Neil McDougall

Date of report	10 Aug 2022
Reference	2022-0251
Deceased	Neil McDougall
Coroner	Samantha Marsh
Coroner area	Somerset
Category	Mental Health related deaths · Alcohol, drug and medication related deaths · Other related deaths
Source	judiciary.uk record · original PDF
Responses published	1

The report

Text extracted from the PDF text layer. 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:

1. Military  of  Defence

Defence  Inquest U nit (D IU )
Direct orate  of Ju dicial Engagement  P olicy
MOD Main Building
London
SW1A2HB

2. Secretary of  State for  Defence (Mr Ben Wallace)

House  of Comm ons
Lond on 
SW1A0AA

1 

CORONER 

I am  Samantha Marsh, Acting senior  Coroner for the coroner area of Somerset 

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 

On the 23rd  February 2021 the then-Senior Coroner,  Mr Tony Williams, 
commenced an investigation into the death of  Neil David James  McDougall, 
aged 43. 

The investigation concluded at the end of the inquest, heard before me, on the 
9th August 2022.  The conclusion of the inquest was Accidental death, including
toxicity with a finding 
medical cause of death being 1 (a) 
in box 3 that "Neil David James McDougall was discovered deceased at his 
home address in the early hours of the 23rd  February 2021.  He had a long 
history of mental health problems following active military service.  Neil used 
alcohol as a coping mechanism which both exacerbated but also masked his 
mental health presentation.  Neil had a history of impulsive behaviour,  especially 
when intoxicated as well as a history of stockpiling medications, some of which 
were  sourced outside of le.9itimate �l:J2rescriptions.  It would appear,  on the 

 evidence, that on the 22nd  Feb 2021  Neil has sadly misjudged the quantities of 
medication that he was to take, resulted In him succumbing the toxic levels of 

 that were in his system". 

4 

CIRCUMSTANCES OF THE DEATH 

Neil had joined the  military when he was 30 (2007).  He remained with the Army 
until he was medically discha rged  on the 9th  July 2018.  He undertook a Tour of 
Afghanistan. 

I hear from  Neil's partner who stated that by 2014 Neil was having  recurrent and 
persistent nightmares and  hallucinations about his experiences on a Tour in 
Afghanistan. 
Mr McDougall was first seen by the military psychiatrists at the DCMH 
(Department of Community Mental Health) on  the 09  October 2009.  He was 
again referred to the DCMH  in December 2016  until the 25th  April 2018 when his 
care was transferred to TILS in anticipation of being seen once he was 
discharged from the Army in  July 2018. 

His recorded diagnosis in  March 2017 was of a depressive episode with marked 
- 20th July 2017 with the 
anxiety.  He had an inpatient admission between 12th 
diagnosis on discharge being given as depression (ICD-10 F33) and Alcohol 
dependency - binge (F10.2) 

I heard that Neil  appeared to go from crisis to  crisis with his mental health; there 
was a recurrent cycle of peaks and troughs.  In the December of 2017 he was 
reporting symptoms more consistent with generalised anxiety and depression. 
Whilst the Inquest found  that Neil's mental health was either exacerbated by 
and/or masked by his alcohol misuse, it was clear that there was an underlying 
mental health situation.  Neil appeared to use alcohol as a coping mechanism, 
but sadly this only made him worse. 

Neil was medically discharged by a Full  Medical Board on the  12th December 
2017 with his last day of service being set as the 9th  July 2018. On  discharge his 
mental health care was transferred to the community/NHS. 

I was told  that one month after discharge, so in August 2018,  Neil was formally 
diagnosed with  PTSD  by Dr 
.  He had  not received this diagnosis whilst 
he was under military mental health care, although the evidence given by the 
military Psychiatrist was that Neil  did not present in  such a way as to  meet the 
criteria/threshold for such a formal diagnosis at that time. 

I heard from a civilian Consultant Psychiatrist who saw Neil in  August and 
October 2020. The long-term treatment plan  was for Neil to join  a men's 
Cognitive Analytical Therapy ("CAT") group wh ich has  been successful for 
numerous ex-military veterans,  but he wasn't anywhere near ready to  engage in 
that level of talking therapy at the time as he was unable to  talk about his past 
experience(s).  I was told that Neil would need to undergo mindfulness and 
Cognitive Behavioural Therapy first to pave the way for him to join the CAT 
group in  time. 

Sadly,  Neil did  not commence any therapeutic intervention as he was 
discovered deceased at his home address on the morning of the 23rd  February 
2021. 

2 

 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)  I was told that the de-brief for serving personnel after returning from  a 

Tour is undertaken as part of a group. There appeared to  be some 
limitations to this process.  I was told that there are no 1-to-1  sessions 
in which personnel can openly talk about their experiences and trauma, 
which is something that they may be reluctant to do in an open setting 
for fear of going against the grain or culture of being physically and 
mentally resilient.  The debrief or recovery process in  itself appeared to 
centre more around the consumption of alcohol rather than the 
encouragement to talk about any distressing or harrowing experiences 
of active combat and service and I remain concerned  that the 
culture/stigma does not lend itself to those suffering taking the first step 
and effectively raising their hands and asking for help. 

(2)  I was told  that on leaving the Army all leavers go through a ·"Re-

Settlement" process.  This transitioning process involves mandatory 
courses that assist with re-integration back into civilian  life and 
endeavour to provide leavers with 'life skills' such as CV writing, 
interview techniques/preparation etc to assist leavers in gaining 
employment once outside of the Army. 

The mandatory transitioning arrangements only apply to 'skills' and  I 
was told that it is entirely possible to 'walk out of the door' without any 
mental health assessment whatsoever, with the Army appearing to rely 
on the availability of services provided with in the community and/or by 
charitable organisations that the Army can either signpost the leaver to, 
or they can access for themselves once a civilian. 

(3)  I believe that action should  be taken to ensure that there is an effective 
and comprehensive assessment of the mental health and/or wellbeing 
of those leaving the Army.  I can  see no justification for some elements 
of re-settlement/re-integration  being mandatory whilst others remain 
purely optional.  I believe that there should be some assessment and 
coordination of the discharge process to ensure that those leaving 
service are assessed , with appropriate intervention(s) identified rather 
than simply being allowed to  leave and rely on help being available 
somewhere/somehow in the community. 

(4)  I am concerned by the level of suicides amongst ex-military personnel 

and I do not believe that Neil  was an exceptional case,  he is 
representative of the rising figures and statistics; ex-military 
(predominantly men) who suffer from poor mental health as a resu lt of 
active service. 

6 

ACTION  SHOULD BETAKEN 

3 

 In my opinion action should  be  taken to prevent future deaths and I believe you 
your organisation has 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 5th  October 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 and to the following 
Interested Persons: 

(i) 
(ii)  Help for Heroes of Unit 14 Parkers Close,  Downton Business Centre 

Neil's partner); and 

Salisbury, Wiltshire SP5 3RB;  and 

(iii) ABF The Soldier's Charity of Mountbarrow House,  12 Elizabeth Street, 

London SW1 W 9RB 

(iv) Combat Stress of Tyrwhitt House (Head Office)  of Oaklawn Road, 

Leatherhead, Surrey, KT22 OBX 

(v)  British Legion  199 Borough High Street.  London SE1 1AA 

who may find it useful or of interest. 

I am also under a duty to send a copy of your response to the Chief Coroner 
and all interested persons who in my opinion should receive it. 

I may also send a copy of your response to any other person who I believe may 
find  it useful or of interest. 

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. 

9 

10th  August 2022 

4

Responses

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.

Response from Ministry of Defence (PDF)

Chief of the General Staff

MOD Main Building
Whitehall
LONDON
SW1A 2HB

DO/CGS

Mrs Samantha Marsh
His Majesty's Acting Senior Coroner for Somerset
Senior Coroner's Office
Old Municipal Buildings
Corporation Street
Taunton
Somerset
TA1 4AQ

(~ October 2022

Thank you for sharing your report following the inquest into the tragic death of Lance Bombardier

Neil McDougall. The British Army appreciates the importance of Coronial oversight and I am

extremely grateful to you for bringing your findings to my attention.

I share your desire to minimise the risk of suicide within the ranks of serving military personnel and

our veteran community. I have therefore enclosed a detailed response to your areas of concern.

This highlights our current policies and procedures, and the measures currently being taken to

improve them. The Army has continued to make tangible progress since Lance Bombardier

McDougall's death and I want to reassure you that I take this issue extremely seriously.

To the extent that the Armed Forces represent wider society, we will sadly never eradicate

incidents of self-harm and suicide entirely. However, I am determined to mitigate the risk by using

education to tackle stigma, providing rapid and flexible access to trauma risk management, and

through comprehensive support to our personnel as they transition to civilian life.

Every suicide is a tragedy; I hope that Neil's family will draw some comfort from knowing that your

report will contribute to reinforce action across the Army and the Ministry of Defence.

w,t"- ~" lNi~J

----------- - - - - -

DETAILED ARMY RESPONSE TO MATTERS OF CONCERN RAISED BY HIS MAJESTY'S
SENIOR CORONER FOR SOMERSET

Matter of Concern 1 - "I was told that the de-brief for serving personnel after returning from a Tour
is undertaken as part of a group. There appeared to be some limitations to this process. I was told
that there are no 1-to-1 sessions in which personnel can openly talk about their experiences and
trauma, which is something that they may be reluctant to do in an open setting for fear of going
against the grain orculture of being physically and mentally resilient. The debrief or recovery process
in itself appeared to centre more around the consumption of alcohol rather than the encouragement
to talk about any distressing or harrowing experiences of active combat and service and I remain
concerned that the culture/stigma does not lend itself to those suffering taking the first step and
effectively raising their hands and asking for help"

Addressing Stigma. In court, you were informed about the mutually supporting policies of

1.
Post Operational Stress Management (POSM) and Trauma Risk Management (TRiM), which work
together to mitigate the risk to mental health from operational experience. Though these policies
have been in place since 2005 and 2008 respectively, we are not at all complacent and these and
other policies and processes remain under constant review by the Ministry of Defence, supported
by the single Services.

2. We agree that the need to address the issue of stigma is crucial. We therefore wish to
highlight the introduction of the Recovery, Readjustment and Reintegration programme, which has
been created by the Royal Centre for Defence Medicine and Academic Department of Military
Mental Health. This will be a non-clinical approach that allows the chain of command to engage
openly with staff, soldiers, and families on stress management. It aims to encourage and facilitate
discussions on themes and experiences which otherwise could face stigma, bias and prejudices.

Furthermore, following a complete review of the underpinning evidence, TRiM policy and
3.
training is being updated across Defence. One of the key changes is that a 3-month TRiM risk
assessment will now be mandatory for all personnel involved in a traumatic incident rather than
being required only if an individual presents with problems. Those subject to these TRiM Risk
Assessments will also be discussed by the chain of command at monthly Unit Health Committee
case reviews.1

4. Our Optimising Performance Through Stress Management and Resilience Training
(OPSMART) programme is also working to break down stigma. It is designed to educate both the
individual and chain of command in monitoring their own health and that of their people.
OPSMART enhances mental health literacy and highlights the need to seek early interventions
where needed. We encourage our personnel to use the chain of command, unit welfare and
pastoral care, the Army Welfare Services and medical teams for support. The Army actively
signposts towards the 24hr confidential Military Mental Helpline and Samaritans helplines.

5. We run regular internal media campaigns and health promotion activity. This started in 2010
when the Army ran a 3-year internal anti-stigma Campaign called "Don't Bottle it Up". We align our
communication and internal media activity to key health promotion events, such as, but not limited
to, World Mental Health Day, World Suicide Prevention Day and National Stress Awareness week.

The Armed Forces carries out considerable research into the health and wellbeing of Armed

6.
Forces Personnel which provides the evidence base to inform policy and process. For example,
the Academic Department of Military Mental Health is preparing to undertake further research in
2023 focussing on stigma, help-seeking and the suitability of the current provision of support.

Decompression. You make reference to a lack of 1-to-1 sessions and a focus on the

7.
consumption of alcohol during the decompression process, which forms part of POSM policy.
Decompression provides personnel with time to rest, relax and reflect with their peers immediately

' AGAI 57 Unit Health Commillees (Enclosure 1).

following an operational deployment. It is tailored to the theatre requirement and, for Lance
Bombardier McDougall, occurred in Cyprus, in a formally structured and monitored environment
before his recovery to the UK. It was mandatory for all personnel who served a minimum of 31
consecutive days in Afghanistan. All individuals returning through Cyprus were supported by on-
site mental health professionals, chaplains and other welfare services, with bespoke briefings on
post-tour mental health also provided.2 During the Homecoming and Mental Health briefs,
individuals were encouraged to speak to the briefer if they were concerned that they have any
mental health issues. They were also signposted to the welfare or medical support personnel for a
1-to-1 session if appropriate. The presentation also tackled the issue of internal and external
stigma and directed individuals to available confidential help if they did not feel they could speak up
in a group.3 Controlled exposure to alcohol did occur during this period to mitigate the risk of post-
operational reintroduction , although the supply was strictly rationed to a maximum of four alcoholic
drinks per person.

' In accordance wrth Joint Service Publication (JSP) 950 leaflet 2-7-1 (Enclosure 2)
' Home Coming and Mental Health Brief (Power Point Presentation. Enclosure 3)

Matter of Concern 2 - "/ was told that on leaving the Anny all leavers go through a "Resettlement"
process. This transitioning process involves mandatory courses that assist with re-integration back
into civilian life and endeavour to provide leavers with 'life skills' such as CV writing, interview
techniques/preparation etc to assist leavers in gaining employment once outside of the Anny. The
mandatory transitioning arrangements only apply to 'skills' and I was told that it is entirely possible
to 'walk out of the door' without any mental health assessment whatsoever, with the Anny
appearing to rely on the availability of services provided within the community and/or by charitable
organisations that the Army can either signpost the leaver to, or they can access for themselves
once a civilian"

Matter of Concern 3 - "I believe that action should be taken to ensure that there is an effective and
comprehensive assessment of the mental health and/or wellbeing of those leaving the Army. I can
see no justification for some elements of re-settlement/re-integration being mandatory whilst others
remain purely optional. I believe that there should be some assessment and coordination of the
discharge process to ensure that those leaving service are assessed, with appropriate
intervention( s) identified rather than simply being allowed to leave and rely on help being available
somewhere/somehow in the community"

Your second and third matters of concern are fundamentally linked and therefore we will

8.
seek to address them concurrently. The principal role of MOD resettlement is to assist all service
leavers in making a successful transition to civilian life at the end of Full-Time military service. The
Holistic Transition Policy, introduced in October 2019, includes individualised support for a wide
range of life changing issues that can affect the individual and their family. These range from basic
needs, such as registering with a doctor, to complex requirements, such as budgeting and debt.

9.
Since 2004, the Army has specifically had a comprehensive policy for the management of
those personnel who are wounded, injured and sick (WIS)4. This policy includes the coordinated
management and support to those transitioning out of service on medical discharge and has been
reviewed. All WIS personnel continue with self-development activities, training
regularly
opportunities, vocational events, and briefings, and have 14-day recovery visits, which includes an
assessment set against specific factors , referred to as the 'HARDFACTS' criteria, covering: health,
accommodation, relocation, drugs/alcohol/stress, finance, attitude, children & family, training,
resettlement, employment and support agencies.

10. WIS service personnel also have Discharge Assessment. This takes the form of a final case
conference prior to discharge to verify that all issues pertaining to the service person are either
resolved or action is being taken towards a workable solution. The assessment is conducted using
HARDFACTS criteria and may be attended by the Responsible Commanding Officer (CO), the
Recovery Officer, a Veterans UK Veterans Welfare Services (Vets UK VWS) representative and the
Patient Group (which may include the service person and family members). The Responsible CO
must ensure that the service person is advised on the services available from Vets UK, Regimental
Associations, and the third sector. The timing of this assessment is recommended to take place 6-8
weeks prior to discharge. For Lance Bombardier McDougall, the unit conducted an assessment on
22 May 2018. It included detail regarding transition services, pensions, compensation, finance and
training for resettlement. Lance Bombardier McDougall was already engaged with Help for Heroes
(H4H) for ongoing support post discharge and was noted to have presented a positive outlook
regarding discharge. The unit closed the WIS Management Information System (WISMIS) record on
13 July 2018 following his discharge.

In addition to the core Resettlement Programme, a bespoke service is also provided for the

11 .
most vulnerable leavers through the Career Transition Partnership (CTP) resettlement
pathway. This function, CTP Assist, delivers an individualised, needs-based service to those
personnel who face the greatest barriers to employment as a consequence of their medical
conditions, including those concerning mental health. Requests to extend exit dates are also

• AGAI 99 Command and Care of Wounded, Injured and Sick Service Personnel (Enclosure 4)

considered on a case-by-case basis, to ensure individuals can complete recovery and resettlement
activities.

12. The Army's resettlement medical reviews cover all aspects of a soldier's well-being, including
mental health. The specific actions regarding continuation of mental health care after discharge from
the Armed forces is wholly dependent on the clinical condition and mode of exit. 5 The care provided
is based on the Murrison White Paper recommendations of 20106 and provides transitional
arrangements into NHS or third sector mental health care on an individual leaving service. Further
details are included below.

13. From 2015, where a serving person has had a mental health problem identified at the time of
discharge that requires referral to a Department of Community Mental Health (DCMH), a veteran
can access care for up to six months beyond their discharge date, providing they are registered with
an NHS GP.7 Lance Bombardier McDougall was registered with a NHS General Practitioner at time
of discharge therefore was entitled to this service. Veterans who have mental health problems which
manifest at a later date, and are believed to be as a result of operational deployment, are also eligible
to be assessed under the Veterans Psychiatric Assessment Programme (VPAP).8

14. Even if an individual is not receiving Defence mental health care, a Structured Mental Health
Assessment is still conducted at the mandatory discharge medical.9 If the outcome of the SMHA
indicates a need for referral to or intervention by a DCMH, this referral will be undertaken promptly,
and will note that the individual is leaving the service and provide civilian contact details as
required. There is currently no provision for inpatient mental health care beyond a service person's
discharge date under the Independent Service Provider (ISP) contract, but their transfer to a local
NHS Crisis Team would be managed should they require inpatient care beyond their discharge
date.

15. Contrary to the evidence that you heard in court raised in your second matter of concern,
these two mechanisms ensure all service personnel receive a comprehensive mental health
assessment as part of the discharge process.

16. The Secretary of State for Defence 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. We continue to develop and enhance Service
provision for our Veterans with continuing healthcare requirements:

Op COURAGE. In March 2021, NHS England launched Op COURAGE The Veterans'

a.
Mental Health and Wellbeing Service, which provides a complete mental health care
pathway for service leavers, reservists, veterans, and their families. 10 Op COURAGE brings
together three services - Transition, Intervention and Liaison Service (TILS), the Complex
Treatment Service (CTS) and the High Intensity Service (HIS) and as of 30 April 2022 had
received over 19,000 referrals, from a veteran population of around some 2.4 million 11 .

(1) Transition, Intervention and Liaison Services (TILS). Launched in April 2017
TILS is a dedicated out-patient service for military personnel approaching discharge
and veterans who are experiencing mental health difficulties. It provides a range of
treatment, from recognising the early signs of mental health problems and providing
access to early support, to therapeutic treatment for complex mental health difficulties

5 JSP 950 Lfit 1-3-4. (Enclosure 5). Specifically, Annex B lays out the general provisions for Mental Health care upon exit from the
Armed Forces
' Fighting Fit a mental he@11h 0lan for servicemen and veterans - GOV.UK (www gov ukl
7 JSP 950 2-7-2 (Enclosure 6)
• as detailed in Annex B to Enclosure 6
• (SMHA) (JSP 950 Leaflet 2-7-5, Enclosure 7)
•• A similar service is provided in each Devolved Administration
11 Veterans Factsheel 2020 /publishing service gov uk}

and psychological trauma. Help may also be provided with housing, employment,
alcohol misuse and social support.

(2) Complex Treatment Service (CTS). Launched in April 2018, CTS is an
enhanced outpatient service for veterans who have military related complex mental
health difficulties that have not improved with previous treatment. The service provides
intensive care and treatment that may include (but is not limited to) support for drug
and alcohol misuse, physical health, employment, housing , relationships and finances,
as well as occupational and trauma focused therapies. Access to CTS is via TILS.

(3) High Intensity Service. The HIS, which launched during 2020 works with the
mainstream NHS services to provide:

(a) Support to crisis care services for veterans presenting in a mental health
crisis.

(b) Support during an inpatient unit stay - including access to a clinician advice
line 24 hours a day, 7 days a week.

(d) Support and care for family members and carers where they need it.

17. Defence Transition Services. Defence Transition Services, which is part of Veterans UK,
was established at the same time as Op COURAGE to provide direct casework support to those
facing the greatest challenges to making a successful transition on their discharge. Veterans UK
also writes to all medically discharged service leavers as standard to raise their awareness of the
organisation and the services provided, including those related to welfare support. Veterans
Welfare Services and Defence Transition Services have also recently been provided training by the
Samaritans on having conversations with vulnerable people. This training took place in 2022, in
recognition of the increasing prevalence of Mental Health-related casework.

18. Management on Discharge. Our records confirm that in accordance with policy, Lance
Bombardier McDougall was referred to the TILs service in March 2018 and a transfer of care
meeting took place on 25 April 2018. There was further communication between the DCMH,
civilian GP and Community Mental Health Team (CMHT) in June 2018 when the DCMH was
informed that he had been reviewed by the CMHT and was due a review with the consultant
psychiatrist. Content that his transfer to the NHS services was in place and that Lance Bombardier
McDougall was registered with a civilian GP he was discharged from the Army on 9 July 2018 with
a care plan in place.

19. The Veterans Welfare Service (VWS) and DBS Vets UK have confirmed that Lance
Bombardier McDougall was supported through his transition from the Army from 2017 and was
seen in both the Personal Recovery Centre and the Personal Recovery Unit by staff from the VWS
and DBS VETS UK departments. During these meeting, records confirm that Lance Bombardier
McDougall was given advice and support with claiming compensation. They have also confirmed
that their last contact with him was in Sept 2020, when he enquired if his request for a Tier review
has been received by Glasgow and whether his review of his mental health had been received by
Norcross. The Welfare Manager confirmed in writing to him both had been received.

Matter of Concern 4 - "I am concerned by the level of suicides amongst ex-military personnel and
I do not believe that Neil was an exceptional case, he is representative of the rising figures and
statistics, ex-military (predominantly men) who suffer from poor mental health as a result of active
service"

20. The trend suggested in your matter of concern is the subject of constant scrutiny and
research. Through official statistics and academic studies Defence and wider Government are
seeking to understand the extent of any problem and how policy can be targeted to respond most
effectively. The current basis of evidence suggests that the rates of suicide among the general
population and veterans are comparable.

21 .
In addition to the medical provisions detailed above, in 2019, to ensure that the nation
provided appropriate care for its veteran community, the Office of Veteran's Affa irs (OVA) was set
up within the Cabinet Office. Its central position allows it to convene departments and drive forward
work in support of veterans. The OVA also collaborate closely with charities and academics to
better understand the needs of veterans and deliver the right support. Defence also continues to
monitor trends carefully, in addition to coordinating suicide prevention policies across the Services.

22.
In September 2021 , the OVA and the Office for National Statistics (ONS) announced that for
the first-time numbers of ex-service personnel who take their lives will be officially recorded by the
Government in England and Wales. In addition, a 10 year look back to examine veterans' deaths
through suicide will be undertaken. This information will inform future policy and interventions in
support of veterans.

23. Publis hed research . A study by Bergman et al in 202212 examined suicide risk amongst
Scottish veterans as compared to the general population. In a 37-year retrospective follow up of
78,000 veterans and 253,000 non-veterans it was concluded that veterans were not at increased
risk overall Other ongoing work includes:

The National Confidential Inquiry into Suicide and Safety in Mental Health - Suicide in

a.
Former Service Personnel of the UK Armed Forces, is a veteran-focused study by
Manchester University, jointly commissioned by Defence, NHS England and NHS
lmprovement. 13 It will investigate the antecedents of veteran suicides for veterans who
served between 1996 and 2018. The study will be using Defence data on military service,
combined with confidential inquiry into suicides and coroners reports to understand the
factors which may lead a former service person to commit suicide. The study started in
September 2020 and was due to provide an initial report on 31 August 2022, (not yet
published), and a full report delivered by the end of March 2023.

b.
In 2023, the Office for National Statistics will undertake analysis to compare the health
of the veteran population with the general population, including the number of veterans with
long-term health conditions or disabilities. This analysis will include suicide-related deaths of
veterans and a new official statistic will be published regularly. This will help provide
Government, the charity sector and others with a better understanding of the incidence of
suicide among veterans, which may then help to inform future policy.

The Veteran Friendly NHS GP Practice Initiative. Defence is now collaborating with the

c.
NHS, with GP practices signing up to become 'veteran friendly' under a national scheme to
improve medical care and treatment for former members of the Armed Forces. The scheme,
called Military Veteran Aware Accreditation, is run in conjunction with Health Education
England (HEE), NHS Education for Scotland (NES) and Health Education Improvement
Wales (HEIW). It has been adopted by the NHS and the Royal College of GPs as a

" Su,c,da among scon1sh m,I~arv ve1eraos follow-up and 1.,nds 191a ac ukl
'' The Na1,ona1 Confiden11a1 Inquiry 1n10 SulClde and Safety In Men1a1 Heallh INCISH) sulOde in former seryq personnel of the UK
armed forces - study information • GOV UK rwww gov ukl

,
nationwide initiative aimed at training family doctors to better identify and treat veterans,
ensuring they get access to dedicated care where appropriate.

Enclosures (sent separately):

1.
2.

3.
4.

6.
7.

AGAI 110 Vulnerability Risk Management dated Aug 20 (PDF)
JSP 950 Leaflet 2-7-1 Mental Health and Wellbeing Briefing Before, During and After
Deployment dated Oct 20 (PDF)
Home Coming and Mental Health Brief dated Aug 13 (PPT)
AGAI 99 Command and Care of Wounded Injured and Sick Service Personnel dated Apr
22(PDF)
JSP 950 Leaflet 1-3-4 Healthcare Transition Arrangements for Military Personnel Leaving
Defence Medical Services Care dated Sep 21 (PDF)
JSP 950 2-7-2 Section 11 Defence Mental Health Services dated Aug 22 (PDF)
JSP 950 Leaflet 2-7-5 Structured Mental Health Assessment dated Dec 20(PDF)

The report

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