PAUL MATTHEW GILLAM · Prevention of Future Deaths report

On 14th June 2018 Cornwall Coroners commenced an investigation into the death of 47 year old Paul Matthew GILLAM. The investigation concluded at the end of the inquest on 8th February 2019.

The four questions - who, when, where and how – were answered as follows ...

Paul Matthew GILLAM died on 3rd June 2018 at flat 8, 34 Downs View, BUDE, from the toxic effect of a reckless overdose of non-prescription drugs.

My conclusion as to the death is that it was a Drug Related Death.

The medical cause of death was established on the evidence as

1a (namely the condition directly leading to death) - Synergistic toxic effects of several central nervous system depressants.

The pathologist noted that the toxicology ‘... results show the presence of morphine and methadone at potentially toxic levels... Diazepam, gabapentin and sertraline were detected at therapeutic levels. CNS depressant drugs may act synergistically to enhance their toxic effects on the cardiorespiratory system...’

Paul was found dead in his bed at his home address on 5th June 2018 by friends.

Paul had a previous medical history of asthma, emphysema, depression, anxiety, chronic obstructive pulmonary disease (COPD), drug and alcohol abuse, including a history of heroin abuse.

████████ was the last person to see Paul alive, on 3rd June 2018. Paul had spent the afternoon drinking in the gardens at Paul’s home address. Paul had arrived at 1400 hours – already under the influence of drugs or drink, and was seen to consume vodka and take six pills, of unknown composition. At around 1930 hours ███████ helped Paul back to his room, at this time Paul was having difficulties walking; ███d assumed this was due to Paul’s COPD.

Paul was not seen alive again after the party on Sunday 3rd June and was found deceased wearing the same clothing on Sunday, when he was last seen.

There was no evidence of any intent to end his own life or of any third party involvement. Due to Paul’s lifestyle and his poor health, a combination of an overdose of drugs and his already weakened respiratory system, likely lead to him dying whilst asleep on 3rd June 2018.

Paul had been under the care of Addaction, drug and alcohol treatment team since his arrival in Cornwall in 2012. There had been a number of referrals to the community mental health team (CMHT).

The evidence indicated that the concerns for Paul’s mental health were ongoing throughout treatment. Paul continued to experience episodes of paranoia, low mood and anxiety until his death.

The evidence revealed issues in communication between Addaction and CMHT.

It was unclear to Addaction why Paul's initial support was ended or why Addaction did not receive further feedback from the further referral in July 2017, other than being advised in August 2017 that Paul was awaiting allocation of a CPN. Addaction were not aware of the repeated failures by Paul to attend appointments with CMHT or the recommendations made by CMHT for Paul to engage in voluntary work. Addaction gave evidence that if they had known of the non-attendance record that steps would have been taken to ensure Paul’s attendance. Addaction were aware that non-attendance at CMHT may lead to discharge.

The evidence suggested that Addaction were unaware of the full extent of the work undertaken by CMHT or of Paul’s subsequent lack of engagement with CMHT.

The court heard that the appropriate policies and service level agreement (SLA) had been developed but that the issue lay with communication between Addaction and CMHT, and the implementation of the policies and the delivery plan concerning the relationship between Addaction and CMHT. The court heard the working relationship between Addaction and CMHT could be improved.

The court did not seek to resolve the issues between CMHT and Addaction. The reasons for the communication breakdown were not directly relevant to the statutory questions that had to be answered by the court. Nevertheless, the issue of the communication breakdown is relevant to the concern of the court to prevent future deaths. There was no requirement to pursue an enquiry in order to seek to unravel the reasons for the breakdown and attribute blame. That is not the role of the Coroners Court, and in addition such an enquiry was not necessary to fulfil the obligations of the Coroners Court.

(1) The operation of the Cornwall dual diagnosis policy and the interface between Addaction and CMHT.

(2) The development and implementation of the delivery plan in relation to the existing service level agreement between CMHT and Addaction.

(3) The working relationship between CMHT and Addaction.