Malik Bunton
PFD Report
All Responded
Ref: 2025-0519
All 1 response received
· Deadline: 10 Dec 2025
Coroner's Concerns (AI summary)
Inadequate inquiry into a previous incident, flawed clinical review processes, and deliberate obstructions to evidence gathering impeded the RAF's ability to assess suicide risk and learn lessons.
View full coroner's concerns
While I was unable to conclude that the following concerns caused or contributed to Mr Bunton’s death, I make this report as I consider they impeded the ability of the RAF to properly assess Mr Bunton’s suicide risk and, if repeated, will continue to impede the ability of the RAF to learn lessons from his death and mitigate future risk to other service personnel.
1. There was insufficient inquiry made of Mr Bunton and those service personnel most closely involved with the 26 March 2023 incident as to the circumstances in which it occurred. While it was accepted that Mr Bunton chose to minimise the incident, it could easily have been established by proper inquiry of these parties that Mr Bunton had sent a concerning message before entering the water with suicidal intent, and then been taken by the police to hospital where he was offered psychiatric assessment. The results of these OFFICIAL inquiries would have better informed subsequent oversight of Mr Bunton’s welfare by his Chain of Command.
2. There were weaknesses in the Clinical Care Review process undertaken by the Defence Medical Service following Mr Bunton’s death. While the review of the 11 July 2023 consultation occurred very promptly after Mr Bunton’s death, the GP involved in the consultation was unaware that her informal discussion of the case with a senior colleague was being captured as part of a formal review process. She was also never asked to check the accuracy of the contents of the review document produced following this discussion, which compromised the accuracy of the review document itself, as well as impacting on evidence subsequently available to the Service Inquiry and the inquest. The purpose of the Clinical Care Review process is to identify any concerns around clinical decision-making and mitigate the risk of recurrence of the same, and should therefore be based on a clear and verified record of events.
3. There were inexplicable delays and some apparent deliberate obstructions to the gathering of important evidence from key witnesses. This impacted on the extent and quality of evidence ultimately available to both the Service Inquiry and the inquest. Examples of this were –
- The long delays in obtaining formal accounts from key witnesses either in writing or via an interview process.
- The absence of any account from Mr Bunton’s colleague who attended hospital with him following the 26 March 2023 incident. Such an account would have informed the process of inquiry referred to at point 1 above as well as the Service Inquiry and inquest.
- The decision to delete Mr Bunton’s service email account without consideration of its potential importance in the context of a suspected suicide.
- Withholding statements of two key witnesses from the Service Inquiry panel for some months following Mr Bunton’s death.
- The absence of a clear and contemporaneous account of the 11 July 2023 GP consultation, either in the Clinical Care Review document and/or a separate formal account of events obtained from the doctor concerned.
1. There was insufficient inquiry made of Mr Bunton and those service personnel most closely involved with the 26 March 2023 incident as to the circumstances in which it occurred. While it was accepted that Mr Bunton chose to minimise the incident, it could easily have been established by proper inquiry of these parties that Mr Bunton had sent a concerning message before entering the water with suicidal intent, and then been taken by the police to hospital where he was offered psychiatric assessment. The results of these OFFICIAL inquiries would have better informed subsequent oversight of Mr Bunton’s welfare by his Chain of Command.
2. There were weaknesses in the Clinical Care Review process undertaken by the Defence Medical Service following Mr Bunton’s death. While the review of the 11 July 2023 consultation occurred very promptly after Mr Bunton’s death, the GP involved in the consultation was unaware that her informal discussion of the case with a senior colleague was being captured as part of a formal review process. She was also never asked to check the accuracy of the contents of the review document produced following this discussion, which compromised the accuracy of the review document itself, as well as impacting on evidence subsequently available to the Service Inquiry and the inquest. The purpose of the Clinical Care Review process is to identify any concerns around clinical decision-making and mitigate the risk of recurrence of the same, and should therefore be based on a clear and verified record of events.
3. There were inexplicable delays and some apparent deliberate obstructions to the gathering of important evidence from key witnesses. This impacted on the extent and quality of evidence ultimately available to both the Service Inquiry and the inquest. Examples of this were –
- The long delays in obtaining formal accounts from key witnesses either in writing or via an interview process.
- The absence of any account from Mr Bunton’s colleague who attended hospital with him following the 26 March 2023 incident. Such an account would have informed the process of inquiry referred to at point 1 above as well as the Service Inquiry and inquest.
- The decision to delete Mr Bunton’s service email account without consideration of its potential importance in the context of a suspected suicide.
- Withholding statements of two key witnesses from the Service Inquiry panel for some months following Mr Bunton’s death.
- The absence of a clear and contemporaneous account of the 11 July 2023 GP consultation, either in the Clinical Care Review document and/or a separate formal account of events obtained from the doctor concerned.
Responses
Action Taken
The RAF has directed that all suspected suicides will now be subject to an immediate fact-finding investigation, formally brought into the RAF Postvention Suicide Response policy. Further direction and guidance has been issued to ensure delays in providing statements to the Service Inquiry panel are avoided in the future, and the Defence Inquests Unit is working to implement a process to retain email accounts of deceased service personnel. (AI summary)
The RAF has directed that all suspected suicides will now be subject to an immediate fact-finding investigation, formally brought into the RAF Postvention Suicide Response policy. Further direction and guidance has been issued to ensure delays in providing statements to the Service Inquiry panel are avoided in the future, and the Defence Inquests Unit is working to implement a process to retain email accounts of deceased service personnel. (AI summary)
View full response
Dear Ms Cundy,
Thank you for your report of 15 October 2025 to the Defence Secretary following your Inquest into the death of AS1 Malik Bunton. First and foremost, I would like to offer my sincere condolences to AS1 Bunton’s family, friends and colleagues.
You have raised concerns regarding the welfare support provided to and oversight of AS1 Bunton, the clinical care review process, and the recovery of evidence. I take the health and wellbeing of our Armed Forces personnel extremely seriously and wholly share your desire to prevent future deaths. I have considered each of your concerns below.
The Chain of Command’s management of AS1 Bunton’s welfare.
I have sought assurance that the Chain of Command at RAF stations are equipped and trained to respond to welfare concerns and that effective welfare training is provided to them. I am assured that the training and processes in place enables managers to safeguard the welfare of their personnel, and I am aware that the RAF has reiterated the importance of ensuring it is continually developed. I will continue to ensure that Defence does all it can to care for its personnel.
It is of course unfortunate that the full details of the River Ouse incident were not known to the Chain of Command in the immediate aftermath of the incident. I am assured that the Chain of Command acted properly based on the information available to them at the time and having had no prior concerns regarding AS1 Bunton’s mental health or welfare.
The Clinical Care Review (CCR) Process
On receipt of your report, the Defence Medical Services (DMS) conducted a review of the CCR undertaken after AS1 Bunton’s death. I can confirm that the CCR was shared by the Senior Medical Officer with the GP. Unfortunately, due to the passage of time, the GP was unable to recall this fact at the inquest. However, I am assured that the correct process was followed in relation to the CCR, and that independent scrutiny was applied to ensure early recommendations for learning were identified and implementation plans were put in place. Defence Primary Health Care regularly review their policies and processes, and recent and separate work has focused on enhancing the approach to clinical reviews of serious healthcare incidents. A key development is the introduction of an early
THE LORD COAKER MINISTER FOR THE HOUSE OF LORDS
MINISTRY OF DEFENCE FLOOR 5 ZONE B MAIN BUILDING WHITEHALL LONDON SW1A 2HB
review by an experienced and independent Learning Event Review Panel, which will supplement the individual review conducted by a local clinician. Additionally, a new Significant Event Reporting system is being developed in partnership with the DMS Healthcare Assurance team to improve recording of reviews and the ability to implement lessons. This will also include a specific requirement to share CCRs with the clinicians involved in the case. These developments build on the existing process to ensure that the CCR process remains a robust mechanism to identify concerns and mitigate the risk of recurrence.
Recovery of Evidence
The loss of AS1 Bunton was and remains a deeply profound tragedy for those who knew him within the RAF. I fully recognise and appreciate the challenging and unprecedented circumstances faced by station personnel at RAF Leeming in the latter half of 2023 to manage wider welfare concerns and safeguard the duty of care to those service personnel most impacted by AS1 Bunton’s death.
Nevertheless, we acknowledge the need for a more robust post incident process within the RAF that gathers relevant material in the immediate hours and days following an event. To address this, the Head People and Families Support, as the RAF lead for personnel welfare, has directed that all suspected suicides within the RAF will now be subject to an immediate fact-finding investigation. This process is designed to ensure timely, compassionate, and thorough understanding of the circumstances surrounding such incidents. Responsibility for gathering this evidence and conducting an initial investigation will rest with the Station Commander and will be formally brought into the RAF Postvention Suicide Response policy as a matter of urgency.
Regarding the delay in providing statements to the Service Inquiry panel, I understand that the statements in question were prepared for the inquest, and I am assured that the delay arose from a desire to adhere to the appropriate disclosure processes. However, further direction and guidance has been issued to ensure such delays are avoided in the future. Furthermore, the Defence Inquests Unit is working to implement a process to retain, where appropriate, the email accounts of deceased service personnel. This will allow for the retrieval of relevant data, should it be required for inquests.
Once again, my deepest condolences go out to AS1 Bunton’s family and all those impacted by his passing. Thank you for bringing these important matters to my attention. I hope my response has assured you that the MOD is committed to ensuring that our processes and policies are robust, transparent and effective and
THE LORD COAKER MINISTER FOR THE HOUSE OF LORDS
MINISTRY OF DEFENCE FLOOR 5 ZONE B MAIN BUILDING WHITEHALL LONDON SW1A 2HB
that we are able to truly learn lessons so we can improve the support provided to our personnel.
Thank you for your report of 15 October 2025 to the Defence Secretary following your Inquest into the death of AS1 Malik Bunton. First and foremost, I would like to offer my sincere condolences to AS1 Bunton’s family, friends and colleagues.
You have raised concerns regarding the welfare support provided to and oversight of AS1 Bunton, the clinical care review process, and the recovery of evidence. I take the health and wellbeing of our Armed Forces personnel extremely seriously and wholly share your desire to prevent future deaths. I have considered each of your concerns below.
The Chain of Command’s management of AS1 Bunton’s welfare.
I have sought assurance that the Chain of Command at RAF stations are equipped and trained to respond to welfare concerns and that effective welfare training is provided to them. I am assured that the training and processes in place enables managers to safeguard the welfare of their personnel, and I am aware that the RAF has reiterated the importance of ensuring it is continually developed. I will continue to ensure that Defence does all it can to care for its personnel.
It is of course unfortunate that the full details of the River Ouse incident were not known to the Chain of Command in the immediate aftermath of the incident. I am assured that the Chain of Command acted properly based on the information available to them at the time and having had no prior concerns regarding AS1 Bunton’s mental health or welfare.
The Clinical Care Review (CCR) Process
On receipt of your report, the Defence Medical Services (DMS) conducted a review of the CCR undertaken after AS1 Bunton’s death. I can confirm that the CCR was shared by the Senior Medical Officer with the GP. Unfortunately, due to the passage of time, the GP was unable to recall this fact at the inquest. However, I am assured that the correct process was followed in relation to the CCR, and that independent scrutiny was applied to ensure early recommendations for learning were identified and implementation plans were put in place. Defence Primary Health Care regularly review their policies and processes, and recent and separate work has focused on enhancing the approach to clinical reviews of serious healthcare incidents. A key development is the introduction of an early
THE LORD COAKER MINISTER FOR THE HOUSE OF LORDS
MINISTRY OF DEFENCE FLOOR 5 ZONE B MAIN BUILDING WHITEHALL LONDON SW1A 2HB
review by an experienced and independent Learning Event Review Panel, which will supplement the individual review conducted by a local clinician. Additionally, a new Significant Event Reporting system is being developed in partnership with the DMS Healthcare Assurance team to improve recording of reviews and the ability to implement lessons. This will also include a specific requirement to share CCRs with the clinicians involved in the case. These developments build on the existing process to ensure that the CCR process remains a robust mechanism to identify concerns and mitigate the risk of recurrence.
Recovery of Evidence
The loss of AS1 Bunton was and remains a deeply profound tragedy for those who knew him within the RAF. I fully recognise and appreciate the challenging and unprecedented circumstances faced by station personnel at RAF Leeming in the latter half of 2023 to manage wider welfare concerns and safeguard the duty of care to those service personnel most impacted by AS1 Bunton’s death.
Nevertheless, we acknowledge the need for a more robust post incident process within the RAF that gathers relevant material in the immediate hours and days following an event. To address this, the Head People and Families Support, as the RAF lead for personnel welfare, has directed that all suspected suicides within the RAF will now be subject to an immediate fact-finding investigation. This process is designed to ensure timely, compassionate, and thorough understanding of the circumstances surrounding such incidents. Responsibility for gathering this evidence and conducting an initial investigation will rest with the Station Commander and will be formally brought into the RAF Postvention Suicide Response policy as a matter of urgency.
Regarding the delay in providing statements to the Service Inquiry panel, I understand that the statements in question were prepared for the inquest, and I am assured that the delay arose from a desire to adhere to the appropriate disclosure processes. However, further direction and guidance has been issued to ensure such delays are avoided in the future. Furthermore, the Defence Inquests Unit is working to implement a process to retain, where appropriate, the email accounts of deceased service personnel. This will allow for the retrieval of relevant data, should it be required for inquests.
Once again, my deepest condolences go out to AS1 Bunton’s family and all those impacted by his passing. Thank you for bringing these important matters to my attention. I hope my response has assured you that the MOD is committed to ensuring that our processes and policies are robust, transparent and effective and
THE LORD COAKER MINISTER FOR THE HOUSE OF LORDS
MINISTRY OF DEFENCE FLOOR 5 ZONE B MAIN BUILDING WHITEHALL LONDON SW1A 2HB
that we are able to truly learn lessons so we can improve the support provided to our personnel.
Sent To
- Ministry of Defence
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56-Day Deadline
10 Dec 2025
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 20 July 2023 I commenced an investigation into the death of Malik BUNTON aged 21. The investigation concluded at the end of the inquest on 03 October 2025. The conclusion of the inquest was that he died as a result of suicide.
Circumstances of the Death
On the evening of the 17th of July 2023 Malik Bunton was found suspended from a ligature . His death was confirmed at the scene on the same date. During the inquest I heard evidence in relation to two separate incidents of self harm/suicidal ideation which preceded Mr Bunton's death. The first occurred on 26 March 2023 when Mr Bunton entered the River Ouse while intoxicated and with suicidal intent. The second occurred on 11 July 2023 when Mr Bunton consulted with a GP in the Defence Medical Service in relation to self harm . He was referred to secondary defence mental heath services for assessment but sadly took his own life six days later.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.