Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0546, written 14 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Oct 2024 |
|---|---|
| Reference | 2024-0546 |
| Deceased | Paul Chase |
| Coroner | Anita Bhardwaj |
| Coroner area | Liverpool and Wirral |
| Category | Suicide (from 2015) · Service Personnel 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 The Ministry of Defence Government Department 2 3 The Chief Coroner’s Office The Minister for Veterans Affairs 1 CORONER I am Anita BHARDWAJ, Area Coroner for the coroner area of Liverpool and Wirral 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 25 March 2024 I commenced an investigation into the death of Paul Anthony CHASE, also known as PAUL ANTHONY MALONE, aged 41 years. The investigation concluded at the end of the inquest on 11 October 2024. The conclusion of the inquest was that: Official Paul Anthony Chase, also known as Paul Anthony Malone, died by Suicide. Paul had a medical history of chronic post-traumatic stress disorder (PTSD) and drug abuse (cocaine). On the morning of 13 March 2024 Paul was found deceased hanging in Woolton Woods off School Lane, Liverpool, alcohol and cocaine. The post mortem examination found the medical cause of death to be: . The toxicological analysis revealed the presence of low levels of 1a Hanging During the inquest evidence was heard how the specialist mental health services for verterans was limited and there was a lack of funding for the services, with some veterans who were desperate for help having to wait 18 months. Evidence was also heard about there being little mental health, alcoholism and addiction support packages to those currently serving in the armed forces which is essentially when the PTSD starts to develop and limited mental health/alcoholism/addiction support for those having left the armed forces. 4 CIRCUMSTANCES OF THE DEATH Paul Anthony Chase, also known as Paul Anthony Malone, was a 41 year old gentleman who had a medical history of chronic post-traumatic stress disorder (PTSD) and drug abuse (cocaine). On the morning of 13 March 2024 Paul was found deceased hanging in Woolton Woods off School Lane, Liverpool, . The toxicological analysis revealed the presence of low levels of alcohol and cocaine. The post mortem examination found the cause of death to be hanging. Paul had been thought to be suffering with post-traumatic stress disorder since leaving the armed forces in 2009 but had not sought medical help until 2020. Over the last three years his mental health had deteriorated. In 2020 the social stresses he experienced resulted in his cocaine use to escalate. In December 2022 he attempted to ligature himself. Paul attended the Royal Liverpool University Hospital accident and emergency department on 22 Regulation 28 – After Inquest Document Template Updated 30/07/2021 November 2023 after recent contact with his GP and Mersey Care Crisis line due to suicidal ideations. He was then a voluntary patient at Windsor House Mental Health unit from 24 November 2023-15 December 2023. On 15 December 2023, Paul was discharged from Windsor House and placed in Tom Harrison House, a specialist addiction recovery service for armed forces veterans. This was a 12-week residential programme. On 1 January 2024 Paul tested positive for cocaine and as the Tom Harrison House had a zero tolerance to drugs and alcohol policy (clearly communicated to the residents so Paul would have been aware of this) Paul was asked to leave Tom Harrison House. Paul was given overnight accommodation on 1 January 2024 and then a 6 month support and accommodation package for him at The Block, County Rd, Walton, a veteran charity for rehabilitation for men in crisis. Paul then chose to go back home and there was no further contact. The care and treatment afforded to Paul through Mersey care and Tom Harrison House was reasonable and appropriate. It is more likely than not Paul did have PTSD on leaving the armed forces and it had remained dormant until the social stresses of life triggered the greater symptoms of PTSD. It is more likely than not Paul carried out the act of self-harm with the intention of taking his own life. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) The lack of mental health/alcoholism/addiction support, treatment and therapy provided to veterans whilst they are: Official 1. Serving within the armed forces. 2. Undergoing intensive combat training whilstserving within the armed forces. 3. When they are released from the armed forces. The availability of resources appears to be extremley limited with some ex-veterans having to wait 18 months before a place is available. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 December 06, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. 2. Mersey Care NHS Foundation Trust 3. Tom Harrison House (specialist addiction recovery service) (wife) I have also sent it to: 1. (Cabinet Office) Regulation 28 – After Inquest Document Template Updated 30/07/2021 2. (Ministry of Defence) who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 15/10/2024 Anita BHARDWAJ Area Coroner for Liverpool and Wirral Official Regulation 28 – After Inquest Document Template Updated 30/07/2021
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
MINISTER FOR VETERANS AND PEOPLE
MINISTRY OF DEFENCE
FLOOR 5, ZONE B, MAIN BUILDING
WHITEHALL LONDON SW1A 2HB
Telephone 020 7218 9000 (Switchboard)
14 January 2025
Dear Ms Bhardwaj,
Ref: your PDFR dated 15 October 2024
Thank you for your letter of 15 October 2024 to the Ministry of Defence enclosing your
Regulation 28 report following the sad death of Mr Paul Anthony Chase (Malone) on
13 March 2024. My deepest sympathies go out to Mr Chase’s wife, daughter and his
friends and family at this difficult time.
Addressing the complex mental health needs of both serving personnel and veterans is a
priority for the Ministry of Defence. While I am very receptive to the concerns that you
have raised, and welcome the challenge to do more, it is unfortunate that the MOD was
not considered an Interested Person at the inquest. This meant that we were unable to
provide you with important information around Mr Chase’s service and medical history,
and the support he had already received from the Ministry of Defence. Going forward, I
respectfully request that you engage the Ministry of Defence much earlier in the inquest
process where an individual’s service history may be of relevance to your investigation.
Nevertheless, I would highlight that Defence has been working hard to provide prompt,
effective support for mental health issues, including addiction issues, amongst our service
population and veterans for several years now. I also understand from the Defence
Medical Services that Mr Chase received treatment from the MOD Department of
Community Mental Health for his addiction issues before being discharged, and there is
no suggestion within the records available, that Mr Chase was experiencing symptoms of
Post-Traumatic Stress Disorder (PTSD) during his service.
HM Coroner Ms Bhardwaj
Area Coroner for Liverpool and Wirral
Gerard Majella Courthouse
Boundary Street
Liverpool
L5 2QD
OFFICIAL-SENSITIVE - PERSONAL
OFFICIAL-SENSITIVE - PERSONAL
That is not to say that we shouldn’t do more, particularly where issues arise after service.
Separately, it is paramount that serving personnel, veterans, and their families engage
with the services we offer, to ensure that they can get the support they so rightfully
deserve. I am conscious that you won’t be sighted on everything we do, and therefore I
have enclosed a summary to try and give you a better understanding.
I hope that this highlights the steps that the Ministry of Defence has already taken, and
under this Government’s leadership will continue to take, to support the mental health and
wellbeing of our people. I can assure you that this will be a priority for my tenure as
Minister for Veterans and People, particularly where there are opportunities to improve.
Thank you for bringing this to my attention.
Yours sincerely,
Annex A: Summary of mental health, alcoholism, addiction support, treatment and
therapy provided to serving personnel, including those undergoing “intensive combat
training” and veterans.
OFFICIAL-SENSITIVE - PERSONAL
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