19 Nov 2020 PAUL HILLS · Prevention of Future Deaths report North East Kent
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Concerns raised 9 Failure to update mental health care plans View source Absence of an urgent assessment and review pathway for deteriorating mental health View source Insufficient local availability of mental health treatment View source Failure to update risk assessments when risk scores or behaviour change View source Failure of communication and sharing of relevant information between treatment services View source Failure to provide effective safety advice addressing imminent dangerous driving thoughts View source Failure to share relevant mental health risk information with family members View source Lack of risk assessment for virtual mental health appointments during service changes View source Failure to document disclosures relevant to mental health risk View source See 6 more concerns
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AI-generated summary
PAUL HILLS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Hills was found deceased at home in his garage on 24 April 2020 after suspending himself from a rafter. He had a history of post-traumatic stress disorder, reported episodes and dry runs of self-harm, and was receiving treatment. Concerns included inadequate risk assessment and care-plan updates, failure to document or share escalating risk information, insufficient planning for remote treatment during the COVID-19 pandemic, and limitations affecting local treatment and communication.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Community Mental Health, Woolwich Station Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to update mental health care plans
Wider context from the report “2. Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Community Mental Health, Woolwich Station Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Absence of an urgent assessment and review pathway for deteriorating mental health
Wider context from the report “1. No risk assessment was completed on the issue of moving mental health appointments to virtual during the COVID-19 pandemic and how patients could be kept safe in the event of deterioration in his mental health. There was no plan in place for patients that required urgent assessment/review due to deterioration in their mental health.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Community Mental Health, Woolwich Station Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Insufficient local availability of mental health treatment
Wider context from the report “6. Evidence was heard during the inquest that RAF Manston was being decommissioned and this impacted on the treatment available locally for Sgt Hills and impacted on communications with the DCMH and the sharing of relevant information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Community Mental Health, Woolwich Station Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to update risk assessments when risk scores or behaviour change
Wider context from the report “2. Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Community Mental Health, Woolwich Station Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure of communication and sharing of relevant information between treatment services
Wider context from the report “6. Evidence was heard during the inquest that RAF Manston was being decommissioned and this impacted on the treatment available locally for Sgt Hills and impacted on communications with the DCMH and the sharing of relevant information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Community Mental Health, Woolwich Station Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective safety advice addressing imminent dangerous driving thoughts
Wider context from the report “5. Sgt Hills was advised not to drive with his wife and children in the car when he disclosed strong thoughts to drive head long into oncoming traffic. This advice would not have protected Sgt Hills or other road users.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Community Mental Health, Woolwich Station Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant mental health risk information with family members
Wider context from the report “3. Risk issues were not shared with the family even though Sgt Hills was in lockdown with them and there were no discussions regarding sharing of information . He disclosed his dry runs of self-strangulation on 28th February and 16th April and his withdrawal/isolation from his family who had been very supportive of him. On 22nd April he disclosed he was looking for a rafter to harm himself from and there was an overreliance on his family as a protective factor in the absence of this knowledge being shared with them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Community Mental Health, Woolwich Station Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment for virtual mental health appointments during service changes
Wider context from the report “1. No risk assessment was completed on the issue of moving mental health appointments to virtual during the COVID-19 pandemic and how patients could be kept safe in the event of deterioration in his mental health. There was no plan in place for patients that required urgent assessment/review due to deterioration in their mental health.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Community Mental Health, Woolwich Station Medical Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to document disclosures relevant to mental health risk
Wider context from the report “4. His risk assessment was not up-to-date and his disclosures during April were not documented .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations