PAUL HILLS · Prevention of Future Deaths report

On 5th May 2020 an investigation was commenced into the death of PAUL HILLS. The investigation concluded at the end of the inquest on 30th October 2020. The conclusion of the inquest was Suicide due to Suspension by the neck

Paul was found deceased at home in his garage on 24th April 2020. He had tied a red rope around his neck and suspended himself from the rafter and placed electrical items around the space to make access difficult. He has over 20 years in the armed forces with two tours of duty and was diagnosed with post-traumatic stress disorder and was receiving treatment. He reported two episodes of self-strangulation on 28th February 2020 and 16th April. He had reported dry run attempts to harm himself.

Sgt Paul Hills was an Royal Air Force Firefighter Trainer, had served over 20 years and had completed two tours of duty in Afghanistan. He experienced mental health problems and was diagnosed with post-traumatic stress disorder and received treatment from DCMH Woolwich a three hour round trip from his home. His treatment continued during the COVID-19 pandemic.

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.

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.

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.

4. His risk assessment was not up-to-date and his disclosures during April were not documented.

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.

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.