is not known how Shaun died, with his cause of death given as “unascertained”
An Essex man was found dead in his car hours after going missing from his home, an inquest has heard.
Shaun Mason, 46, was sadly found dead on September 13, 2020, the same day that he had gone missing from his home in Witham.
He had last been seen at 6am that day driving a Blue Ford car in Bramston Green, Witham.
Sadly, Shaun was found deceased in his car by police at around 5.55pm the same day.
At the time, his death was treated as unexplained but not suspicious. A post-mortem examination later gave Shaun’s cause of death as unascertained.
In a two day inquest at Essex Coroners Court in Chelmsford, Essex, overseen by Area Coroner for Essex, Sean Horstead, the court heard that Shaun had struggled with his mental health, which declined during lockdown, as well as having issues with alcohol.
The court heard that Shaun had struggled with alcohol abuse for the last 20 years and he would binge drink every two or three weeks to solve his problems. He also used cocaine weekly and smoked cannabis very occasionally.
Shaun also had “chronic and long-standing thoughts of taking his own life constantly,” where he had “thoughts of taking his life” and that he had “always felt like it”.
The risk of Shaun committing suicide was increased when he was intoxicated with alcohol and alcohol was a trigger for him.
However, the court heard that he had “no intent or plan to end his life”.
Shaun had sought counselling and medical advice for ticks and outbursts of anger, particularly, but not limited to, when he drank, the court heard.
A life letter, provided by Shaun’s partner and his mother, stated that he had been diagnosed with bipolar disorder or schizophrenia, as well as struggled with drink.
They stated that “he suffered tragedies in his life” and that they believe “the mental health services failed Shaun.”
“He would lose all sense of control and it was like he was possessed and a shell of himself. He said about how people wanted him dead and were out to get him,” the life letter added.
“He was always such a beautiful, kind and popular soul,” his family added.
“Heartbroken and hopeless doesn’t come close to describing how we feel now. The system failed him.
“This was a desperate man who didn’t want this to be his life plan. He was the most loving and kind person you could ever wish to meet.”
Shaun sought help from mental health services and was “positively engaging” with the services. He was also given anti-depressants at his GP.
However, the court heard that he wished for a “review” of his medication, but he was told that a medication review could not happen until he underwent a detox and a period of abstinence from alcohol.
A period of abstinence from alcohol was required before nurses could make an assessment of his mental health because as long as he continued to drink it was “impossible” to assess his mood and make any changes to his medication, the court heard from Shaun’s nurses.
Giving evidence in court, Dr Fiona McDowall, Consultant Psychiatrist as part of the mental health liaison team at Broomfield Hospital said: “The three of us [Dr McDowall, Shaun and his mother] agreed the most important issue was to address his alcohol misuse.”
The court also heard that Shaun was at “no immediate risk of suicide” at the time of their meeting as there was “no plan or intent” to take his own life.
However, the court heard that lockdown negatively affected his mental state as he “couldn’t do anything”. Shaun also told mental health services that he had suicidal thoughts “all the time”.
The court heard that in August 2020 – one month before his death – there were two occasions of a drug overdose within one week, where he was admitted to hospital twice.
However, his family said: “This was by no means an act to commit suicide.”
After his second overdose and detox in hospital, Shaun stayed sober for five weeks.
Then, an initial risk assessment took place after Shaun was released from hospital, which showed that he had had previous suicide ideation, but had not acted upon these. Shaun also had a history of self-harming “to stop the pain in his head”.
Three days before his death, on September 10 last year, Shaun was due to receive a phone call from Essex Partnership University NHS Foundation Trust (EPUT) regarding a booking for a mental health assessment, but he did not receive it.
He was described as pacing the room with his mother trying to calm him down. The missed call was a “trigger” for him, the court heard.
The court also heard that the hospital did not have the correct phone number for him, as he had changed his number a few days before.
The nurse had tried getting in touch with him for 45 minutes but was unable to, so requested for a letter to be sent out – there was a four day delay in the letter being sent out.
A post mortem examination was conducted by pathologist Dr Kamel at Broomfield Hospital on September 18, 2020, who gave the cause of death as unascertained.
Toxicological samples were also taken, which found a quantity of the sedating drug promethazine, as well as traces of cocaine and alcohol in his system, which was a level over the drink-drive limit.
However, the court heard that the levels of the drugs and alcohol were “unlikely” to contribute to death.
The court also heard that promethazine was “unstable” after death, which meant that within the toxicological findings, the levels of the drug could be higher or lower in the blood.
Coroner Horstead stated that the drug was “unlikely to account for fatality in circumstances of this case”.
Following Shaun’s death, a Serious Investigation report (SI) was conducted by mental health service, EPUT, which found that actions needed to be taken to prevent similar deaths.
The court heard that there “should have been contact” with Shaun following the missed telephone call on September 10, and that Shaun’s family should have been contacted after the missed appointment.
A representative from EPUT, Ms Hibhill, stated that the “issue has been escalated and processes are being made to make a ‘tighter process’”.
The court also heard that there was a “delay” in contacting Shaun following his missed appointment, with a letter being sent days after the missed call.
Due to the lockdown, it made face to face appointments trickier, meaning that they could not attend Shaun’s home address to contact him, the court heard.
The SI report stated that there “should have been further planning following missed appointment other than generic letter”, however.
Ms Hibhill stated that there are “options” now in place to make further attempts at contacting patients who have missed their appointments, as well as contacting the next of kin, as long as consent has been made to do so.
Coroner Horstead stated that Shaun had “significant personal issues and trauma”, and had a number of triggers that affected his mental health.
“He was battling demons that he could only confront,” Mr Horstead said.
Coroner Horstead concluded that regarding Shaun’s medication review, it “would have been helpful having a greater deal of clarity and could have been spelt out,” in relation to the time period Shaun would have had to abstain from alcohol.
He added that the actions taken by the nurses at the time were “appropriate”, including the need for him to battle his drinking problems before an evaluation of his mental state and medication could take place.
“In all of those circumstances, the appropriate course was exactly the course taken,” Mr Horstead said.
Coroner Horstead gave a narrative conclusion stating: “Whilst evidence confirmed no third party involvement, the evidence does not disclose a required standard of proof of balance of probability of how he died, he had a settled intention to end his life or his death was an unintended consequence of a deliberate act, ie an accident.
“The appropriate conclusion is, therefore, an open conclusion”.
Credit Essex Live
