A VULNERABLE missing man who died from drug-related pneumonia may have been saved had police raised his risk level earlier, a jury has ruled.
Shaun Elliott died in Wycombe Hospital on July 11, 2011, from bronchial pneumonia as a result of multiple drug use, a three-week inquest at Beaconsfield Coroner’s Court was told.
Returning a narrative verdict, jurors ruled that had the Wycombe care home that Mr Elliott disappeared from reported him missing earlier, police would categorised him as a "high risk" missing person sooner.
Jurors also found that had police followed up on lines of enquiry from the family, it probably would have led officers to Mr Elliott, who took drink and drugs at an acquaintance’s flat in the days prior to his death.
The 43-year-old, who had a history of mental health issues, left 10 Hawthorne Road, High Wycombe, on the morning of July 6, 2011.
He appeared in good spirits and was heading to a dyslexia course in Maidenhead but he did not return home, care home staff told the court.
But as he had previous for staying out overnight drinking, care home staff told the inquest their policy of calling police after a resident had been missing for 24 hours did not apply to Mr Elliott.
Police attended the care home to take a statement and search the property after they were called on the morning of July 8. It was decided Mr Elliott should be classed as “medium risk”.
Witnesses told the inquest that Mr Elliott arrived at Ryan Cronin’s flat in Quarrendon Road, Amersham, at about 10am the same morning, July 8.
Angela Simpson, who was at the flat, said Mr Elliott had a can of super-strength lager in his hand and ‘appeared drunk’.
Mr Elliott proceeded to take methadone, alcohol and heroin at Mr Cronin’s flat in the three days prior to his death.
The drugs would have left him in a comatosed state leaving him unable to clear his secretions or tell others of his deteriorating condition, medical experts told the court.
Witness Martin Mallinson said he heard Mr Elliott, who was ‘passed out’ and sitting up on the sofa, “breathing like Darth Vader” during a short visit he made to the flat at about 9pm on July 9.
He asked Mr Cronin if they needed to call an ambulance but he was told Mr Elliott ‘had a lung disease and he was over-reacting’.
That night, PC Michael Ellyard and Sgt Ashley Rattray attended the home of Mr Elliott’s sister Clare to obtain consent and gather further information about his disappearance.
It was alleged by Kez Elliott that he told the officers his brother had previously been hurt by Mr Cronin, who he described in court as a “black, gay predator” and a “police informant”.
But during their evidence, the officers said they had no recollection of that discussion, had not made any note of Mr Cronin’s name and if they had they probably would have been ordered to attended Mr Cronin’s Amersham flat. Mr Elliott was still a "medium risk" missing person.
Ms Simpson told the court Mr Cronin made a series of phone calls to her over July 9 and 10 saying Mr Elliott kept drifting in and out of consciousness.
But it is believed Mr Elliott woke up and smoked a cigarette on the morning of July 10 before the final telephone discussion Ms Simpson would have with Mr Cronin about Mr Elliott’s condition.
Mr Cronin phoned her at about 10pm on July 10, 2011, and told her Mr Elliott’s lips were blue, his breathing was inconsistent and he had called an ambulance.
He was rushed to hospital but, despite the heroic efforts of doctors, experts said there was “next to nil chance” of saving Mr Elliott – who died on July 11.
Chief Inspector Colin Seaton had raised Mr Elliott’s risk level to “high” at 9pm on July 10 – about an hour before Mr Cronin dialled 999.
The family told the inquest they had pleaded with police to raise the risk level long before then.
Dr David Potts, a consultant called in by the coroner to give his expertise, said after looking at the reports he believed Mr Elliott had probably passed the point of no return by about lunchtime on July 10.
Anyone with any medical knowledge would have recognised the serious need for Mr Elliott to be treated by doctors sooner – but the general population had little idea about first aid, he added.
On Friday afternoon, the six men and four women of the jury returned a narrative verdict.
Jurors believe the Hawthorne Road care home should have alerted the police on July 7 – the day after his disappearance – not July 8.
They found that had Mr Elliott been upgraded to “high risk” by police earlier, “the probability that a more thorough secondary investigation would have highlighted Ryan Cronin and prioritised this [lead] due to the lack of any other actions/leads they could take."
Jurors stated police should have treated Mr Elliott as “high risk” on the morning of July 9. This would have been moved forward to July 8 had the care home reported him missing on July 7.
They also decided there was a ‘probability based on the evidence’ that Mr Cronin’s name was mentioned to officers, which may have led them to the flat in Amersham sooner.
Jurors believed Mr Elliott's condition was beyond medical intervention by the evening of July 10.
Buckinghamshire Coroner Richard Hulett said he will be sending a report to the College of Policing regarding the prevention of future deaths.
Thames Valley Police has since amended their policies for missing persons following Mr Elliott’s death, with four officers receiving “management advice” at the conclusion of an Independent Police Complaints Commission probe.
Mr Cronin was murdered in August 2011.