Cpl Ryan Lovatt
PFD Report
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Ref: 2021-0373
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· Deadline: 27 Sep 2021
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
The MATTER OF CONCERN is as follows. –
I am concerned about whether the existing alcohol policy is fit for purpose and whether there are systemic failures in respect of it. According to the Learning account, I understand the policy was reviewed as a result of this tragic incident and deemed to be appropriate.
I understand that Op Cabrit is unusual in that it is a formal operation but one that is within allied nations. I note from the Learning Account that there is an emphasis on normalising the deployment to make it appealing to soldiers to re-deploy for a second time. I also understand though that the facilities at the camp where Cpl Lovatt was based in Poland left a lot to be desired and morale was not high. There is what appears to be a fairly restrictive alcohol policy, the 2 can rule.
The deployment appears to sit somewhere between an operational tour and being normalised. The result of this appears to be a systemic problem with regard to understanding the policy and complying with it. It is possible that a restrictive alcohol policy and poor conditions in the base might lead to excessive/binge drinking when on a trip such as this one. Rather than tightening the policy, it is possible that less restrictive conditions at the base is part of the answer.
Whichever view is taken of the above, whether it is a 2 can rule, 4 can rule or more, an important safeguard is the requirement for a soldier, normally an NCO, to be nominated as shark watch and to remain sober and vigilant. It is a well known and common sense concept. It is not clear to me if there is a formalised policy. I anticipate the system may operate differently depending on the personnel and location. In this case, the system did not operate effectively as the person nominated as shark watch did not appear to know that he had been nominated. Others who gave evidence were unclear about the existence or requirements of such a system.
In short, my concern is that there is not a realistic, workable, or widely understood policy that is capable of being enforced with regard to alcohol on Op Cabrit and that, furthermore, the role of shark watch is not given greater prominence.
I am concerned about whether the existing alcohol policy is fit for purpose and whether there are systemic failures in respect of it. According to the Learning account, I understand the policy was reviewed as a result of this tragic incident and deemed to be appropriate.
I understand that Op Cabrit is unusual in that it is a formal operation but one that is within allied nations. I note from the Learning Account that there is an emphasis on normalising the deployment to make it appealing to soldiers to re-deploy for a second time. I also understand though that the facilities at the camp where Cpl Lovatt was based in Poland left a lot to be desired and morale was not high. There is what appears to be a fairly restrictive alcohol policy, the 2 can rule.
The deployment appears to sit somewhere between an operational tour and being normalised. The result of this appears to be a systemic problem with regard to understanding the policy and complying with it. It is possible that a restrictive alcohol policy and poor conditions in the base might lead to excessive/binge drinking when on a trip such as this one. Rather than tightening the policy, it is possible that less restrictive conditions at the base is part of the answer.
Whichever view is taken of the above, whether it is a 2 can rule, 4 can rule or more, an important safeguard is the requirement for a soldier, normally an NCO, to be nominated as shark watch and to remain sober and vigilant. It is a well known and common sense concept. It is not clear to me if there is a formalised policy. I anticipate the system may operate differently depending on the personnel and location. In this case, the system did not operate effectively as the person nominated as shark watch did not appear to know that he had been nominated. Others who gave evidence were unclear about the existence or requirements of such a system.
In short, my concern is that there is not a realistic, workable, or widely understood policy that is capable of being enforced with regard to alcohol on Op Cabrit and that, furthermore, the role of shark watch is not given greater prominence.
Responses
Response received
View full response
Dear Mr Salter, Thank you for your Regulation 28: Report to Prevent Future Deaths dated 3 August 2021 following the Inquest into the very sad death of Corporal Ryan Lovatt. You concluded his death was accidental and highlighted your concerns that an accident of this type could occur again without further action from the Ministry of Defence (MOD). The MOD and I take the health and safety of members of the Armed Forces very seriously and I very much share your desire to prevent any such recurrence. I am grateful to you for bringing your findings to my attention and I set out below the steps that have been taken on the issues you have raised. As you highlight in your report, the environment experienced by personnel deployed on Operation CABRIT is unusual. They are providing formal defence output in a contested information space, where vigilance is constantly necessary to minimise the risk of operational or reputational compromise, but in a European nation where there are significant similarities with the UK. Balancing operational readiness, the preparedness to meet a threat with military force, with the requirement to maintain the mental wellbeing of our soldiers whilst deployed is a constant challenge. On Op CABRIT, attempts are made to create opportunities for those deployed to step away from the intensity of their role to relax and recharge. Whilst alcohol consumption is not a primary focus of this activity, it is one of the many UK norms, not usually present on operations, that the operation looks to permit in a controlled manner. Commanders constantly review Force Protection policies, which include rules on alcohol consumption and supervision outside camp.
Matters of Concern – "my concern is that there is not a realistic, workable, or widely understood policy that is capable of being enforced with regard to alcohol on Op Cabrit and that, furthermore, the role of shark watch is not given greater prominence."
The ‘2-can rule’, which was used on Op CABRIT at the time of this incident, is commonly ordered by all three armed Services on Operations and Exercises where alcohol is permitted but there is a requirement to limit consumption to ensure maintenance of operational effectiveness. On Op CABRIT it was briefed on arrival in theatre and on each occasion before leaving camp. Failure to adhere to standing orders, including alcohol restrictions, is addressed by commanders through a combination of administrative and disciplinary measures.
Nonetheless, following this incident there was a comprehensive review of the force protection policy on Op CABRIT. This review has replaced the 2-can rule with impact criteria, moving focus from the amount of alcohol consumed to the negative effects of consumption, in particular on the behaviour of personnel. This more nuanced direction states soldiers must “drink in moderation” ensuring they do not allow their judgement to become impaired or their behaviour to fall short of the Army’s values and standards. It is combined with an education programme regarding the consequences of excessive alcohol consumption. I believe removal of the universal 2-can limit ties in with your remark that a less restrictive alcohol policy may reduce temptation to engage in excessive drinking when off camp. The current alcohol policy is at Paras 19–25 of Enclosure 1.
This policy review also considered whether the existing Sharkwatch direction was sufficient. Sharkwatch is an established military protocol, which grew out of requirements in Northern Ireland and West Germany to prevent soldiers being taken advantage of by those who wished them harm (‘sharks’). A member of the group is nominated to remain sober, to keep watch in a supervisory role. It was outlined in the Force Protection policy that was extant at the time of Corporal Lovatt’s death, but there was no explicit direction that the nominated individual should acknowledge their responsibility. The Sharkwatch policy was amended on 13 Nov 19 to include written orders which include the requirement to keep the group together, to return everyone safely to their overnight location and to report any deviation from orders to the Chain of Command. These orders are to be signed by the nominated individual and retained by the commander. I believe that this change has effectively addressed your concerns about the understanding of this policy and prominence of the role. The current, updated Sharkwatch policy is at Enclosure 2.
Part 1 Orders are issued daily and required to be read by all ranks. These orders contain regular repeats of all aspects of the Force Protection policy, including the prevailing restrictions on alcohol and the actions required of duty personnel, including those undertaking Sharkwatch. This is targeted at ensuring an instinctive understanding of the alcohol and Sharkwatch policy at all levels among the deployed force. An example of recent Part 1 Orders from Poland is at Enclosure 3.
Thank you for writing to me about this important matter. The MOD is a learning organisation and I hope that my response has demonstrated that Defence has learned, and will continue to learn, lessons from the tragic death of Cpl Lovatt. I hope too that Cpl Lovatt’s family will draw some comfort from the knowledge that action has been taken to address your concerns.
Matters of Concern – "my concern is that there is not a realistic, workable, or widely understood policy that is capable of being enforced with regard to alcohol on Op Cabrit and that, furthermore, the role of shark watch is not given greater prominence."
The ‘2-can rule’, which was used on Op CABRIT at the time of this incident, is commonly ordered by all three armed Services on Operations and Exercises where alcohol is permitted but there is a requirement to limit consumption to ensure maintenance of operational effectiveness. On Op CABRIT it was briefed on arrival in theatre and on each occasion before leaving camp. Failure to adhere to standing orders, including alcohol restrictions, is addressed by commanders through a combination of administrative and disciplinary measures.
Nonetheless, following this incident there was a comprehensive review of the force protection policy on Op CABRIT. This review has replaced the 2-can rule with impact criteria, moving focus from the amount of alcohol consumed to the negative effects of consumption, in particular on the behaviour of personnel. This more nuanced direction states soldiers must “drink in moderation” ensuring they do not allow their judgement to become impaired or their behaviour to fall short of the Army’s values and standards. It is combined with an education programme regarding the consequences of excessive alcohol consumption. I believe removal of the universal 2-can limit ties in with your remark that a less restrictive alcohol policy may reduce temptation to engage in excessive drinking when off camp. The current alcohol policy is at Paras 19–25 of Enclosure 1.
This policy review also considered whether the existing Sharkwatch direction was sufficient. Sharkwatch is an established military protocol, which grew out of requirements in Northern Ireland and West Germany to prevent soldiers being taken advantage of by those who wished them harm (‘sharks’). A member of the group is nominated to remain sober, to keep watch in a supervisory role. It was outlined in the Force Protection policy that was extant at the time of Corporal Lovatt’s death, but there was no explicit direction that the nominated individual should acknowledge their responsibility. The Sharkwatch policy was amended on 13 Nov 19 to include written orders which include the requirement to keep the group together, to return everyone safely to their overnight location and to report any deviation from orders to the Chain of Command. These orders are to be signed by the nominated individual and retained by the commander. I believe that this change has effectively addressed your concerns about the understanding of this policy and prominence of the role. The current, updated Sharkwatch policy is at Enclosure 2.
Part 1 Orders are issued daily and required to be read by all ranks. These orders contain regular repeats of all aspects of the Force Protection policy, including the prevailing restrictions on alcohol and the actions required of duty personnel, including those undertaking Sharkwatch. This is targeted at ensuring an instinctive understanding of the alcohol and Sharkwatch policy at all levels among the deployed force. An example of recent Part 1 Orders from Poland is at Enclosure 3.
Thank you for writing to me about this important matter. The MOD is a learning organisation and I hope that my response has demonstrated that Defence has learned, and will continue to learn, lessons from the tragic death of Cpl Lovatt. I hope too that Cpl Lovatt’s family will draw some comfort from the knowledge that action has been taken to address your concerns.
Report Sections
Investigation and Inquest
On 23rd June 2021 at Oxford Coroner’s Court I conducted the inquest into the tragic death of Cpl Ryan Lovatt in Warsaw in the early hours of 1st August 2019 when he fell from his hotel balcony. I returned a conclusion of Accident and found as follows; Cpl Ryan Lovatt was based in Poland and on an organised cultural visit with army colleagues to Warsaw on 31st July 2019 and 1st August 2019. He was drinking heavily on the evening of 31st July 2019 and early hours of 1st August 2019 and was intoxicated with alcohol but also pepper sprayed by a bouncer on leaving a club. He was put to bed by a colleague in his 7th floor room in the City Comfort hotel but subsequently fell, accidently and unwitnessed, from the balcony of his room to his death. Cpl Lovatt’s family attended the inquest. They were represented by Counsel, . The MOD were also represented by Counsel, . A number of witnesses attended (remotely) to give oral evidence. This included friends and colleagues of Cpl Lovatt who were out with him on the night in question.
Circumstances of the Death
As will be seen from the above, Cpl Lovatt fell accidentally to his death at a time when he was intoxicated with alcohol. The fall was unwitnessed. There was no evidence of suspicious circumstances or third-party involvement and no evidence that this was an intentional act on his part. Cpl Lovatt was part of a small group of soldiers on what was an organised cultural trip to Warsaw. Following the schedule of trips during the day, he and the others went to their hotel to prepare for a night out. Some went for a meal and returned quite early to the hotel but the others including Cpl Lovatt went drinking in bars/clubs until, it seems, the early hours. It is clear that this involved heavy drinking and drunkenness. There were two incidents outside clubs where some members of the group were pepper sprayed by door staff but, on the evidence I heard, this appeared to be unprovoked and heavy handed. Cpl Lovatt was pepper sprayed during the second incident and returned to the hotel in a taxi with a colleague who took him to his room. A short time later the accident occurred.
I heard evidence about Op Cabrit and a force protection policy with regard to drinking alcohol, Annexe E, and the extension of the normal 2 can rule to 4 cans on cultural trips such as this one. I also heard evidence about curfews and a stipulation that a member of the group should be appointed as ‘shark watch’ with the responsibility of remaining sober and being in a supervisory capacity. It was clear however from the evidence I heard from the soldiers that this system was not well understood and not complied with.
I heard evidence about Op Cabrit and a force protection policy with regard to drinking alcohol, Annexe E, and the extension of the normal 2 can rule to 4 cans on cultural trips such as this one. I also heard evidence about curfews and a stipulation that a member of the group should be appointed as ‘shark watch’ with the responsibility of remaining sober and being in a supervisory capacity. It was clear however from the evidence I heard from the soldiers that this system was not well understood and not complied with.
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who in my opinion should receive it
You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 03 August 2021
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.