Blackburn man facing drug dealer threats lacked full mental health support before suicide, coroner concludes
A Blackburn man who was receiving violent threats from a drug dealer did not receive the full support of mental health teams before his suicide, a coroner concluded.
Shaun Robert Cahill had struggled with mental health issues following several family bereavements, which led to increased drug use and emotional distress.
The court heard the 39-year-old fell into debt with a drug dealer who made violent threats, including attempts to break into his home.
On November 18, 2024, Mr Cahill attempted suicide by overdose and was admitted to hospital for treatment.
He was assessed by mental health professionals the following day and discharged to a home-based treatment team.
Despite policy requiring a 24-hour follow-up, an inquest heard no visit was made by the treatment team at the time of his death.
An appointment was scheduled for November 21, but Mr Cahill missed it. A follow-up attempt wasn’t made until November 23.
On November 24, with no contact from services, police attended Mr Cahill's address in Blackburn and found evidence his door had been damaged by a third party.
Inside, they discovered Mr Cahill’s body, with his phone showing further threats from the drug dealer.
Coroner Kate Bissett concluded that Mr Cahill intended to end his life, influenced by mental health struggles, lack of support and escalating threats.
She also raised concerns about gaps in mental health care and the need for better intervention to prevent similar tragedies.
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.”
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