The inquest into the death of Shannon Nora Shine concluded yesterday (6 December 2023). The inquest was heard over four days from 11-14 September 2023 at Manchester City Coroner’s Court in front of HM Area Coroner Mr Zak Golombeck.

Shannon was described by her family as ‘very loving’ and ‘full of fun’. The Coroner specifically referred to a photograph he was shown of Shannon with her children and that it had stuck with him for a number of days after.

Shannon sadly died on 11 June 2020 when she was just 29 years old, having suffered a decline in her mental health, linked to domestic abuse. Shannon had a long history of mental health illness and has been admitted to hospital in February and May 2020 following attempts on her life. At the time of her death, she was living in a homeless B&B and had been separated from her children. She had recently been discharged from the Greater Manchester Mental Health NHS Foundation Trust (GMMH) Home-Based Treatment Team (HBTT).

On 1 June 2020, Shannon was discharged from the HBTT. Whilst the Coroner did not find this a causative failing, he referred to feeling some unease following the evidence heard around this discharge and that the decision to discharge Shannon didn’t involve oversight.

Shannon was found on 8 June 2020 and taken to hospital, where she died on 11 June 2020.

The Coroner concluded that Shannon died by suicide.

The Coroner found a number of failings in Shannon’s care, but found that it would be speculative to say whether these contributed to her death. The Coroner found there was insufficient appreciation of Shannon’s vulnerabilities, including her domestic situation, the protection she required and the effect on her. The Coroner highlighted that the systems in place didn’t prevent Shannon from spiralling and ultimately taking her life.

The Coroner found a specific failure in the care provided by GMMH, including general inadequacies and with multi-agency working. He also found a lack of mutual working between Islington Council and Manchester City Council children’s services.

The Coroner ruled that Article 2 of the ECHR (the right to life) was engaged for the inquest on the basis of the systems duty – Shannon was a vulnerable woman with a known history of suicide attempts, and there were questions around the effectiveness of frameworks from multiple agencies which should have ensured Shannon’s safety.

One of the central issues that the Coroner considered was Nearest Relative requests. The Coroner found that Shannon’s family had made a Nearest Relative request for Shannon to have a Mental Health Act assessment, but that the HBTT worker did not act appropriately and the fact that no steps were taken thereafter was a failure in care. The Court heard evidence from a number of GMMH witnesses who were not familiar with the Nearest Relative process or policies, and had not received training on Nearest Relative rights.

The Coroner commended the impressive dignity shown by the family throughout the inquest process and that they were a credit to Shannon, as were Shannon’s children.

Shannon was able to save others through her organs being donated. Hospital staff formed a guard of honour and applauded as she was taken for the surgery. The family are grateful to those who gave Shannon CPR which allowed for this to happen.

Shannon’s family were represented by Alice Wood and David Corrigan of Farleys Solicitors’ inquests team and Ciara Bartlam of Garden Court North Chambers.