19 January 2024

This is a press release by Ison Harrison, reshared by INQUEST

Before HM Senior Coroner Terence Carney
Gateshead and South Tyneside Coroner’s Court
11 January – 19 January 2024

Shaun Luke was 49 years old when he died a self-inflicted death on 20 April 2018 at Cheswold Park Hospital in Doncaster shortly after a difficult care plan review meeting. Now an inquest has found that Shaun died after an acute exacerbation of his mental ill health.

Shaun was originally from the Newcastle area and had been transferred to Cheswold Park in 2017 from St Nicholas Hospital in Newcastle. The transfer meant he was moved over 130 miles away from his immediate family, whom he was very close to, including his parents Allen and Margaret, sister Sharon and twin brother Stephen. 

Shaun was diagnosed with schizophrenia. He had been detained under section 37 of the Mental Health Act in 2014, and he remained in hospital under that section until his death in 2018. 

On 19 April 2018, Shaun attended a care plan review meeting (known as a CPA). By the time of the meeting, Shaun had been detained without leave for over two years. The jury heard how Shaun is likely to have believed, going into the meeting, that his circumstances would improve. 

His family had not been invited to attend that CPA meeting due to a number of incidents that happened within Cheswold hospital which led to Shaun feeling distrust towards not just staff but his family. 

However, during the CPA meeting Shaun was informed that his treatment team were considering changing his medication to a drug that only years before had caused him to develop neutropenia. Neutropenia  is a life-threatening condition which led to him being admitted to intensive care. 

The family believe that the idea of being given this particular medication again would have been terrifying and traumatising to Shaun and would have left him in fear of his life. 

In addition to this medication being discussed, a comment had also been made by his social worker that if Shaun did not start engaging in treatment, they would still be there in another 10 years. The inquest heard how Shaun is likely to have believed that this amounted to a ‘sentence’ of ten years’ further detention. 

The family again believe that this would have caused Shaun to feel hopelessness, disappointment and devastation. The family through their legal team tried to convey to the inquest that Shaun, who had been considered for an Autism assessment only the year or so before his death, had a very rigid mindset and saw things in black and white. This meant he could not grasp the concept of hypotheticals. This aspect of his mindset, supported by a comment to his named nurse that evening, showed that Shaun believed he was being locked up for another 10 years. 

Shaun’s family strongly believe that had they been able to attend that CPA meeting they would have been able to convey to the clinicians the heightened risk that Shaun would have been at following the meeting, and how Shaun would have viewed the discussion.

The fact that they were not able to offer this insight as they were not present meant that Shaun’s risk was underestimated and therefore steps were not put in place to put him under greater observation on the evening of 19 April. 

The coroner refused to allow Stephen to give evidence to the jury at the inquest. The jury having heard evidence from those involved in his care, returned a narrative conclusion. They found that Shaun had suffered an acute exacerbation of his mental illness, misjudged the situation and ended his life. 

They also referenced the fact that at the CPA meeting on 19 April, Shaun had become angry and frustrated about what was being required of him, and in particular to progress to opportunities for section 17 leave from hospital. He became particularly distressed by his perception that he may be detained for a further 10 years. Further stressors for him from this meeting appear to have been issues of medication, psychological intervention, occupational therapy and the lack of section 17 leave. 

Shaun’s identical twin brother and carer said: “I feel extremely disappointed that I was not allowed to give evidence at the inquest, which I believe would have helped give the jury a broader understanding, and which may have given rise to a different outcome. 

The feeling of not being heard in the inquest seems to us to mirror our feeling of not being heard by the hospital where Shaun was detained.”

Sharon, Shaun’s sister, said: “We feel like our voice has not been heard. The fact that Stephen was not allowed to give live evidence profoundly affects my feelings about, and confidence, in the inquest process. I feel disillusioned.” 

Gemma Vine, Ison Harrison, said: “One of the most important things for a bereaved family in this situation is for their voices and concerns to be heard. To be stopped from giving live evidence before a Jury only seeks to compound their feelings of distrust in the system.” 


For further information, interview requests and to note your interest, please Leila Hagmann on [email protected]

The family are represented by INQUEST Lawyers Group members Gemma Vine, Ison Harrison Limited and Paul Clark Garden Court Chambers.The family are supported by INQUEST caseworker Selen Cavcav.

Other Interested persons represented are Cheswold Park Hospital, Doncaster and Gateshead Council.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests