Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0398, written 25 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Nov 2021 |
|---|---|
| Reference | 2021-0398 |
| Deceased | Joel Robinson |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| Category | Service Personnel related deaths · Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Classification: OFFICIAL-SENSITIVE REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief of the General Staff Army Headquarters Blenheim Building Marlborough Lines ANDOVER SP11 8HJ 1 CORONER I am Mrs Heidi J. Connor, senior coroner, for the coroner area of Berkshire. 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST I conducted an inquest into the death of Joel Robinson at Reading Town Hall between 9th and 11th November 2021. I returned a conclusion of suicide. 4 CIRCUMSTANCES OF THE DEATH The f amily asked me to refer to the deceased as Joel during the inquest. I will respect that wish in this report. Joel Robinson was born on 9th July 1994. He had no previous recorded mental health history, apart from a brief period of time in 2016 when he sought medical advice f ollowing the death of his father the previous year. He was posted to the Equestrian Centre in Paderborn in Germany in June 2017. It was not within the scope of the inquest to determine whether the allegations Joel made about his time in Germany were accurate or not. It was clear however that, at the very least, there was tension between Joel and another officer. Joel described this as bullying. He wrote a service complaint, which was shown to his Commanding Officer. The army appears to have kept no record of this letter. The only reason we have seen it is because he sent a draft of it to his mother. Joel described himself as being lonely and depressed in his letter. Inf ormal attempts to resolve the issues were not successful, and a senior officer brought f orward a trip to Germany to deal with this. One of the senior officers who gave evidence stated that he believed that the formal service complaint process had begun, but it is clear from correspondence between Joel and his mother that, after a period of time, even Joel did not expect a f ormal response, and thought it not worth proceeding with. Joel was clear that he did not wish his colleague to be the subject of disciplinary proceedings. He did not know, and his superior officers did not advise him, that that was not necessarily always the outcome of a service complaint. It was clear that the officers dealing with Joel’s complaint at the time were fully or partially unaware of the service complaint procedure. Classification: OFFICIAL-SENSITIVE 1 Classification: OFFICIAL-SENSITIVE Joel took his own life by on 25 March 2019. I did not conclude on the balance of probabilities, that this tragedy would have been avoided had his service complaint been dealt with differently. Coroners have to consider whether there is evidence of a risk of future deaths, and it is our duty to address these. We heard in evidence that the army has the highest suicide rate of the armed forces generally. We also heard evidence about studies that have been undertaken around suicide in the army and in the wider armed forces. These studies were published in July 2017 and November 2018. The impression I was left with, af ter reviewing these reports and hearing evidence in court, was that the investigations have not gone much further than acknowledging the problem. A Suicide Prevention Group has been set up, but is still in its infancy. It is due to meet again this year. I am conscious that we heard a relatively small amount of evidence about the work that is being done by the Suicide Prevention Group. It may be that they have already considered these matters, and can answer this letter in those terms. I am concerned that, although awareness of available services, such as helplines etc, is important, the approach appears on the face of it to be a passive one. By this I mean that a soldier would need to raise his or her hand to say that s/he is struggling rather than having a process which actively looks at risk factors to identify soldiers who may be vulnerable. We regularly screen for physical disease, such as cancer or heart disease, and perhaps mental health should be viewed in the same way. Some work around identifying risk f actors should be considered, with the input of mental health professionals, and consideration should be given to regular review of soldiers with these risk factors in mind. As set out in the case of R (Dr Siddiqui and Dr Paeprer-Rohricht) -v- Assistant Coroner f or East London, the issuing of a Regulation 28 Report entails no more than the coroner bringing some information regarding a public safety concern to the attention of the recipient. The report is not punitive in nature. 5 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. 2. 3. 4. Consideration should be given to having a clear timeline for the setting up of the Suicide Prevention Group, in terms of not just collecting data, but also analysing it and putting new strategies in place. I am aware that work has begun on this, but in my view, consideration should be given to doing this more quickly, and certainly within a realistic but clear timeframe. Consideration should be given to identifying key risk factors, and how (in very practical terms) that information can be used to reduce suicide risk. Consideration should be given to regular review of individual soldiers, to screen their mental as well as physical health. It may be that that would be something which would sit better outside of their chain of command. Consideration should be given to increasing awareness of how to handle service complaints within the army. Service complaints are made when, by definition, things are not going well, and this could be viewed as a risk factor. 6 ACTION SHOULD BE TAKEN Classification: OFFICIAL-SENSITIVE 2 Classification: OFFICIAL-SENSITIVE In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20 January 2022. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner, to 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 f orm. 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. 9 25 November 2021 Mrs Heidi J. Connor Senior Coroner for Berkshire Classification: OFFICIAL-SENSITIVE 3
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.
DETAILED ARMY RESPONSE TO MATTERS OF CONCERN RAISED BY HER MAJESTY’S SENIOR CORONER FOR BERKSHIRE Matter of Concern 1 – “Consideration should be given to have a clear timeline for the setting up of the Suicide Prevention Group, in terms of not just collecting data, but also analysing it and putting new strategies in place. I am aware that work has begun on this, but in my view, consideration should be given to doing this more quickly, and certainly within a realistic but clear timeframe.” 1. While it is recognised that both central-MOD and Army-specific progress around the suicide prevention has incurred delays, delivery of comprehensive and cohered suicide prevention activity across Defence is now a Priority Health Theme within the revised Defence People Health and Wellbeing Strategy. A dedicated sub-group will be established by March 2022 to examine and improve information sharing processes and the MOD will develop a Defence Suicide Prevention Plan with an initial draft to be produced by the summer. More detail into recent progress is provided below. Suicide Prevention Working Group (SPWG). The MOD-wide Service Personnel Suicide 2. Prevention Working Group (SPWG) was established in 2019 in response to the Defence Safety Authority (DSA) publication ‘Focused Review of Suicides among Armed Forces Personnel’ (November 2018).1 The review’s first recommendation was to ‘reinvigorate the Suicide Prevention Working Group to drive the implementation of suicide prevention measures and to share best practice across Defence” (Enclosure 1, Page 7). The SPWG’s primary aim is to act as the lead for coordinating suicide prevention policies across Defence and identifying and sharing best practice. The SPWG has also reviewed the recommendations in the DSA review and made evidence-based decisions whether to implement; to date 16 out of 22 have been actioned and closed. In December 2021, the Group agreed to develop a Defence Suicide Prevention Plan. This will both better cohere existing policies and interventions, and identify priority areas and actions. This will align with Public Health England policy and the cross-government Suicide Prevention Strategy for England. A roadmap will be agreed with senior leadership in February 2022, and an initial draft by the summer. Defence Suicide Register (DSR). The SPWG also recommended the creation of a Defence 3. Suicide Register (DSR). This was an Army initiative which transferred to the Chief of Defence People’s area within the MOD in August 2020. It will provide the evidence base to inform Defence Suicide Prevention Plan and ensure that any lessons identified can help prevent others from taking their own lives. In January, the Group discussed the initial draft DSR report. It has provided the baseline data and evidence, using the data gathered from the 95 deaths that occurred between 1 January 2015 and 31 December 2020, to allow the development of a plan to continuously improve support. One of the early identified deductions from the DSR is that information sharing between organisations within Defence is an area of improvement. A dedicated sub-group will be established by March to investigate current processes in more depth and explore potential solutions, with the aim of reporting by early Autumn. In January 2022, the SPWG discussed the report, examined where it can be matured and how the early deductions can be implemented, including confirmation of timelines. Army Wider Mental Health Initiatives. Specific to the tragedy of LCpl Robinson, the Army 4. has developed internal suicide prevention and postvention plans. Additionally, it has commissioned external specialist suicide bereavement counselling to support units and common employment groups identified at increased risk. In March 2019 our Optimising Physical Stress Management Resilience Training Team (OPSMART) was launched to provide specific training, education and support to all Army personnel. We also initiated an internal campaign in 2020 – ‘Ask, Intervene, Disclose’ (AID), which has been embraced by the NHS and shared with Defence. Complementary to our own training, Defence has also developed its own mandated training (the Defence Mental Fitness Brief, launched in November 2021), available to all personnel. 1 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/755366/20181112_- _DSA_Review_into_Suicide_Rates_in_Armed_Forces.pdf 1 Matter of Concern 2 – “Consideration should be given to identifying risk factors, and how (in very practical terms) that information can be used to reduce suicide risk.” 5. The Army continues to maximise the use of extant policy, training and digital tools to aid in the identification and subsequent mitigation of suicide risk factors. The overarching policy, Army General Administrative Instruction 110 (which highlights the risk factors detailed below), is subject to regular reviews to consider all lessons identified in the Service Inquiry process and through internal stocktakes. Specific training on mental health resilience and identifying risk factors is delivered through multiple mechanisms and at a regular frequency during a soldier’s career. Targeted digital communication campaigns on the topic are also linked to specific dates, such as Time to Talk day in February, Mental Health Awareness Week in May and World Suicide Prevention Day in September. We have also brought in several digital tools to aid in explaining how to identify suicide risk factors throughout the organisation. Policy. Army General Administrative Instruction (AGAI): Vulnerability Risk Management 6. (AGAI 110, at Enclosure 3) contains a comprehensive guide to suicide risk factors (summarised below) and is readily accessible to Army personnel and Defence Medical Services. All Units are also required to convene regular Unit Health Committees (as per AGAI 57, at Enclosure 4) which provide the forum for these risks to be discussed and changes to policy briefed. The following risk factors have been associated with suicidal or self-harm behaviour in the UK Armed Forces: • History of previous suicide attempts. • History of self-harm. • Family history of suicide. • Suicide Ideation. • Mental health referral or diagnosis. • Discharge from a Mental Health In-Patient Facility. • An unexpected/sudden or ‘miraculous’ apparent improvement in mental state. • Relationship problems. • A Sense of powerlessness, helplessness or hopelessness. • Loneliness. • Poor social skills including difficulty interacting with other (social and emotional isolation). • Social media. • Sexual abuse and bullying. • Current or pending disciplinary or legal action. • Investigations in relation to sex offences. • Alcohol misuse. • CDT failure. • Gambling problems/addiction. • Financial problems. • Domestic abuse. • LGBT+ issues. • Adult at risk. 7. Mental Health Training. Since LCpl Robinson’s death, a significant amount of work has gone into improving the mental health resilience and risk identification training we provide to those who serve. The OPSMART project will ensure all serving personnel will now receive Mental Resilience Training (MRT) and Mental Fitness Training (MFT) at all career stage courses through every rank, from Private to General. Additionally, we provide annual training to all personnel on mental fitness, stress management, mental resilience, help seeking and coping skills. For those in positions of authority, extra training is provided around the roles and responsibilities of leadership with reference to suicide, self-harm and the Vulnerability Risk Management process. 2 Digital Access for Service Personnel. Defence Digital Communications have recently 8. updated their communications plans to place greater emphasis upon accessibility for serving regular and reserve personnel and their support networks, including mental health apps that are available to download and focused information campaigns annually. In addition, the NHS’s Operation COURAGE launched in March 2021, and NHS Urgent Care continues to provide access to all personnel. Our mental health support for veterans, Mental Health Transition, Intervention and Liaison Services (TILS), continues to provide multiple helplines via Combat Stress, The Samaritans, CALM, Togetherall (formerly Big White Wall), All Call Signs, Shout and HOPEline UK. To ensure support to those tragically affected by suicide, we continue to maximise our service provision and links with Cruse Bereavement Care, MIND UK, SSAFA and Suicide Bereavement UK. Vulnerability Risk Management Process. As per AGAI 110, once key suicide risk factors 9. are identified in a serviceperson, a positive risk reduction strategy is delivered through the Vulnerability Risk Information System. The document also includes further guidance on potential service specific risk factors, including service complaints, and other contributory factors which may be considered. The Army also recognises the findings of the Royal Society of Psychiatrists report ‘CR229’ (at Enclosure 5) which advises that an over-focus on risk factors can be misleading and falsely reassuring. Some who attempt suicide may not demonstrate high risk warning signs and many exhibiting risk factors do not complete suicide. 10. Future work. The Army will continue to seek to enhance Mental Health capability, with the development of Force Mental Health Teams announced as part of our recent Future Soldier transformation programme. To be fully operational no later than November 2023, they will concentrate existing dispersed capability into two clinical teams that are held at readiness to support priority areas. In 2020, Commander Field Army directed the provision of Mental Health Champions across Units. In 2022, these will be reinforced by the provision of Mental Fitness Advocates at Sub-Unit level. Training delivery will be cohered ensuring access to all serving Army personnel in both single service and joint service establishments. 3 Matter of Concern 3 – “Consideration should be given to regular review of individual soldiers, to screen their mental as well as physical health. It may be that, that would be something which would sit better outside their Chain of Command.” 11. Our medical reviews remain ‘holistic’ to cover all aspects of a soldier’s well-being. The Secretary of State has directed that our processes and supporting policies should be continually reviewed and should be informed by the most recent research and evidence-based medical approaches accessible to date. 12. Medical Screening Guidance. While Defence and the Army will continue to act upon new research, evidence, and best practice as it emerges, the UK National Screening Committee’s evidence summary (at Enclosure 6) shows a highly complex picture and does not currently support screening for mental health disorders. Recent research continues to reflect a similar view, both within the Armed Forces and nationally. Additionally, a landmark Academic Department of Military Mental Health (ADMMH) study (at Enclosure 7) concluded that screening did not reduce prevalence of mental health disorder or help-seeking. Therefore, Defence does not currently screen for mental health disorders, in line with the policy set out in the Defence People Mental Health and Wellbeing Strategy 2017-2022 (at Enclosure 8). However, this strategy is currently under review. 13. Medical Employment Standards. The Surgeon General’s Department conducted a Medical Employment Standards Review in January 2021, which informed our continued clinical management and understanding of risk factors. The Army will monitor any changing requirements to ensure all recommendations are implemented and detail can be found in the independently reviewed Enclosure 9, (Para 1.4.5 and Para 1.4.6), and at Enclosure 10 (Para 2.0, Sub Para 2). Furthermore, Defence has been directed to complete a further review no later than December 2023. 14. Chain of Command. The concerns surrounding LCpl Robinson’s access to support outside the direct Chain of Command is a known and acknowledged risk. We seek to continually enhance support to our soldiers and families through chaplaincy, charitable and external providers and our regimental associations. An Army Welfare Review is ongoing, which has recommended an enhanced professionalised service provision, including access to trained civilian personnel. This should enhance support to both serving personnel and their wider support network, which we hope will address your specific concern. 15. Passage of Information. The need for the effective distribution of information to all levels to signpost where our personnel can access help and support is recognised. The Army’s Health and Wellbeing Communication Directive has driven comprehensive reviews of our activity in 2020 and 2021 to ensure increased ‘reach’ to our people and their support networks. Multiple products are now accessible to our personnel and available on various mediums such as MODNET, Defence Connect, the Army Knowledge Exchange, and the British Army Website, with detail to ensure parity of access for all ranks. These directly link soldiers with support agencies through their electronic devices. 4 Matter of Concern 4 – “Consideration should be given to increasing awareness of how to handle service complaints within the Army. Service complaints are made when, by definition, things are not going well, and this could be viewed as a risk factor.” 16. Service Complaint Records. Since the death of LCpl Robinson, awareness of the service complaints procedures throughout the Army has significantly improved, a trend regularly reported through the Armed Forces Continuous Attitude Survey. The Army takes its commitment to Service Complaints (SC) and Complainants extremely seriously and continues to collaborate with Defence to further raise awareness of the SC process for all parties. This includes signposting the welfare support available, noting those that raise SCs are often in a vulnerable position. To complete the assurance process, we have no record of an SC entered on our Joint Personnel Administration System for ‘ Lance Corporal Joel Robinson’ and the Unit do not have any record of a complaint, either formal or informal. 17. Service Complaint reform. As part of 2019’s SC Reform work, there is an aspiration to move to a digitised and paperless process for all SCs, digitally recording them on a centralised database so that records can be found easily. This is awaiting review by the SC Reform Team and, if approval is obtained, would facilitate the complainant submitting a direct SC report without going through their chain of command or the SC Ombudsman. In the interim, SC terminology has been made simpler to give users greater understanding, which is critical in addressing your concern. To demonstrate our commitment, the Army has recently committed an additional investment of £1.1M to SCs reform, primarily towards an Outsourced Investigation Service (OIS) to allow independent investigation of Bullying, Harassment and Discrimination SCs. 18. The Army, MOD and Service Complaints Ombudsman Armed Forces continue to promulgate awareness about SCs through published policy, bespoke publications, outreach and education. This includes presentations, internal and external websites, instruction on courses, mandatory annual training, pamphlets and policy documents and various multimedia sites. 19. The outcomes anticipated from the SC Reform will address some of your concerns regarding LCpl Robinson. As detailed above, SCs are identified within policy as a suicide risk factor and awareness training is now provided to all Army personnel on a mandated basis. This includes explanation around the options for submitting a complaint and how to access Unit Diversity and Inclusion Advisors. The aspiration is that soldiers will be able to submit a complaint via virtual means, recognising that they may be reluctant to approach the uniformed Unit Welfare Officer or the Unit Chaplain. 20. Service Complaint Training. The Army SC Secretariat presents to a variety of internal career courses on how to manage SCs, and provides training and presentations to individual formations. Training is delivered to all officers at several points in their career and the Army SC Sec also presents to the Late Entry Officer Course (LEOC), when other ranks (ORs) enter the officer corps on commissioning. At the user level, Army SC Sec present on the Staff Support Assistant (SSA) course – SSAs are the soldiers within a unit that input and manage SCs within the Joint Personnel Administration (JPA) Portal system. The Army SC Sec also deliver a presentation to the Higher Formation Discipline Authority (HFDA) course, aimed at both civilian and military personnel working within the discipline arena in 1- and 2-star levels formations. It is their responsibility to provide oversight and guidance of their discipline and SC cases. 5 Enclosures (sent separately): Enclosure 1 - DSA Review into Suicide Rates in Armed Forces 12 Nov 2019 (PDF) Enclosure 2 - Public Health England Local Suicide and Prevention Plan Sep 2020 (PDF) Enclosure 3 - AGAI 110 dated Aug 2020, Risk Indicators Annex C (PDF) Enclosure 4 - AGAI 57 dated Sep 21 (PDF) Enclosure 5 - Royal College of Psychiatrists CR229 2020, Page 28 (PDF) Enclosure 6 - UK National Screening Committee evidence process 2017 (HTML) Enclosure 7 - KCMHR post deployment screening Rona et al 2017 (PDF) Enclosure 8 - Defence Mental Health and Wellbeing Strategy 2017-2022 (PDF) Enclosure 9 - Medical Employment Standards Review Jan 21 (PDF) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Enclosure 10 - KCMRH Independent Review Jan 21 (PDF) 6
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