A Blackburn man who was being pursued by an “immoral and illegal drug dealer” did not receive the full support of the home treatment team before his suicide, an inquest has concluded.
Shaun Cahill was described as the “life of the party” and as “very fun” by his family, who explained how he was outdoorsy and regularly enjoyed camping trips.
However, following the death of his father, mother and sister in a short space of time between 2021 and 2023, Shaun began to use drugs and was struggling to cope with the stress of rising debts.
Coroner Kate Bissett explained she believed Shaun had taken up the habit after the death of his family members.
A statement written by his girlfriend, Fiona Whiteside, said: “He wasn’t good at coping with stress.
“He was a plumber, and he wasn’t paying his bills and was worried about money, and we became convinced he was gambling.”
On November 18, Fiona found Shaun at his property in Sharples Street after he had taken a concoction of drugs, after receiving threats from a drug dealer known as Kurt.
She said Kurt had also driven past her after she discovered someone had tried to force entry into the house.
In her statement, she also explained how Kurt had threatened Shaun with both harm and theft.
Fiona, who was unaware of the drug use, said she didn’t want to see Shaun but told him that she would still be there for him.
His lifelong friend Peter Hargreaves said: “I know he would have been scared of Kurt as he did not like confrontation.
"He had borrowed money from several people, and we would have known he was unwell and could have helped.”
Detective Inspector Tammy Woodhouse said the man suspected to be Kurt is now dead.
After an attempted overdose, Shaun spent some time at Royal Blackburn Hospital, when he was assessed by the medical teams who deemed that he was fit to leave the hospital that evening.
Shaun had told them his mood was a four out of 10 and that he wanted to live and had future plans, informing the staff that members of his family had passed away in a short space of time and he worried he was going to be the next to die.
However, he did not inform them about the threats made against him and said he regretted trying to take his own life and would be willing to work with the home treatment team as well as the substance misuse service.
The home treatment team were unsuccessful in contacting Shaun for an assessment on November 19 and failed to arrange a follow-up visit.
Laura Doll, a mental health nurse, gave evidence on the back of an independent review, and said there was no evidence of notes or a plan for Shaun.
She said: “There were significant reasons for him to go to hospital in the first place.
"Someone had been banging on his door and he had made an active attempt on his life.
“A plan should have been developed, and a cold call should have been attempted.”
Daniel Whittaker from the NHS Foundation Trust said that the homebase treatment team acknowledged the issues raised.
Ms Bissett said: “His death was a combination of deteriorating mental health and absence of intervention from mental health services.
“It should have had the full support of the homebase treatment team.
"They fell far short of what should have been expected, they breached their own policy, there was no follow up, no conversation with next steps and failure to stop increased risks.
“The only reason he left hospital was that he was willing to work with the services but nobody was available to contact him.
“They also failed to escalate on November 23 when no contact had been made with Shaun.”
The police outlined that by November 23, the homebase treatment team had become concerned about Shaun and had called the police, who had seen an attempt by someone to force entry into the home.
Shaun had left a will and testament in the kitchen and examinations of his phone show conversations with Mr Hargreaves, which suggested a deterioration in his mental health.
Ms Bissett said: “There was an individual putting pressure on Shaun, he was not attempting his own life before someone started bleating on his door.
“This is particularly heartbreaking because the drug dealer has an awful lot to answer for, and for people who deal drugs are immoral and illegal and it is the straw that broke the camel’s back.”
She offered a narrative conclusion, saying: “Shaun Cahill died on November 24 from hanging after he struggled with mental health and increased drug use as his wellbeing deteriorated.
“A drug dealer had made threats to him and on November 18 he attempted to end his own life.
“He had not been seen by the home base treatment team and was booked for November 21 and was not attended, November 23 and was not attended and when no contact had been made by November 24.
“There was evidence that his door had been damaged, and his telephone showed evidence of further threats from the drug dealer.”
Dr Gareth Thomas, Chief Medical Officer and Deputy Chief Executive Officer at Lancashire and South Cumbria NHS Foundation Trust (LSCft), said: “We fully respect the conclusion reached by HM Coroner relating to the death of Shaun Cahill and I would like to extend our condolences to his family.
“Safe patient care is at the heart of what we do and following Mr Cahill’s sad death, we carried out a thorough investigation which identified some areas where care delivery could have been better. Disappointingly, this included the time taken between the referral and initial appointment, which went beyond what is contained in our policy.
“We take the findings very seriously and in our commitment to continuous improvement and learning, we have addressed some of the issues raised through staff training and better working procedures.
“Once again, our thoughts remain with Mr Cahill’s loved ones at this difficult time.”
If you are struggling with your mental health, contact Samaritans on 116 123.
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