Alexander Tostevin

SECRETARY OF STATE 
MINISTRY OF DEFENCE 
FLOOR 5, ZONE D, MAIN BUILDING 
WHITEHALL  LONDON  SW1A 2HB 

 15 February 2022 

Dear Mr Allen, 

ALEXANDER CHARLES GEORGE TOSTEVIN 
 REGULATION 
28: REPORT TO PREVENT FUTURE DEATHS DATED 6 DECEMBER 2021 

Thank  you  for  your  Regulation  28:  Report  to  Prevent  Future  Deaths  dated  6 
December 2021 following the Inquest into the tragic death of Cpl Tostevin on 18 
March  2018.    You  concluded  his  death  was  as  the  result  of  suicide  and  have 
raised concerns regarding the provision of support to Service Personnel facing 
mental  health  challenges.    I  take  the  health  and  wellbeing  of  members  of  the 
Armed Forces extremely seriously and very much share your desire to mitigate 
the risks of future such tragedies.  

In  considering  my  reply,  I  have  taken  advice  from  the  Commander  Defence 
Primary  Healthcare  and  the  Defence  Consultant  Advisor  for  Psychiatry  and 
received  information  from  Cpl  Tostevin’s  Unit  on  how  the  handling  of  issues 
around  mental  health  and  wellbeing  have  evolved  since  2018.  I  also  draw  on 
some wider context from the Armed Forces People Team.   

I  would  observe  that  Defence  has  been  working  hard  to  remove  the  stigma 
around,  and  provide  effective  support  for,  mental  health  issues  amongst  our 
Service population. Sadly, as with wider society, we cannot completely eradicate 
the risk of suicide. However, the Defence People Mental Health and Wellbeing 
Strategy1 sets out our commitment for:  “All Defence People to enjoy a state of 
positive  physical  and  mental  health  and  wellbeing,  feeling  connected  with  and 

1 Defence people mental health and wellbeing strategy - GOV.UK (www.gov.uk) 

Mr Brendan Joseph Allen 
Area Coroner for Dorset  
Coroner's Office  
BCP Council, Town Hall 
Bournemouth, Dorset  
BH2 6DY  

Email: Dorset Coroners coroners.system@bcpcouncil.gov.uk 

Enclosures: 2021DCMHSOP-03-03-18 Confidentiality Guidelines for DCMHs and MHTs 
DCMH and RNFPS Joint Working Protocol – dated Mar 2 

 
 
 
 
 supported  by  the  military  and  wider  community.  The  risk  of  suicide  can  be 
mitigated  through  the  application  of  robust,  pragmatic  policies  based  on 
detection,  early  intervention  and  prevention  by  tackling  stigma,  education  and 
enabling access to mental health support and healthcare services.  

I am confident that we are making progress in supporting the mental health of our 
Armed Forces.  This is an ongoing journey, which is supported and driven by the 
MOD-wide  Service  Personnel  Suicide  Prevention  Working  Group  (SPWG)  - 
established  in  November  2018-  which  coordinates  suicide  prevention  policies 
across Defence and identifies and shares best practice. On 2 December 2021, 
the group agreed to develop a Defence Suicide Prevention Plan. The SPWG also 
recommended  the  creation  of  a  Defence  Suicide  Register  (DSR),  which  is 
currently  being  developed,  to  provide  the  evidence  base  to  inform  the  MOD 
suicide prevention strategy.  

Your Regulation 28 Report relating to the death of Cpl Tostevin in March 2018 
raises a number of important matters.  I have addressed each issue below. 

Dorset Coroner’s Matters of Concern Paragraph 2.i.  reads as follows:  “The 
lack  of  independence of  DCMH services  risks  service  users minimising  and/or 
under reporting the risks they may pose to themselves for fear that information 
may be disclosed to the Chain of Command.  If the true extent of the risk of suicide 
is not known by DCMH, an effective risk management plan to mitigate the risk of 
suicide cannot be formulated”. 

Situations where service personnel mask their own concerns or provide different 
information  to  different  mental  health  and  support  services,  invariably  produce 
very challenging circumstances for those seeking to provide support. Defence’s 
approach to disclosing information and encouraging people to seek mental health 
support  aims  to  ensure  Department  of  Community  Mental  Health  (DCMH)  is 
provided  with  the  information  it  needs  to  formulate  effective  risk  management 
plans in each case. I will address each area in turn. 

Disclosure  of  information  between  DCMH  and  the  Chain  of  Command.  

DCMH  operates  as  an  independent  organisation,  which  sits  within  Defence 
Primary  Healthcare  (DPHC),  a  Tri-Service  organisation  in  UK  Strategic 
Command. Although military DCMH staff2 are drawn from the medical services of 
the Royal Navy (RN), Army and Royal Air Force (RAF), DCMH is independent of 
all  three  Service  chains  of  command.  Mental  health  services  play  a  vital 
Occupational Health role in supporting the Unit and the holistic care of  Service 
personnel. Therefore, a close relationship with an individual’s Chain of Command 
and  DPHC  is  often  a  key  to  ensure  the  best  possible  outcome  for  personnel 
experiencing mental health issues.   

2 DCMH staff can be both civilian and military.  

 
 
 
 
 
 
 
 
 Service  personnel  are  entitled  to  a  confidential  medical  service,  which  mirrors 
medical  confidentiality  applied  in  the  civilian  population.  As  Registered 
Healthcare Practitioners, DCMH  clinical staff comply with the framework of the 
Caldicott Principles3 and the extensive guidance provided by the General Medical 
Council regarding confidentiality4.  

DCMH best practice is for confidential patient information to be shared only with 
the  patient’s  consent.    However,  disclosure  of  confidential  patient  information 
without  consent  may  be  justified  in  exceptional  circumstances  to  protect  the 
individual or someone else from possible harm or where it is in the public interest 
to do so. Holistic care does become more challenging when consent is not given 
and  the  threshold  for  sharing  without  consent  is  not  reached.  DCMH  staff  will 
provide  guidance  on  how  the  affected  personnel  should  be  employed  and 
managed while receiving care. Examples of information which can normally be 
shared  without  consent  are  laid  out  in  DPHC  Standard  Operating  Procedure 
(DCMHSOP) 03-03-018 (Enclosure 1) which reads: 

The  following  information  can  normally  be  disclosed  to  an  appropriate 
member of Command without patient consent: 

a. 

b. 

c. 

The  occupational  limitations  that  apply  to  the  patient  (iaw 
what they can and cannot do), but  not why the limitations 
are recommended.  

The patient’s schedule of appointments. 

The anticipated duration of any restrictions. 

d. 
Any  risk  information  Command  must  know,  as  actions  are 
required from them to manage it or monitor it…If in doubt that the 
threshold 
for  disclosure  has  been  reached,  consult  senior 
colleagues  in  your  DCMH  in  the  first  instance,  or  alternatively 
contact one of the DCAs [Defence Consultant Advisors].   

Such  guidance  may  include  an  individual being  precluded  from  driving  military 
vehicles,  being  placed  on  guard,  or  having  access  to  weapons  or  ammunition 
restricted or denied. This allows for appropriate measures to be taken to ensure 
the safety of the individual and others without the need for sharing of confidential 
patient information. 

3https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/
file/942217/Eight_Caldicott_Principles_08.12.20.pdf  
4 Staff must also comply with all other relevant data protection legislation when sharing 
information. 

 
 
 
 
 
 
 
 
 
 
 
 
 Any independent provider of mental health services to Service personnel (i.e. one 
which sits outside of Defence) holds the same duty of confidentiality and would 
operate  within  an  identical  legislative  and  regulatory  framework.  However, 
informed advice from military clinical staff, helps ensure that serving personnel 
can  be  employed  productively  and  safely,  while  managing  their  mental  health 
issues.  

Managing SPs Underreporting Symptoms.  

Without consistency and openness, making an accurate assessment of a 
person’s mental health can be extremely difficult. I have provided more detail 
below regarding how Defence, including Cpl Tostevin’s Unit, approaches such 
matters.  

Societal stigma regarding mental health issues has reduced in recent years but 
does endure. This is a recognised risk within service communities with regards 
to  the  management  of  vulnerability.    Cpl  Tostevin’s  Unit  has  now  adopted  the 
Army  General  Administrative  Instruction  (AGAI)  110  –  Vulnerability  Risk 
Management (VRM)5, which acknowledges the ongoing challenges, stating: 

“Stigma is a cultural issue and it is the responsibility of every commander 
and individual to address it. Men in general, and male Army personnel in 
particular, have been shown to delay seeking help due to lack of insight, 
stigma  and  fear  that  disclosure  of  their  personal  circumstances  will  be 
seen as a sign of weakness and/or have an adverse effect on their military 
career”. 

To support commanders with addressing stigma, programmes across each of the 
Services have been developed to help improve mental fitness and resilience, and 
help-seeking behaviours within the Service population (see Annex A for further 
information). 

Since 2018 Cpl Tostevin’s Unit has established further measures to improve both 
mental  health  resilience  and  management.  The  Wounded  in  Service  Warrant 
Officer  (WISWO)  position,  a  key  post  within  the  Unit  dedicated  to  managing 
injured  personnel,  has  received  significant  investment  in  the  past  three  years, 
with  increased  continuity  of  the  individual  in  post,  and  additional  workforce 
capacity to assist in the management of down-graded personnel. This has better 
supported stable and trusted relationships between the WISWO, the wider team 
and  the  individual  under  their  immediate  care.  Infrastructure  to  house  and 

5 Information regarding AGAI vol 3, chapter 110 Army suicide vulnerability risk management 
(SVRM) policy (publishing.service.gov.uk) 

 
 
 
 
 
 
 
 
 
 
 
 
 administer  personnel  in  recovery  has  also  developed  significantly,  providing 
spaces  for  recovering  personnel  to  discuss  issues  in  a  safe  and  supportive 
environment.   

In addition, an in-unit support team delivers briefs (including mental health, sleep, 
hygiene, and coping strategies), which complements the work of the Royal Navy 
Family  Personnel  Services  (RNFPS)  (Welfare)  team,  WISWO  and  clinicians. 
These briefs are delivered to new joiners and existing personnel.  The collective 
aim is to raise awareness of what personnel should look for in their colleagues 
and in themselves to identify mental health concerns. Wellbeing initiatives have 
also progressed, including a poster campaign which uses anonymised QR-coded 
signposting to increase access to physical/mental health support and material.  

The  Unit  also  receives  enhanced  support  from  an  embedded,  independent, 
psychiatric  nurse-  a  key  asset  in  promoting  mental health  and  wellbeing.    The 
Unit is also exploring options to increase DCMH endorsed clinical mental health 
support and dedicated psychologist support.  Each squadron has its own General 
Practitioner supported by a full-time medic. The close relationship between the 
Chain  of  Command  and  medical/welfare  practitioners  continues  to  enable  any 
stigma associated with mental health issues to be combated, while also ensuring 
mental health First Aid measures can be implemented early and referrals made 
in a timely manner to ensure our SP are effectively supported. 

Dorset  Coroner’s  Matters  of  Concern  Paragraph  2.ii.  Paragraph  2.ii.  of 
Reference  A  reads  as  follows:  “The  primacy  of  the  view  of  DCMH  when 
considering the risk of suicide in MDT/Case Conferences again means that the 
true risk of suicide may not be accounted for, particularly where a service user is 
providing  different  information  to  DCMH  and  Welfare  and/or  where  there  is 
disagreement  between  DCMH  and  Welfare  as  to  the  presenting  level  of  risk.  
Adapting a process similar to a Multi-Agency Risk Management Meeting (MARM) 
or Multi-Agency Risk Assessment Conference (MARAC) in a civilian context may 
assist: in a MARM or MARAC, the level of risk adopted is the highest level raised 
in the meeting / conference, without any agency having primacy.  Therefore, the 
risk  management  plan  subsequently  formulated  addresses the highest  level of 
risk bought to the meeting.”   

While each Service has its own policies and frameworks to manage its vulnerable 
personnel, every case across Defence is Chain of Command led and supported, 
as  appropriate,  by  welfare  agencies,  pastoral  support  and  healthcare 
professionals  (including  DCMH).      Cpl  Tostevin’s  Unit  applies  the  Army’s 
Vulnerability Risk Management (VRM) Framework, which states: 

“The  CO  is  responsible  for  deciding  whether  an  individual  should  be 
considered  at  risk  of  suicide  or  self-harm  behaviours,  formulating  the 
management response and selecting the appropriate measures to reduce 
risk.  They  must  ensure  close  collaboration  with  the  immediate  Chain  of 

 
 
 
 
 
 Command, welfare, pastoral and medical personnel and, most importantly, 
the individual at risk.”  

It  also  states:  “COs  are  advised  to  err  on  the  side  of  caution  and  place 
individuals  on  the  VRM  register6  in  circumstances  where  there  is  any 
doubt”.  

For personnel on the VRM, Command-led multidisciplinary meetings are held to 
produce and maintain a management strategy that incorporates pastoral, medical 
and welfare input, as well as the views of the affected individual.  Cpl Tostevin’s 
Unit uses the Army framework for such case conferences, which results in the 
production of a Care Assessment Plan (CAP) (see below for more detail).  The 
policy makes clear that a conference must take place and directs who should be 
present to allow the CO to make an informed decision from all around the table 
(CoC,  Welfare,  Medical,  Pastoral  etc).  The  overt  aim  therefore  is  to  secure  a 
holistic  representation  of  views  across  the  agencies  involved,  from  which  a 
balanced, considered view of risk can be reached.  The opinion of DCMH carries 
due weight, while also being balanced against opinions provided by the welfare 
agencies or the individual’s own immediate Chain of Command. In cases where 
the  individual  is  under  the  care  of  the  DCMH,  this  construct  complements  the 
professional  medical  care  provided  by  the  Defence  Medical  Services,  as 
appropriate clinical care will already be in place.    

Since the tragic passing of Cpl Tostevin, to ensure this process runs effectively 
in the Unit, a joint working protocol between DCMH and the Royal Navy Families 
and  People  Support  (RNFPS)  team  was  agreed  and  signed  in  March  2020.  A 
copy of this protocol is provided at Enclosure 2. This outlines the actions to be 
taken in cases where disagreements occur between the two organisations, which 
promotes improved lines of communication accounts for all views to ensure the 
wellbeing of the individual is protected.  

Dorset  Coroners  Matters  of  Concern  Paragraph  2.iii.  Paragraph  2.iii.  of 
Reference A reads as follows: “Where there is no composite risk assessment and 
care plan document that draws together all the relevant information for a patient 
and  identifies  the  plan  in  place  at  any  given  time,  there  is  a  risk  that  key 
information and risk factors are missed”. 

In line with AGAI 110, composite CAP documents based on a holistic assessment 
of  risk  are  now  in  place  within  Cpl  Tostevin’s  Unit.  The  Case  Conferences 
continue to employ a multi-disciplinary approach to managing personnel deemed 
to be at risk, with carers’ meetings being conducted fortnightly. Meeting attendees 
now  feed  into  a  collaborative  tool  to  manage  vulnerable  personnel,  which  is 
hosted on the Vulnerability Risk Management Information System (VRMIS).   

6 Please see AGAI 110 publication for more information on the VRM register. 

 
 
 
 
 
 
 
 
 The use of VRMIS enables a single CAP to be produced, collating the advice and 
opinions of all those responsible for an individual’s care. Once the initial CAP is 
completed on VRMIS, carers then feed their relevant amendments as required 
via  the  nominated  CAP  lead  (usually  a  specified  individual  within  the  Chain  of 
Command). When the CAP is updated with information from any of the carers, 
an  instant  electronic  notification  of  the  changes  is  sent  to  all  members  of  that 
specific carers group, informing them of the change. These measures together 
are  designed  to  ensure  that  a  single  holistic  care  plan  is  contributed  to  by  all 
interested parties and that real time information is passed to carers should the 
information on the CAP change. 

Thank you for raising your concerns with me. I hope you will appreciate from my 
response that lessons have been learned. With the adoption of AGAI 110 in Cpl 
Tostevin’s former Unit, the investment in the WISWO team, welfare infrastructure 
and  the  disagreement  resolution  agreement  between  welfare  agencies  and 
DCMH,  which  collectively  contributes  to  an  improved,  more  streamlined 
management process for those at risk of self-harm or suicide. I recognise there 
is  more  work  to  be  done  within  the  Unit  and  across  the  organisation.  Defence 
remains  committed  to  further  improving  the  care  of  those  with  mental  health 
challenges and, driven by the SPWG, work will continue to further reduce the risk 
low  as  possible.  
of  suicide  across  all  of  our  Armed  Forces 

to  as 

My thoughts remain with Cpl Tostevin’s family and I hope this will provide some 
element of solace to them following their tragic loss.   

Yours sincerely, 

THE RT HON BEN WALLACE MP 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Annex A: Further Information on Single Service Mental Health Initiatives 

a.  Royal  Navy.   The  RN  utilises  a  mixture  of  the  Army  Mental  Fitness 
Training  programme  and 
initiative  Project  
REGAIN-  designed  to  encourage  all  ranks  to  seek  help  if  they  have 
concerns about their mental health. RN Human Performance team are also 
identifying how to improve mental health learning, leadership the culture of 
reporting concerns in self and others. Mandatory mental health briefs from 
designated nurses, online tools and wellbeing apps have also been utilised.  

the  Royal  Marine 

b.  Army  Mental  Fitness  and  Resilience  Training.   As  part  of  
Op  SMART,  a  comprehensive  Army  framework  was  created  to  improve 
mental health literacy, reducing stigma associated with mental health short 
term  performance  and  long-term  mental  health  outcomes.  This  was 
achieved by the creation of a mental resilience and mental fitness training 
and  education  program  that  delivered  personal,  psychological  and  social 
skills that was embedded throughout the career pathway. 

c.  RAF  Thriving  at  Work.   The  RAF  have  invested  in  research  and 
developed  a  comprehensive  Whole  Force  specialist  mental  health  and 
wellbeing  programme  called  Thriving  at  Work  (T@W).   T@W  is  about 
Leadership, support, communications, and treatment. It makes best use of 
existing resources, tools and agencies and is inclusive of civil servants.