Missing Balcombe man took his own life, inquest hears


A missing Balcombe man who suffered from mental health problems took his own life, an inquest heard.

Ervin Underdown, 32, was living with his sister and her partner in Meadow Close, Balcombe, but failed to return home on April 30, last year, sparking a major search around the area.

His body was found ten days later in a tent in Tilgate Woods, Crawley, by an off-duty police officer who was walking his dog.

At the inquest, held at Crawley Coroner’s Court on Friday (January 12), a statement from his sister, Nell, described how Mr Underdown had been feeling ‘very low’ and had been diagnosed with acute stress reaction.

It added: “Ervin loved gaming, cycling and fishing. He was hardworking and strong, but was quite a private man. In the last few days we thought he was making good progress.”

The inquest heard how Mr Underdown had moved from Scotland to Balcombe to stay with his sister after breaking up with his partner of 11 years, which had come as a ‘huge shock’.

It was also heard that he had previously attempted to take his own life, leaving him in hospital for three days.

A statement by Dr Christopher Shearn was read out and said Mr Underdown had ‘thoughts of suicide’ but that he was getting ‘plenty of support’.

He was signed off work by Dr Shearn and was diagnosed with acute stress reaction.

Mr Underdown presented himself to A&E at the Princess Royal Hospital in Haywards Heath on March 22, complaining of mental health problems, the inquest heard.

He was treated by Brian Mpinyuri, a senior nurse practitioner, who told the inquest Mr Underdown had ‘symptoms of low mood and acute stress reaction’.

He added: “He had thoughts of suicide, but said he had no plans of doing this. I assessed him as not a high risk of suicide and he told me his previous attempt had been impulsive.”

Just days after Mr Underdown was referred as a ‘high risk’ to senior nurse practitioner Jon Sepenoo at Crawley Urgent Treatment Centre (UTC) after attending A&E again, but this time by ambulance.

It was heard that he had planned on taking his own life, prompting a 999 call on a train.

Dr Sepenoo referred Mr Underdown for mental health support as a priority.

He told the inquest: “Ervin was tearful and had suicide thoughts. He spoke of his previous suicide attempt, relationship breakdown and that he was not working at the moment and was missing his daughter.

“He was feeling frustrated, unhappy and disappointed his previous attempt to end his life had not worked.

“He told me he had not made any plans but was thinking about it. He engaged well and wanted help. He said hospital admission and being referred to the crisis support team was too much when I offered this to him.

“We went through all the options and I was happy and confident with my assessment.”

The next day Mr Underdown attended an emergency GP appointment with Jane Lazib, a community health nurse at Linwood Community Mental Health Centre in Haywards Heath, and appeared ‘distressed’.

Mrs Lazib told the inquest: “He came in with his sister, Nell, and presented to me as distressed with low mood and self blame due to his relationship breakdown, along with feelings of guilt.

“He said he had no planned attempts to take his own life and in my view he didn’t present as an immediate risk of suicide and he was assuring me he would not act on his thoughts.

“He also assured me he would go to Crawley UTC if he needed to. He was willing to engage with mental health services at Linwood. He was also reluctant to take any medication.”

The inquest heard how Mrs Lazib had reportedly offered Mr Underdown treatment from the crisis support team and had discussed hospital admission, but this had not been recorded in her notes.

Mrs Lazib referred Mr Underdown to the mental health team at Linwood, which she told the inquest would take up to five days.

It was later confirmed that due to it being a bank holiday weekend, this would have actually taken eight days.

Only a few hours after attending the appointment with Mrs Lazib, Mr Underdown attended Crawley UTC by ambulance with ‘thoughts of suicide’.

He was seen by Andrew Shaw, a senior nurse practitioner, who assessed them as ‘thoughts’ and not ‘plans’.

Dr Shaw told the inquest: “He engaged well and I was happy at that time for him to be supported by the mental health team at Linwood.

“After we spoke he said he felt much better and I was assured that he was fine to go home with his sister.

“He told me he was a very keen cyclist and cycled 100 miles a week in his peak and that he enjoyed work.”

Dr Shaw added that he did not feel it was ‘necessary’ to call an oncall psychologist for a second opinion.

The inquest heard how Mr Underdown had posted a YouTube video at Beachy Head talking about suicide.

This prompted a welfare check from Sussex Police after being contacted by Police Scotland, who were concerned.

PC Parry, who works at Haywards Heath Police Station, was called to make the check with a colleague after midnight on April 29.

He told the inquest: “Ervin told me he was feeling low after a break-up. He conversed well and told me his was fine. His sister told me she took care of him and it was clear he was in a safe place.”

Glen McCready, service manager for Mid Sussex Assessment and Treatment service at Sussex Partnership NHS Foundation Trust, told the inquest staff ‘could only assess what was in front of them’.

“Risks were increasing but every assessment was satisfied,” he said.

“On behalf of Sussex Partnership we are incredibly sorry and send our condolences to Ervin’s family.”

Professor Kevin Gourney, a registered psychologist, chartered scientist and registered nurse, told the inquest Mr Underdown’s death was a ‘lost opportunity’.

He said: “In my opinion he required a crisis team or hospital inpatient team. One of the risk factors was his previous suicide attempt which left him in intensive care.

“The other risk factors were there – helplessness, hopelessness and feelings of guilt, these are very important.

“I think Ervin was a long way along the severe end of the spectrum. When someone sees a professional when they feel suicidal and they feel better because of the human contact, this is still not intervention and dealing with the problem in depth.

“He wasn’t really being provided with any intervention and there were many big red flags in the background.

“There was the initial relationship breakdown and his reaction to this, his potentially lethal attempt on taking his life before, low mood, hopelessness and helplessness and suicidal idealisation.

“And this was a man of aged 32 – in an age category of lots of suicides.

“Staff were in a difficult position, you do have to go with the patient’s best interest but sometimes it is going against their wishes, and all the information was there for everyone to see.

“Ervin needed the crisis team straight away and if this was given to him that might have changed things.

“I think the time taken for a referral was inadequate, and when he was seen by Mr Shaw just a few hours after seeing Mrs Lazib, by this point there was an increased risk.

“I am somewhat bewildered that a decision was not made for him to be referred to the crisis team.”

Assistant Coroner Bridget Dolan QC recorded a conclusion of suicide and the cause of death as carbon dioxide poisoning.

She told the inquest: “It is clear to me that Mr Underdown was suffering with mental health problems.

“As a high risk of suicide this man should have had an intervention quickly and should have been seen as soon as possible and what was put in place for him at the time didn’t seem to do this, however I recognise and acknowledge the staff decision making.”

Ervin Underdown attended Balcombe Church of England Primary School and Warden Park. He worked in retail management.

His family were aware the inquest was taking place but did not wish to attend.

For emotional support, people can contact the Samaritans 24-hour helpline on 116 123, email jo@samaritans.org, or visit the Samaritans website.