Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0335, written 24 Jul 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Jul 2017 |
|---|---|
| Reference | 2017-0335 |
| Deceased | Ben Jukes |
| Coroner | Nick Stanage |
| Coroner area | Manchester City |
| Category | Service Personnel related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: e Ministry of Defence: Sir Michael Fallon MP, Secretary of State for Defence, and General Sir Nicholas Patrick Carter, Chief of the General Staff. Copied for interest to: e Chief Coroner e Family of the deceased CORONER | am Nick Stanage, H.M. Assistant Coroner for the area of Manchester City. CORONER’S LEGAL POWERS ! 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. INQUEST On Wednesday 19 July 2017 | concluded the inquest into the death of Ben Alan Jukes, an army captain serving in the Royal Corps of Signals. | attach the Record of the Inquest and Captain Dukes' service history. CIRCUMSTANCES OF THE DEATH During the hearing | heard evidence inter alia from the sister of th d, HE 2" 2 close friend of the deceased, The law requires that | write this report because the evidence given by both these witnesses gives rise to a concern that circumstances creating a risk of other deaths will continue to exist and action should be taken to prevent the recurrence of such circumstances. CORONER’S CONCERNS 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: stated under oath that she had been aware that the deceased regularly used heroin and cocaine during the five years prior to his death when he should at ail material times have been subject to the army's random drug- testing regi Captain Jukes on one occasion attended a meeting of Narcotics Anonymous. Captain Jukes obtained heroin by persuading the homeless in Manchester City centre to take him to known heroin suppliers. As payment for such assistance Captain Jukes then supplied to the homeless a portion of the heroin which they had enabled him to obtain. wondered how the deceased's drug use had not been detected by random testing. From that evidence the following concerns arise: 1. Whatever drug-testing regime may have been operated by the army during the five year period failed to detect Captain Jukes’ regular use of heroin and cocaine. More regular testing by the army in that period would have increased the likelihood of detection. 2. Captain Jukes’ supply of heroin to homeless drug users in Manchester City centre exacerbated an already high risk of death among that group. More regular testing by the army in that period would have increased the likelihood of detection. Evidence of BEE: 2s<i0-0 the deceased as one of his best friends. He had shared a jouse in Leeds with the deceased and had gone out socialising with him on hundreds of occasions. He knew Captain Jukes well and, in evidence which | accept as truthful and accurate, said that in the three or four years prior to death he became aware that the deceased was "an extreme recreational user" of drugs. ie «=<: on oath that Captain Jukes on one occasion about one or one and a half years ago confided that he had been warned in advance that he was to be drug-tested by the army. PE «2103 that Captain Jukes knew that he had very recently taken illicit rugs which would be detected. Captain Jukes therefore feigned an injury, deliberately banging his head so as to contrive a need for a medical appointment on the following day. Captain Jukes was thus able to evade the army drug test on the following day. From that evidence the following concerns arise: 3. It appears that on at least one occasion as set out above Captain Jukes was forewarned of a drug test. 4. Thus forewarned, Captain Jukes was easily able to evade the drug test which would as a near certainty have exposed him as a user of heroin and cocaine. 5. Unless drug testing is random and unannounced it will fail to detect illicit drug use among servicemen and women. Failure to detect illicit drug use increases the likelihood of further deaths as a result of the same. The above evidence and concerns lead me to suggest that you should review your procedures on drug-testing. ACTION SHOULD BE TAKEN tn my opinion action should be taken to prevent future deaths and t believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20 September 2017. 1, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to tnterested Persons. | have also sent it to organisations who may find it useful or of interest. | 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 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. DATE Nick Stanage PA Svby DOF ide Sean Sramrage
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
SECRETARY OF STATE oi MINISTRY OF DEFENCE oie FLOOR 5, ZONE D, MAIN BUILDING WHITEHALL LONDON SW1A 2HB Ministry Telephone: 020 721 82111/2/3 of Defence Fax: 020 721 87140 E-mail: defencesecretary-group @mod.uk Msn 4[2]2Iy 30 September 2017 Dear Mr Stanage, Thank you for your letter dated 24 July 2017 which enclosed a Regulation 28: Prevention of Future Deaths report following the death of Captain Ben Jukes in December 2016. | hope the attached information allays your concerns regarding the Army's Compulsory Drugs Testing (CDT) policies. The Values and Standards expected of individuals serving in the British Army and Armed Forces as a whole are quite unequivocal in that drug misuse is not only illegal; it poses a significant threat to operational effectiveness. The Armed Forces are clear that drug misusers are a liability to themselves and to the wider Service community and will not be tolerated, Dine a fh Mt oF at THE RT HON SIR MICHAEL FALLON KCB CORONER’S CONCERNS 1. “Whatever drug-testing regime may have been operated by the army during the five year period failed to detect Captain Jukes’ regular use of heroin and cocaine. More regular testing by the army in that period would have increased the likelihood of detection. 2. Captain Jukes’ supply of heroin to homeless drug users in Manchester City centre exacerbated an already high risk of death among that group. More regular testing by the army in that period would have increased the likelihood of detection. 3. It appears that on at least one occasion (as set out above) Captain Jukes was forewarned of a drug test. 4. Thus forewarned, Captain Jukes was easily able to evade the drug test which would as near certainty have exposed him as a user of heroin and cocaine. 5. Unless drug testing is random and unannounced it will fail to detect illicit drug use among servicemen and women. Failure to detect illicit drug use increases the likelihood of further deaths as a result of the same”. Captain Jukes — background Capt Jukes was assigned to ISS Corsham on 5 September 2016 where he was initially employed as SO3 Army in the Customer Services area of the Service Operations Directorate. At the time of his death Capt Jukes was detached to a specialist project team, the Non Standard Service Requests (NSSR) team, within ISS Corsham. On 8 December 2016 Capt Jukes was found dead in his permanent home address, a flat in Manchester, by his girlfriend. Capt Jukes was a weekly commuter to Corsham and lived in the Corsham Mess during the week. At the time of his death Capt Jukes was employed as an !T project manager in the NSSR team working on a number of small, complex projects which involved the managing of requests that had gone to single Managed Service Providers (e.g. Atlas, Fujitsu etc). The detachment to the NSSR team followed Capt Jukes’ application to Notice To Terminate / Premature Voluntary Release and was agreed with his resettlement plan / successful transition from the Service to Civilian life in mind and seen as assisting with an aspiration he had already expressed to go into project management on leaving the Service. The detachment had had a tangible effect for the team and had proved to be extremely useful for the understanding of, visibility of, chasing down of single tower NSSRs, benefiting both the NSSR team (ISSR) and more importantly the customer. It was proving to be an excellent detachment for both Capt Jukes and the NSSR team. Unfortunately, it is now known that Capt Jukes was a regular drug user who had successfully managed to conceal his drug taking from the Army during his short service career. At what point his habit began is unclear, but it is known that some civilian friends and family members had been aware of his drug taking for some years prior to his death. From the Army’s investigations, there is no known evidence of his misuse of drugs impacting upon his work, nor were there any indications to his work colleagues, his military friends or to the chain of command that he was misusing drugs. Army Drugs Misuse Strategy The Values and Standards expected of individuals serving in the British Army are quite unequivocal in that drug misuse is not only illegal; it poses a significant threat to operational effectiveness. The Army is quite clear that drug misusers are a liability to themselves and to the wider Service community: their judgement is impaired; their health damaged; and their performance degraded. In short they can be neither trusted nor relied upon. The Army’s policy for those who commit a drug offence is based on dismissal. The Army's drug misuse strategy was revised in November 2016. It is based on three pillars: prevention through education, deterrence through testing, and regulation. Education begins from initial entry into military service, whether it be as an officer or a soldier. It is made quite clear through education to all Service Personnel that the misuse of controlled drugs is incompatible with military service. It is also made clear during this education that Service Personnel have a personal responsibility to adhere to these values and standards Compulsory Drugs Testing Compulsory Drugs Testing (CDT) delivers the deterrence strand of the Army’s drugs misuse strategy. The Army’s annual target for CDT testing is 87,500 tests and, in 2016, over 93,000 tests were conducted. Given the Army’s strength of circa 82,000, this allows sufficient testing to enable ail members of the Army to be tested annually. Indeed, the Army’s drug misuse strategy directs that all Regular and Reserve units be tested annually. It is, however, acknowledged that this does not guarantee that all personnel will be tested annually as an individual may be detached from their unit at the time it is visited for testing or, as with Capt Jukes in 2016, may be posted from one unit to another mid-year and may miss the testing at both units. It is further acknowledged that CDT can only act as a deterrent — it cannot detect misuse at a time after the traces of misuse have left the body and are no longer detectable. It is therefore impracticable for the Army to test each soldier and officer frequently enough to ensure that all drugs misuse is always detected. Nonetheless, the combined effect of education and deterrence are assessed to have effect. The 2015/16 Crime Survey of England and Wales reports drug misuse across society to be at 8.4% or 1 in 12. While any misuse in the Army is unacceptable and strenuous efforts to reduce it continue, the level of misuse in the Army is reported at 0.7 — 0.9%. In relation to Capt Jukes, he was tested as a result of random CDT visits to his unit on more than one occasion in 2015 and was tested most recently in September 2015. On each occasion, his tests produced a negative result. Conduct of a Test CDT visits are scheduled by the CDT team with unit notification usually made with as little as 24 hours’ notice. This period of notice will only be varied in exceptional circumstances, such as when security clearances for Northern Ireland are required or where there is a specific intelligence led need. The initial notification of the visit will be made through the Adjutant, who is expected to notify the Commanding Officer. Prior notification is necessary to enable this core element of the unit command structure to plan the support required from the unit to facilitate the testing and to make contingencies for the disruption of unit activity that will occur as a result of testing. It will also enable the Adjutant to make an assessment of the number of personnel expected to be in barracks and thus available for testing at the time of the scheduled CDT visit. In doing so, the Commanding Officer and his immediate team will manage the information with the utmost discretion to avoid pre- warning anyone not required to know in advance. In future, the need for absolute discretion will be reiterated to units as part of their initial notification. On the day, at the point at which the CDT is declared, individuals are paraded within the unit and are randomly selected for testing by the CDT officer using a nominal roll provided by the unit. How many are selected will depend on the CDT team’s plan for the particular visit. On some visits, the CDT team will seek to test the whole unit. On others, the team may seek to test only a proportion of the unit (eg 50 or 100 personnel). In the latter case, some and possibly a considerable number of unit personnel will not be tested during a CDT visit. However, this flexibility allows the CDT team to maximise the deterrent effect of testing by balancing how many they test in each visit with how often they visit. Relevant to Capt Jukes’ case, the Armed Forces Act 2006 places a number of restrictions on CDT collections. Of these, one relates to the testing of an individual under medical care. Specifically, an individual in the Medical Centre as a patient cannot be tested without the express permission of the attending medical practitioner and the CDT officer cannot ask the individual to provide a sample for testing. Following the evidence iim! an investigation has been undertaken to identify how Capt Jukes gained advance notice of a CDT. No corroborating evidence has been found that he was forewarned and thus how this might have occurred. Nonetheless, the evidence provided describes him receiving prior notice. This should not have happened given the protocols in place. He was not a member of the Commanding Officer’s immediate command team and would not have been informed as part of the prior notification or pre-planning conducted by the unit. As indicated above, in future, the need for absolute discretion will be reiterated to units as part of their initial notification. Finally, the Armed Forces Act does not limit the number of CDT visits that can be made to a unit for testing each year. Nor is there a constraint on how soon after a visit, a return visit can occur - indeed it is not uncommon for the same unit to be visited on consecutive days. Every effort is therefore taken to make testing unexpected and to maximise the deterrent effect arising from it. As such, every effort is taken to minimise the chance that a test can be either predicted or, once declared and an individual is then selected for testing, that it can be avoided.
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