A ‘troubled’ Essex man has tragically committed suicide in a popular Essex park after battling mental health issues for years.
John Moore, 39, was found hanging in a playground in Lower Castle Park in ColchesterEssex, around 6:45 a.m. on June 10, 2021.
Police erected a cordon near the area where John was found, who was up shortly after, around 10 a.m.
READ MORE: Local news in Essex
The inquest into John’s death took place at Essex Coroner’s Court in Chelmsford, Essex on Friday (4 February), overseen by Essex Area Coroner Sean Horstead.
The court heard that John was known to the mental health service, Essex Partnership University Trust (EPUT), in the years before his death.
John was diagnosed with adult ADHD, personality disorder, and bipolar disorder. The court heard that his mental health was “erratic” and that he had several life events that “derailed him”, leading to two overdose attempts.
The court heard that John often took illicit drugs when he was happy to “keep fit” and that he also served short stints in prison for “drug-related incidents”.
The inquests do not investigate every death that occurs, but they will hear of unexplained or suspicious deaths of people. They will hear from witnesses from organizations, health services, as well as officers and police who investigated the incidents.
The law says that the medical examiner must open an inquest into a death if there is reasonable cause to suspect that the death was due to something other than natural causes.
An inquest is a limited fact-finding inquiry to establish:
- Who died;
- When they died;
- where they died;
- how they died; Y
- Information needed by the Death Registrar in order to register the death.
There is a formal court setting and everyone must stand as the coroner enters and exits the court.
It is in the great public interest to have an effective investigation system, as it safeguards the legal rights of the family of the deceased and other interested persons. It highlights lessons to be learned and advances in medical knowledge.
Many families also find it helpful to have the opportunity to question witnesses and, at the end of the process, to know that they have complete and accurate facts about their loved one’s death.
John, who was a painter and decorator, tried to take his own life in 2017 due to a drug overdose.
He attempted to get his life back on track a year later, but his mental health deteriorated and he had “reached a much lower period than before”.
John was admitted to a mental health facility at Goodmayes, Essexwhere he tragically tried to hang himself in the shelter’s garden.
As a result, he was taken to A&E at Queens Hospital in Romford, where he was released into the community and monitored.
(Image: Susan Moore)
After this event, John went to live with a friend in Colchester, Essex, but was then “required to leave”, where he became homeless, the court heard.
During this time, John stole from members of his family, something John’s family said was because he “was expressing himself.”
The court heard that months later, John had taken another overdose.
In November 2019, he had overdosed on his prescription drug while in police custody.
Three months later, he was taken to The Lakes mental health service in Colchester and admitted as a voluntary inpatient.
He was later admitted to the Peter Bruff Ward at the Kingswood Center in Colchester on March 6, 2020.
Vicky Jones, John’s mental health care coordinator, stated at inquest that upon admission to Peter Bruff, he was identified as having “self-neglect and vulnerability, ADHD, homelessness, history of alcohol and illicit drug use, suicidal thoughts, ideas and plans.
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Just a few days later, on March 18, 2020, he was released from the ward. However, the court heard that John did not yet have a fixed address when he was discharged.
The court was told that John’s family had stopped receiving communications from him and “disassociated” himself in August 2020, after he was released from hospital.
He had also stopped communicating with mental health services.
Coroner Horstead asked if it was common for a homeless person coming into mental health services to be released back onto the streets.
The court heard that due to John’s prior convictions and criminal charges, as well as a restraining order, his options were ‘limited’ as he was unable to go to a homeless shelter.
If you have mental health problems or need to talk to someone, there are a variety of charities to help you.
You can call or talk to samaritans anytime of the day, 24 hours a day, seven days a week, all for free at 116 123.
Stone wall also recommends the LGBT+ Helpline where nothing is prohibited and conversations are 100% confidential. You can call them between 10am and 10pm on 0300 330 0630.
MindLine Trans+ also offers a confidential mental health and emotional support helpline for people who identify as transgender, agender, genderfluid and non-binary on 0300 330 5468.
you can phone child line on 0800 1111: all calls are free and will not appear on your bill.
PAPYRUS is a voluntary organization supporting suicidal adolescents and young adults that you can call on 0800 068 4141.
Coroner Horstead emphasized that due to the ongoing Covid-19 pandemic at the time, there was a change in national policy regarding homelessness during the pandemic.
Months after his discharge, John was able to live inside a hotel.
However, the court heard that John took his own life more than a year after being discharged from mental health services.
A post-mortem examination was carried out by pathologist Shaobin Wu at Colchester General Hospital, who gave the cause of death as a fatal 1A pressure to the neck.
Toxicology was also taken, which revealed that no illicit drugs, alcohol, or medication were detected in John’s blood.
‘Improper record keeping’
During the investigation, questions were raised about the quality of records kept by mental health professionals.
The court heard that the documents regarding John’s admission to mental health services had “inconsistencies” as well as that the document was not completed correctly.
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At the time John was admitted to the hospital, Mrs Jones was shadowing a senior member of staff, Clive Fowell, who was supervising her.
Coroner Horstead expressed concern about the discrepancies in the dates that Ms. Jones was being supervised, as well as the lack of finalization of the documents.
He added that the lack of documentation of John’s risk assessment could mean “it didn’t happen” and that some of the documents appeared to be “a cut-and-paste job.”
She stated that it is the Nursing code of conduct to keep proper records.
Coroner Horstead said it was an “inappropriate way of keeping records from supervision because, in my opinion, there should be a new document, rather than using an old document that is modified.
“My concern is [the record] lends itself to losing things.”
Ms. Jones said that she has since received training on record keeping and EPUT added that they have implemented new policies regarding record keeping, which will be implemented in the “coming months”.
‘Improper training’
Coroner Horstead also raised concerns about the lack of training care coordinators receive across the UK.
The court heard that Ms. Jones did not have any formal training as a care coordinator, but was shadowing a senior member of staff.
Horstead called the lack of training for care coordinators “inadequate and inappropriate” and urged that a formal training course of some sort be “considered” to prevent another death.
As a result, Coroner Horstead stated that he will make a report preventing future deaths, following the discovery.
He said: “There is a risk of future deaths if the policy of having care coordinators who are not sufficiently trained in all aspects of their role continues.”
Mr. Horstead added that there were “lessons to be learned” in the event someone “disengaged” from mental health services, something EPUT stated has been changed.
Coroner Horstead added that John intended to take his own life and concluded that he tragically passed away as a result of suicide.
‘John was disappointed’
Susan Moore, John’s mother, said: “John was much loved by family and friends and we cannot bear to contemplate life without him.
“He was really loved. But troubled, really troubled. But he’s in a better place.”
Susan added that she felt the mental health services had “let down” John.
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