Paul Chase: Prevention of Future Deaths Report
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Date of report: 14/10/2024
Ref: 2024-0546
Deceased name: Paul Chase
Coroners name: Anita Bhardwaj
Coroners Area: Liverpool and Wirral
Category: Suicide (from 2015) | Service Personnel related deaths
This report is being sent to: Ministry of Defence
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. The Ministry of Defence Government Department 2. [REDACTED], The Minister for Veterans Affairs 3. The Chief Coroner’s Office | |
| 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: 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, using [REDACTED]. The toxicological analysis revealed the presence of low levels of alcohol and cocaine. The post mortem examination found the medical cause of death to be: 1a Hanging During the inquest evidence was heard how the specialist mental health services for veterans 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 support 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, using [REDACTED]. 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 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: 1. Serving within the armed forces. 2. Undergoing intensive combat training whilst serving within the armed forces. 3. When they are released from the armed forces. The availability of resources appears to be extremely 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. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. [REDACTED] (wife) 2. Mersey Care NHS Foundation Trust 3. Tom Harrison House (specialist addiction recovery service) I have also sent it to: 1. [REDACTED] (Cabinet Office) 2. [REDACTED] (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: 14/10/2024 Anita BHARDWAJ Area Coroner for Liverpool and Wirral |