Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0057, written 31 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Jan 2025 |
|---|---|
| Reference | 2025-0057 |
| Deceased | Aeran Taylor |
| Coroner | Joseph Turner |
| Coroner area | West Sussex, Brighton and Hove |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: , Minister for Veterans and People, Ministry of Defence 1 CORONER I am Joseph TURNER, Area Coroner for the coroner area of West Sussex, Brighton and Hove 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 01 November 2023 I commenced an investigation into the death of Aeran Luke Sebastian TAYLOR aged 38. The investigation concluded at the end of the inquest on 22 January 2025. The conclusion of the inquest was that: On 27 October 2023 Aeran Taylor was sadly found deceased at his home address in Crawley. There was evidence of drug use but nothing to indicate intent, or the involvement of a 3rd party. Post mortem analysis showed the presence of multiple substances combined to fatal toxic effect, likely as a result of an accidental overdose. 4 CIRCUMSTANCES OF THE DEATH Mr Taylor had rapidly fallen into drug addiction, having been discharged from the Army for substance misuse in December 2006, following an operational tour to Iraq (Op Telic 7 – Nov 2005-May 2006) with the Royal Regiment of Fusiliers. He was subsequently diagnosed with PTSD arising from combat operations. Despite the payment of compensation by MoD, and prior engagement with and help from Combat Stress, as well as with and from local GP, Housing, and Adult Addiction services in West Sussex at the time of his death, he had relapsed into addiction and had not fully recovered from PTSD. He was under probation at the time of his death. His death resulted from an accidental overdose of primarily illicit drugs. 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: - - When found to have taken illicit drugs months after completing an operational tour, there appears to have been no inquiry or check as to possible correlation with potential PTSD or other reasons for the behaviour, such as a lack of effective post- tour decompression. There appears to have been no formal, clinical assessment of mental health at point of discharge, which may have identified the emergence of PTSD. I understand this may now be routine, or more prevalent, but there remains a community of veterans at risk for whom no such assessment may have been in place. I heard evidence of a lack of awareness of regimental welfare staff and the role such organisations can play in supporting veterans. Again, those now serving may be more aware but there appears to be a community of veterans at risk who may - Regulation 28 – After Inquest Template Updated 15/10//2024 TG - remain unaware, including as to how such organisations fit and work within the overall veteran support landscape. Despite the introduction of Op Courage and sharing of information between - and recognised efforts by - MoD, NHS and organisations such as Combat Stress to treat individuals, there appears to remain a lack of readily available, fully funded, long term rehabilitation and substance abuse recovery for veterans with PTSD at risk, notably for those only diagnosed well after leaving the Armed Forces, and/or who are ‘long term cases’ for whom treatment has not succeeded and/or who have relapsed after and despite such interventions. 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 March 28, 2025. 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 (mother) and (sister) I have also sent it to The Chief Executive, Combat Stress 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: 31/01/2025 Joseph TURNER Area Coroner for West Sussex, Brighton and Hove Regulation 28 – After Inquest Template Updated 15/10//2024 TG Regulation 28 – After Inquest Template Updated 15/10//2024 TG
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 28 April 2025 Dear Mr Turner, Thank you for your letter of 31 January 2025 to the Ministry of Defence (MOD) enclosing your Regulation 28 Report following the sad death of Mr Aeran Taylor on 27 October 2023. My deepest sympathies go out to all those affected by Mr Taylor’s death. Your report raised four concerns, surrounding assessments made following drug misuse in service, and the availability and awareness of support for veterans. I am grateful to you for bringing these matters to my attention. In considering my response, I have reviewed Mr Taylor’s service records and consulted with The Royal Regiment of Fusiliers (RRF), the MOD’s Veteran Welfare Service (VWS) and Office for Veterans’ Affairs (OVA). It is evident from Mr Taylor’s service records that checks were made as part of the discharge process to establish any mitigating factors which may have led to his drug use. Mr Taylor was interviewed following a positive compulsory drug test and his mental health was reviewed by the Medical Officer as part of his release medical. No significant concerns were noted on the contemporaneous record to indicate a possible correlation with potential PTSD, or other reasons for the behaviour. As you highlight, clinical mental health assessments are routine and since 2012, all personnel at discharge medicals or boards potentially leading to discharge undergo a Structured Mental Health Assessment (SMHA). If a SMHA indicates a need for a referral to the Department of Community Mental Health (DCMH), this is promptly arranged and support can last up to 6 months post-service, ensuring continuity of care. The delivery of support for veterans, including long term treatment, is a multi-agency effort. On discharge, the MOD makes every effort to ensure individuals are appropriately transitioned into civilian life and that aftercare is in place should this be required. Support HM Coroner Mr Joseph Turner Area Coroner for West Sussex, Brighton & Hove Email: OFFICIAL SENSITIVE PERSONAL OFFICIAL SENSITIVE PERSONAL is provided throughout and following transition, by the Defence Transition Services (DTS) and VWS. Access to VWS is available at any time for veterans, recognising that some life challenges do not become apparent until post-transition, such as addiction or issues concerning mental health. Indeed, I understand Mr Taylor was in contact with and received support from VWS between 2013 and 2018. In terms of healthcare following transition, this is delivered by statutory health services in collaboration with the third sector. The MOD continues to support veterans through the OVA, which works to improve coordination of veterans’ issues across Government. I recognise that we need to ensure our veterans, past, present, and future are aware of the support available to them as this provision develops. The OVA has a support directory on gov.uk to ensure this information is readily available and accessible to our veterans. The OVA are also exploring options to better coordinate and cohere the support for veterans. This includes those with the most complex needs, across central, devolved and local government, and the third sector. The focus is to improve data and insights, governance and accountability in an institutionally resilient way, and how we work more closely with local service providers including local authorities. Raising awareness of the support available will include the promotion of regimental welfare associations, whom I agree have an important role to play. While membership is voluntary, each Regimental or Corps Headquarters in the Army has an Association or equivalent for its serving personnel and veterans. In Mr Taylor’s regiment, the RRF, everyone who has served is entitled to be a member and receive support from the Regimental Charity, The Fusiliers Aid Society (FAS), who I understand did provide Mr Taylor with support. I know that the RRF ensure that all Fusiliers are briefed on joining and discharge on the support available to them. However, I accept that does not mean support and awareness is universal, but I would highlight that Regimental and Corps Headquarters are working to increase awareness of their Associations to current and former personnel. I will ensure that this continues. I hope my response is clear and reassures you that there are sufficient processes in place to identify any possible correlations between an individual’s service and a behaviour. Ensuring veterans can access the support available to them is a priority for me, and this Government. We will continue to work hard to raise awareness of the support available to our Armed Forces community to ensure it does not go unnoticed by those who most need it. OFFICIAL SENSITIVE PERSONAL OFFICIAL SENSITIVE PERSONAL Thank you for writing to me regarding these matters. Your challenge is imperative to ensure that the MOD learns from these tragic events and continues to provide the best support to our Armed Forces personnel. My thoughts remain with Mr Taylor’s family and all those affected by his very sad death. Yours sincerely, OFFICIAL SENSITIVE PERSONAL
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