James Paul Michael Masheter · Prevention of Future Deaths report

On the 3rd April 2024 the Coroner’s Office was notified of the death of James Paul Michael Masheter and an investigation commenced into his death. An inquest was opened and adjourned on the 11th April 2024 and a final inquest took place on the 13th of February 2025 with conclusions delivered on the 25th February 2025. The conclusion of the inquest was that:

“James Paul Michael MASHETER died on the 1st April 2024 at his home address by hanging. Mr MASHETER had struggled with his mental health and had previously engaged in self-injurious behaviours. On the 31st March 2024, Mr MASHETER made a number of cuts to himself with a knife and telephoned friends telling them he was dying and asking for help. Mr MASHETER’s friends called for an ambulance and one friend attended his home address. Mr MASHETER was distressed and bleeding from superficial wounds. Due to demands of the service, there were significant delays in ambulance allocation but Mr MASHETER’s friend was told that that delay was significantly less than was the case. Believing an ambulance to be arriving imminently, the friend left Mr MASHETER, who went on to secure a ligature which caused his death. Incorrect information about the waiting times for ambulance attendance was provided to Mr MASHETER’s friend and this contributed to his death. It is not possible to determine Mr MASHETER’s intentions at the time at which he secured the ligature given his behaviour was in the context of a significant mental health crisis”.

Mr James Masheter was a 42-year-old man with a history of self-injurious behaviour when in a mental health crisis. Prior to his death, a relationship had ended and he had financial concerns.

On the 31st March 2024, Mr Masheter telephoned his friend and ask for help as he was “dying”. His friend telephoned 999 and requested an ambulance. The request was triage as a category 3 incident. There were 3 further calls to the ambulance service on the evening of the 31st March 2024. All resulted under the triage systems as a category 3. There were also significant delays in resource availability on this night.

In the final 999 call, Mr Masheter’s friend was told there were delays of one and a half hours and his original call was one hour ten minutes ago. Believing the ambulance to be due imminently, the friend left. The ambulance did not arrive until 08:10am on the 1st April 2024 and the crew found Mr Masheter deceased by hanging.

1. The NHS Pathways system is used for triage. This asks standard questions to ascertain the seriousness of the situation including whether the patient is awake and breathing and so on. The triage pathway includes some options for mental health situations but these are limited. Evidence was heard in the inquest that the North West Ambulance Service (NWAS) had liaised with NHS Pathways with a view to exploring how mental health calls are triaged. NHS Pathways declined to make any changes to mental health triage but offered advice to NWAS in how to triage mental health situations.

2. The evidence heard at the inquest was that notwithstanding the seriousness of the situation in which Mr Masheter presented, his appropriate categorisation was category 3. This led to significant delays in an ambulance attending. It is not clear to me whether it is possible for serious mental health crisis situations which present a risk to life are capable of being properly risk assessed on the basis of the NHS Pathways mental health triage which exists at present.