Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0061, written 7 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Feb 2024 |
|---|---|
| Reference | 2024-0061 |
| Deceased | James Day |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Service Personnel related deaths · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Ministry of Defence 1 CORONER I am Alison Mutch, Senior Coroner, for the coroner area of South Manchester 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On 9th May 2023 I commenced an investigation into the death of James Colin Day. The investigation concluded on the 26th October 2023 and the conclusion was one of Narrative: Died from health complications arising from use of alcohol and medication to try to deal with the complications of severe post-traumatic stress disorder caused by his service in the army. The medical cause of death was 1a) Acute Left Ventricular Failure; 1b) Left ventricular hypertrophy on background of alcohol-related liver disease with superimposed combined drug toxicity; II) Post-traumatic stress disorder 4 CIRCUMSTANCES OF THE DEATH James Colin Day served his country. As a consequence of his deployment in Afghanistan he developed severe post-traumatic stress disorder. He was discharged from the army having received little support to help him deal with his post-traumatic stress disorder. He used alcohol to excess and prescribed medication to try and deal with his post- traumatic stress disorder. On 6th May 2023 he collapsed on Malvern Road, Old Trafford. Attempts to resuscitate him were unsuccessful. Post- mortem examination found he had developed alcohol related liver disease which had led to left ventricular hypertrophy and an acute left ventricular failure exacerbated by combined drug toxicity. 1 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – The inquest heard evidence that James Day had served his country as a member of the armed services. He had been deployed to Afghanistan as part of his service where he had witnessed traumatic events that had led to him developing post-traumatic stress disorder. He needed support to help him deal with the trauma. However that had not been provided in such a way whilst he was serving to allow him to deal with his PTSD. He had subsequently left the army and had continued to struggle to cope with his PTSD. He used alcohol and prescribed medication to try and cope with the severe symptoms of his PTSD. The inquest heard that support for service personnel with severe PTSD such as Mr Day whilst they were still serving and following discharge was patchy, difficult to access and did not appear to recognise how significant the impact of events they had witnessed whist serving could be on their mental health. The inquest heard that better mental health support whilst serving and following discharge may have avoided Mr Day having to turn to self- medication to try and have respite from his PTSD symptoms. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 3rd April 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 2 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following on behalf of the Family, who Interested Persons namely may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Alison Mutch HM Senior Coroner 07.02.2024 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
OFFICIAL SENSITIVE PERSONAL MINISTRY OF DEFENCE FLOOR 5, ZONE B, MAIN BUILDING WHITEHALL LONDON SW1A 2HB Telephone 020 7218 9000 (Switchboard) MINISTER FOR VETERANS AND PEOPLE 4.7.1. 23 January 2025 Dear Ms Mutch, I have recently been made aware of the Regulation 28 Report regarding the former Sergeant James Colin Day that you sent to the then Defence Secretary, Grant Shapps on 7 February 2024. First and foremost, and most importantly, my thoughts and sympathy go out to Mr Day’s family. Every person lost early is a tragedy, and their loss is felt across the whole Armed Forces and Veterans community. I would like to acknowledge that your Regulation 28 Report was received under a previous government, who I would have expected to respond. I personally take my responsibility to support members of our Armed Forces community very seriously and recognise that the delay in responding is unhelpful. In the specific case of Mr Day, I am concerned that the Ministry of Defence (MOD) were not considered an Interested Person at the inquest. This means your Regulation 28 Report may be based on an incomplete understanding of Mr Day’s medical history and the support that was provided to him by the MOD. I have asked the Head of the Defence Inquests Unit (DIU) to provide you separately with the details of the support Mr Day did receive. The wellbeing of our Service community is of paramount importance and there are already a range of measures in place to support those with mental health issues. Between June 2018, when Mr Day first presented with mental health symptoms, to when he was medically discharged in October 2020, Mr Day received significant and consistent medical input from the Defence Medical Services (DMS), including mental healthcare, occupational health, and primary medical care. While I am aware a diagnosis of PTSD was made when Mr Day was an inpatient at a civilian hospital in Germany, it is important to note that the DMS could not confirm this diagnosis. I understand that the primary focus for the DMS was to address Mr Day’s alcohol HM Coroner Ms Alison Mutch OBE Senior Coroner for Manchester South 1 Mount Tabor Street Stockport SK1 3AG Email: OFFICIAL SENSITIVE PERSONAL OFFICIAL SENSITIVE PERSONAL dependency which was an essential requirement before clinicians could seek to make any assessment of PTSD. Following Mr Day’s discharge from the Army in late 2020, continuity of care was provided by the Defence Transition Services and Veterans Welfare Services, together with the NHS. Considering this, and the suite of mental health services that do exist for the Armed Forces community, I do not feel there is an immediate need to change MOD policies in response to your Regulation 28 Report. However, that is not to assume everything is perfect, and I am committed to improving the overall level of support given to both Service Personnel and Veterans. I can assure you, and Mr Day’s family, that if there are any significant improvements that can be identified, steps will be taken to implement them. Despite my conclusion, I thank you for raising these important questions. This type of challenge is essential to ensure that this government provides the support our Armed Forces need. As ever, my thoughts remain with Mr Day’s family and all his friends and colleagues who continue to feel his loss so acutely. Yours sincerely, OFFICIAL SENSITIVE PERSONAL
See every Prevention of Future Deaths report matching Service Personnel related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.