Paul Hills

SECRETARY OF STATE 
MINISTRY OF DEFENCE 
FLOOR 5, ZONE D, MAIN BUILDING 
WHITEHALL  LONDON  SW1A 2HB 

Telephone 
Fax: 020 721 87140 
E-mail: defencesecretary-group@mod.gov.uk 

4.7.2.1 

16 February 2021 

Dear Ms Hayes, 

Thank you for your letter of 19 November 2020 in which you enclosed a copy of 
your Regulation 28 Report following the Inquest into the very sad death of Sgt 
Paul Hills. Suicide is a tragedy, not only for the individual and their family, but for 
us as an institution; we owe a unique debt of gratitude towards those who serve.  
I very much share your desire to prevent any recurrence of such tragic events 
and I am grateful to you for bringing your findings to my attention.  

I set out below the steps that have already been taken on the issues you have 
raised, and the further action planned. 

The challenge of improving the mental health and wellbeing of our Armed Forces 
personnel is an important one.  In July 2017, the Defence People Mental Health 
and  Wellbeing  Strategy  was  launched,  emphasising  the  continued  need  for  a 
coordinated approach to prevent, detect, and treat mental health and wellbeing 
issues,  as  well  as  introduce  measures  to  promote  the  importance  of  mental 
health.  The Ministry of Defence (MOD) provides a 24-hour mental health helpline 
for Armed Forces personnel and their families allowing them to access support 
for mental health problems and a new online platform, HeadFIT, was launched in 
2020  with  tools  and  techniques  to  support  to  the  Armed  Forces  community 
manage good mental fitness and resilience.  From April 2021, mandatory, annual, 
military  mental  health  and  wellbeing  training  will  be  introduced  as  part  of  a 
redesign of mental health provision in the Armed Forces. 

Matters  of  Concern  1  –  “No  risk  assessment  was  completed  on  the  issue  of 
moving mental health appointments to virtual during the COVID-19 pandemic and 
how patients could be kept safe in the event of deterioration in his mental health. 
There was no plan in place for patients that required urgent assessment/review 
due to deterioration in their mental health.”  

Ms Sonia Hayes 
Assistant Coroner for North East Kent,  
North East Kent Coroner 
Cantium House, County Hall 
Sandling Road 
Maidstone 
Kent ME14 1X 

Email:  

 
                           
                        
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 We  recognise  the  importance  of  face  to  face  appointments  for  urgent  clinical 
assessments, particularly with respect to mental health matters.  Throughout the 
COVID-19 pandemic in-person consultations have been offered to patients who 
are assessed as being at high risk.  However, the pandemic has meant that in-
person  attendance  is  not  always  possible,  or  indeed  preferred,  by  some 
individuals.  In making available remote video consultation during the pandemic, 
the MOD prioritised mental health services in recognition of the particular needs 
of such cases.  The “Attend Anywhere” platform is now available for appointments 
to  be  conducted  remotely.  The  use  of  video  allows  our  clinicians  to  identify 
additional  diagnostic  clues  and  facilitates  a  therapeutic  presence,  despite  not 
being able to meet a patient in person.  Telephone consultations, as used in the 
early  stages  of  the  first  COVID-19  lockdown,  remains  as  an  alternative  option 
where face-to-face meetings or remote video consultation cannot be conducted.  

The  provision  of  mental  healthcare  follows  a  stepped  approach,  following  the 
introduction of the Defence Mental Health Unified Care Pathway in March 2018. 
Care starts with an individual’s General Practitioner in Primary Care and may be 
stepped up to our bespoke military mental health service if required:  this may be 
because treatment in the Primary Care setting has proved to be ineffective, or 
that  specialist  mental  assessment  and  intervention  is  necessitated  from  the 
outset.  The  Defence  Mental  Health  Service  is  based  on  the  provision  of 
community  mental  health  services  through  a  series  of  regional  centres 
(Departments of Community Mental Health and associated mental health teams).  
Inpatient  mental  healthcare  services  are  provided  under  contract  by  Midlands 
Partnership NHS Trust that leads a consortium of eight NHS providers throughout 
the UK.  

Sgt Hills’ risk was assessed by treating clinicians in Department of Community 
Mental  Health,  London,  and  as  a  result  he  was  offered  a  face-to-face 
appointment.  Following  discussion  with  Sgt  Hills,  who  was  concerned  about 
attendance  in  person,  a  telephone  appointment  was  agreed  as  an  alternative.  
We agree that the factors his clinicians considered in proceeding with telephone 
consultations should have been documented more clearly.  Steps have now been 
taken to ensure better record keeping. This is covered in more detail below, in 
the response to your matters of concern 2 and 4. 

As  outlined  above,  there  is  a  stepped  approach  to  the  provision  of  mental 
healthcare.  The  assessing  clinician  will  consider  the  severity  of  a  patient’s 
condition.  This  is  largely  a  decision  based  on  clinical  assessment  and 
observation.   In a  case  where a  patient  is significantly  deteriorating,  MOD  has 
processes in place to arrange, at any time, emergency admittance to an inpatient 
mental  health  unit.    Service  personnel  are  assessed,  stabilised  and  treated  in 
hospitals as close to their home or parent Unit as possible.  

In Sgt Hills’ case, he was not offered hospital admission. This was based on a 
clinical assessment of his mental state, together with consideration of protective 
factors such as the support from his family, friends and employer.  

Matters  of  Concern 2  –  “The  Care plan  had  not been updated  since  October 
2019 and his risk assessment remained the same even when the scores changed 
and there was evidence of escalating risk behavior”  

 
 
 
 
 
 Matters  of  Concern  4  –  “His  risk  assessment  was  not  up-to-date  and  his 
disclosures during April were not documented.” 

In your matters of concern 2 and 4 you raised the lack of detailed record keeping 
and risk assessments.  You rightly highlight the importance of clear and accurate 
recording  of  all  aspects  of  patient  care  to  ensure  a  coherent  history.    Record 
keeping  is  an  essential  tool  for  communication  between  clinicians  and  for 
effective  care  planning.    There  is  clear  guidance  set  out  in  Defence  Primary 
Healthcare  standard  operating  procedures  on  the  standards  required,  and  all 
patient medical and clinical documentation should be recorded electronically on 
the MOD case management system.  The guidance is clear that all routine clinical 
notes  should  be  entered  directly  on  to  the  patient’s  electronic  file,  and  any 
handwritten notes shredded after that happens. 

Sgt Hills’ care plan was updated on a number of occasions and his risk levels 
were being reviewed. However, the records of this case were not to the standard 
expected.  Sgt Hills’ initial care plan, dated October 2019, formed the basis for 
treatment.  Within  a  Department  of  Community  Mental  Health,  subsequent 
updating of the care plan is part of the overall treatment record, which clinicians 
document on a review/assessment template.  On this template, there is a section 
for recording any updates to the care plan, or to confirm the extant care plan, as 
well as assessment of risks, clinical reasonings and any prescribed medication.  

During the inquest, printouts of the review/assessment template were provided: 
however,  the  purpose  was  not  clearly  explained  and  in  Sgt  Hills’  case  the 
review/assessment template had not been completed with the level of detail and 
clarity expected.  As a result, it was not clear that from the printout provided  in 
evidence  at  the  Inquest,  that  Sgt  Hills’  care  plan  had  been  updated  on  five 
occasions  after  October  2019,  (23/12/19,  10/02/20,  28/02/20,19/03/20  and 
02/04/20).  I regret that this was not clearly explained at the Inquest.  

You will wish to be aware that the treating clinician involved is receiving monthly 
caseload supervision from a Senior clinician (normally this form of supervision is 
carried  out  every  six  to  eight  weeks).  This  will  ensure  that  the  individual’s 
casework  management,  including  the  completion  of  the  review/assessment 
record,  is  to  the  detail  required  and  contains  sufficient  clinical  rationale  to 
demonstrate a coherent picture of care.  This monthly supervision will continue 
for the rest of this year.  If the treating clinician’s performance has improved, his 
caseload  supervision  will  return  to  the  normal  six  to  eight-week  cycle.    The 
treating  clinician  has  also  undergone  further  training  in  risk  assessment 
management. 

More broadly, steps have been taken to ensure that Senior clinicians focus on 
the quality of record keeping and, should the performance of any treating clinician 
fall  below  the  expected  standard,  that  person’s  performance  will  be  reviewed 
regularly until the required quality is achieved.  To support this, Defence Primary 
Healthcare is currently updating its guidance on the delivery of mental healthcare 
to ensure clinicians, Departments of Community Mental Health and Regions have 
the support they require and can be held to account for their adherence to clinical 
policy.  

 
 
 
 
 
 
 Matters of Concern 3 – “Risk issues were not shared with the family even though 
Sgt  Hills  was  in  lockdown  with  them  and  there  were  no  discussions  regarding 
sharing  of  information.  He  disclosed  his  dry  runs  of  self-strangulation  on  
28th February and 16th April and his withdrawal/isolation from his family who had 
been  very  supportive  of  him.  On  22nd  April he  disclosed  he  was  looking  for  a 
rafter  to  harm  himself  from  and  there  was  an  overreliance  on  his  family  as  a 
protective factor in the absence of this knowledge being shared with them.” 

On  the  issue  of  risk  management,  Defence  Primary  Healthcare  is  introducing 
enhanced  risk  management  training  for  all  Department  of  Community  Mental 
Health clinical staff.  This will be delivered by a recognised national provider and 
will be completed for all mental health clinicians by the end of March 2021.  The 
training will provide best-practice tools to recognise, assess and manage risks for 
mental health and related matters. 

You  have  raised  important  points  about  communication  with  families  around 
issues of risk, and we recognise the invaluable support provided by loved ones 
in often distressing circumstances.  As you will appreciate, if a patient is receiving 
mental  health  support,  there  is  no  routine  engagement  with  families  as  some 
patients  might  not  want  their  family  to  know  that  they  are  receiving  treatment.   
If the patient refuses permission for his or her clinician to contact their family, this 
will be considered as part of the risk management procedures, and in accordance 
with guidelines on the disclosure of patient information.  I understand Sgt Hills’ 
consultant was in contact with his family, however, I do appreciate your concern, 
and this will be addressed further in the risk management training.  

Matters  of  Concern  5  –  “Sgt  Hills  was  advised  not  to  drive  with  his  wife  and 
children  in  the  car  when  he  disclosed  strong  thoughts  to  drive  head  long  into 
oncoming  traffic.  This  advice  would  not  have  protected  Sgt  Hills  or  other  road 
users.”  

You have raised a specific concern about individuals who are a risk to themselves 
and others when driving.  For patients with mental health issues, it is especially 
important  to  carry  out  and  record  an  appropriate  risk  assessment:  this  should 
include the risk of driving and form a standard part of all consultations even if the 
assessment of risk is considered low.  I understand that Sgt Hills was advised not 
to drive and to inform the Driving and Vehicle Licensing Agency (DVLA) of his 
medical condition, in accordance with DVLA guidance, to mitigate risk to himself 
and others.  I also understand that Sgt Hills advised his clinicians that he did not 
intend  to  drive  and  had  arranged  that  his  wife  would  drive  him  to  his 
appointments.  A staff vehicle and driver were also made available to transport 
him to his medical appointments.  

However, I recognise the significance of this concern and about the way this issue 
may have been approached - this would not have protected Sgt Hills or other road 
users.      In  future,  Clinicians  will  be  required  to  provide  evidence  where  an 
individual has been instructed not to drive and to advise the DVLA, to ensure that 
this can be monitored throughout care.  

 
 
 
 
 
 
 
 Matters  of  Concern  6  –  “Evidence  was  heard  during  the  inquest  that  RAF 
Manston  was  being  decommissioned  and  this  impacted  on  the  treatment 
available locally for Sgt Hills and impacted on communications with the DCMH 
and the sharing of relevant information.” 

I note your concern, but I hope I can rectify any misunderstanding created at the 
Inquest about the planned closure of RAF Manston.  Department of Community 
Mental Health clinicians were aware that the Defence Fire Training Development 
Centre Manston1 was being decommissioned.  Some confusion may have arisen 
about the gap between the MOD-wide announcement of the planned closure of 
the site and the planned decommissioning date itself.  The decommissioning of 
the Centre did not begin until November 2020.  Before and during April 2020 the 
Centre was still carrying out its assigned training tasks and all key staff remained 
in  place.    There  was no  impact  on  any  patient  care  as  a  result  of  the planned 
decommissioning of the Manston base.  

The  standard  process  of  communication  and  information  sharing  therefore 
continued between the Department of Community Mental Health and Sgt Hills’ 
Chain  of  Command,  with  the  Senior  Medical  Officer  and  Unit  Medical  Officer 
attending the Unit Health Committee and Station Personnel Support Committee.  

In light of my response to the specific concerns you have raised, I hope that you 
are reassured about the seriousness with which the MOD regards Regulation 28 
letters.  The MOD greatly values Coronial oversight. We are committed to being 
a  learning  organisation  and  supporting  service  personnel  and  their  families, 
especially where, tragically, a death occurs.  As in society as a whole, the Armed 
Forces will never be able to eradicate the incidence of suicide:  however, we must 
ensure we continue to reduce the risks by tackling stigma, providing education 
and having easily accessible, rapid and flexible access to mental health support 
and  healthcare  services.    We  are  continually  examining  ways  of  developing 
mental health  support for serving  personnel and  the  introduction  of  mandatory 
mental health training will further help promote mental wellbeing and resilience. 

We have improved the support provided to enable our people to recognise the 
signs  of mental health  distress  in  themselves  and  in  others, and to  encourage 
them  to  seek  help  earlier.  This  includes  pre  and  post-operational  stress 
management training; a wide range of psychiatric and psychological treatments;  
and  initiatives  such  as  Trauma  Risk  Management  which  provides  peer-to-peer 
support after a traumatic incident.  

The MOD is member of the Department of Health and Social Care-led National 
Suicide  Prevention  Strategy  Delivery  Group,  working  with  partners  across 
government to identify ways to reduce the risk of suicide.  The Defence Suicide 
Registry project has begun; this will provide an evidence base to inform a MOD 
suicide  prevention  strategy  and  ensure  that  any  lessons  identified  can  help 
prevent others from taking their own lives. 

1 [1] RAF Manston formally closed on 31 Mar 99, leaving the site as a Ministry of Defence (MOD) 
establishment, known as Fire Service Central Training Establishment. It was still managed to a 
certain extent by the RAF. The site became the responsibility of the Army in 2007 when all 3 
Services’ (RAF, Army and Navy) Fire & Rescue capability was transferred to Army.   

 
 
 
 
 
 
 
 The  MOD  is  also  a  member  of  the  National  Suicide  Prevention  Alliance,  a 
coalition  of  public,  private,  voluntary  and  community  organisations  in  England, 
funded  jointly  by  the  UK  government  (NHS/Public  Health  England)  and  the 
Samaritans.  The Alliance’s focus is on suicide prevention, and to support those 
affected by suicide.  

Thank you for writing me about this important matter.  I hope that my response 
has demonstrated that the MOD has learned and will continue to learn lessons 
from the tragic death of Sgt Hills.  I hope too that Sgt Hills’ family will draw some 
comfort from the knowledge that your report has prompted action. 

Yours sincerely, 

THE RT HON BEN WALLACE MP