Paul Dow: Prevention of future deaths report

Suicide (from 2015)

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Date of report: 10/04/2024

Ref: 2024-0192

Deceased name: Paul Dow

Coroner name: Matthew Cox

Coroner Area: Manchester North

Category: Suicide (from 2015)

This report is being sent to: Ambulance Service | Department of Health and Social Care

North West Ambulance Service ( NWAS)
Secretary of State for Health and Social Care
I am Matthew Cox, Assistant Coroner for the Coroner area of Manchester North
I make this report under paragraph 7, Schedule  5, of the Coroner’s  and  Justice Act  2009 and Regulations 28 and 29 of the Coroners investigations Regulations 2013
On the 5th June 2023, I commenced an investigation into the death of Paul Dow, date of birth 25th August 1957 who died on the 3 April 2023 at the Royal Oldham Hospital The medical cause of his death was confirmed as
1a) Combined drug toxicity
2) lschaemic heart disease, Type 2 diabetes mellitus, urinary tract infection.
On 28th March 2023 Mr Dow was arrested and charged with criminal offences. On 29 March he was bailed subject to conditions not to go within 100 metres of his home address where he lived with his partner as a result of which he started staying at the Travelodge, Rochdale. Mr Dow was on his own in a room at the Travelodge when at 18.35 on 2 April 2023 he made an emergency call to the ambulance service . He made contact with a call handler employed by NWAS. He reported that he was a type 2 diabetic and said “I’ve taken a pile of tablets and I mean a pile” when asked whether this was an attempt to take his life he replied, “Well yeah, possibly.” He was asked what he had taken and he said he had taken [REDACTED]. When asked whether he had taken a lot, boxes of each he replied “yeah.” He said he felt weird. Mr Dow was told there were delays of over an hour and a half in dispatching an ambulance. The call was coded as a category 3 response defined as 9 out 10 responses within 120 minutes. A clinician from the clinical hub attempted to call Mr Dow but received no response to calls at 19.09, 19.22 and 19.25. Mr Dow called the ambulance service again at 19.38 and  spoke to the same  call handler. He  said “I’ve taken loads  of tablets  the ones I  have form   diabetes.” He was  asked again  whether  this was an attempt to take his life and said “I don’t know, could be.” This call was also coded as category 3. An ambulance arrived on scene at 20.27. Mr Dow stated to the paramedic that the overdose was intentional as he wanted to take his own life. Mr Dow was transported to hospital arriving at 21.43. Attempts to resuscitate him were unsuccessful and his death was confirmed on 3 April 2023.
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:
In my opinion action should be taken to prevent future deaths and I believe each of you respectively have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely 5 June 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.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:­ The family of Paul Dow
North West Ambulance Service
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 from. 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.
910 April 2024