Devon trawlerman died after 10-hour ambulance wait

The delay was due to huge pressures on ambulance and police

A Brixham trawlerman was found dead at home more than 10 hours after calling 999 asking for help after feeling suicidal. An inquest into the death of 50-year-old Scott Shay, who had stopped fishing after almost losing his life at sea, heard both the police and ambulance services were under 'extreme pressure' when he rang on October 8, 2022.

Both the police and ambulance services were said to have been under extreme pressure at the time, with the situation compounded by a need to have them there at the same time after Mr Shay reported he had a weapon. The inquest at Exeter Coroner's Court today, October 15, heard in the 36 hours before his death on October 9, 2022, he had seen by or talked to a number of different health or emergency service professionals.

As well as having to contend with a 'very significant' delayed emergency services response, he was not contacted by the Community Mental Health Team until after his death. It is believed he intended to end his life by consuming a toxic level of medication he was prescribed.

South Western Ambulance Service NHS Foundation Trust conceded in a review following Mr Shay's death it had not met its target times due to its delayed handover processes at hospital trusts in Devon. On October 8, it said it lost over 464 hours of ambulance time to handovers over the 15-minute target at Derriford, Torbay, Royal Devon and Exeter Hospital, and North Devon District Hospital.

The following day, the situation was said to have been even worse with over 486 hours lost - equivalent to around 44 doubled crewed ambulance shifts. The pressures were said to be not isolated to the south west with a national report the previous year highlighting the potential for harm to occur.

Mr Shay's medical records stated he had a history of alcohol dependence and amphetamine abuse, mental health behaviours disorders due to alcohol dependency and dependency syndrome, and health conditions including diabetes.

In the early hours of October 8, he was taken to the emergency department at Torbay Hospital by police having called them with suicidal thoughts. He was reviewed by its liaison physiatry team later that morning who concluded he presented with a 'moderate risk' of harm.

It was noted he had chronic suicidal thoughts but with no plans or intent, and that his suicidal ideations were often related to alcohol use and social stresses. Mr Shay was discharged home with a plan refer him to the local home treatment team to further assess him within his home environment.

Paramedics were called to his home later that morning. He described being in a mental health crisis and struggling with alcohol withdrawal. He was said to have appeared 'calm' with normal clinical observations.

He admitted having had suicidal thoughts and surrendered a knife to a friend that morning that he had intended to harm himself with. He added a recent alteration to his medication may have affected his mood.

As Mr Shay already had a mental health referral in place and told the crew he no longer had plans to harm himself he was left at home. A subsequent review of that decision concluded the assessment should have been more in depth, but it was believed that outcome for his treatment would have been the same.

That evening, at 9.45pm, Mr Shay called the emergency services again reporting he was in a mental health crisis and made subsequent calls saying he was hallucinating and in the early hours of the morning said he was feeling violent and had a firearm.

There were said to be 30 incidents awaiting allocation in south Devon at the time alongside handover delays at local hospitals. The trust was also said to be at the highest pressure alert level.

An ambulance arrived outside his home and was sat outside at around 2.20am, but as police were not there, the crew could not enter and were eventually dispatched to another emergency call. During that time, Mr Shay had visited his next door neighbour.

In a statement made to police, he described Mr Shay as having been in a 'distressed state', but not armed, and recalled having seen him take medication before he left to return to his own flat at 2.30am. He was said to have accidentally left his bag behind with medication and his phone inside which meant the ambulance service was unable to contact him.

When paramedics arrived in the morning at around 8.25, they were instructed to wait for police arrival due to concerns there may be a firearm in the property. Despite that instruction, paramedics recognised the address, having dealt with him before, so entered the property and found him passed away in the living room.

DC Tia Smallridge told the inquest there had been 'unprecedented demand' on police resourcing at that time. A police investigation concluded there were no suspicious circumstances and no evidence was found of a weapon at Mr Shay's home.

In a statement, his daughter Rio told how Mr Shay, who was born in Bodmin and grew up in Port Isaac. He was said to have left school early to become and fisherman and later moved to Devon, working in Exmouth and then Brixham from 2018, and was known as Wurzel by his friends.

She recalled he stopped fishing around four years before his death after a series of incidents at sea, including a bad accident in rough seas in 2018, which left him in a coma for 10 days and in hospital for three months. She added he had also suffered near drowning experiences when falling into the sea.

Tragically, Rio recalled he had suffered with his mental health from a young age due to trauma and had made previous suicide attempts. In the months before his death, she said she called the police several times due to concerns about his mental health.

Paying tribute to him, she said: "Whilst my relationship with my dad was difficult, his passing leaves an unfillable void." She added: "I shall miss him dearly and relish fond memories I have of him."

Recording a conclusion of suicide, Alison Longhorn, area coroner for Devon, said: "He had been voicing thoughts of self-harm and taking his own life in the hours before his death and clearly had been thinking about it for some time."

Referring to what she described as a 'very significant' delay in emergency services attending, alongside a delay with his home treatment referral, she said: "Although it has been established there was a delay in his referral being picked up by the home treatment team, I am not able to determine whether had it been answered promptly if it woud have altered the outcome for Scott, particularly as he was seen by paramedics later that morning."

She continued: "I acknowledge both the pressures on the ambulance service and the police as set out in the report by South Western Ambulance Service and as described by DC Smallridge. I also consider the decision made by the ambulance service to await police attendance given the potential presence of a firearm where the reporting person was said to be feeling violent was entirely appropriate."

Following his inquest, his daughter Rio said the ambulance, police and mental health services were under meant he did not receive the care he should have.

She said: "I truly believe my dad was begging for help and someone to talk to when he was calling 999 on the evening of October 8, 2022. Had the mental health referral been in place when he left Torbay A&E, I believe the outcome would have been different as he would have had professional support as his mental health crisis escalated on the evening of October 8 and into the early hours of October 9 when the public services were too busy to help him.

"He will be very missed."