Neil McDougall
PFD Report
All Responded
Ref: 2022-0251
All 1 response received
· Deadline: 28 Nov 2022
Coroner's Concerns (AI summary)
Military debriefs lack individual trauma support and promote alcohol use over discussion. The resettlement process for leavers fails to provide mandatory comprehensive mental health assessments, leaving ex-personnel reliant on external services.
View full coroner's concerns
(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 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.
(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 result of active service. ACTION SHOULD BETAKEN
(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 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.
(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 result of active service. ACTION SHOULD BETAKEN
Responses
Action Taken
The Army has current policies and procedures to minimise the risk of suicide within the ranks of serving military personnel and the veteran community including education to tackle stigma, providing rapid and flexible access to trauma risk management, and through comprehensive support to personnel transitioning to civilian life. The response includes enclosures detailing specific policies, briefings, and healthcare arrangements. (AI summary)
The Army has current policies and procedures to minimise the risk of suicide within the ranks of serving military personnel and the veteran community including education to tackle stigma, providing rapid and flexible access to trauma risk management, and through comprehensive support to personnel transitioning to civilian life. The response includes enclosures detailing specific policies, briefings, and healthcare arrangements. (AI summary)
View full response
MOD Main Building Chief of the General Staff 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 ofbeing physically and mentally resilient. The debrief orrecovery process in itself appeared to centre more around the consumption ofalcohol 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"
1. Addressing Stigma. In court, you were informed about the mutually supporting policies of 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.
3. Furthermore, following a complete review of the underpinning evidence, TRiM policy and 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.
6. The Armed Forces carries out considerable research into the health and wellbeing of Armed 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.
7. Decompression. You make reference to a lack of 1-to-1 sessions and a focus on the 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). 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) 2
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 ofthe 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 ofthe mental health and/or wellbeing of those leaving the Army. I can see no justification for some elements ofre-settlement/re-integration being mandatory whilst others remain purely optional. I believe that there should be some assessment and coordination ofthe 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"
8. Your second and third matters of concern are fundamentally linked and therefore we will 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 regularly reviewed. All WIS personnel continue with self-development activities, training 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. 11 . In addition to the core Resettlement Programme, a bespoke service is also provided for the 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) 3
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:
a. Op COURAGE. In March 2021, NHS England launched Op COURAGE The Veterans' 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 million11 . (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} 4
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. (c) Care navigation - helping veterans and their carers find the local services best suited to their needs. (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. 5
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 ofthe rising figures and statistics, ex-military (predominantly men) who suffer from poormental health as a result ofactive 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 Affairs (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. Published 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:
a. The National Confidential Inquiry into Suicide and Safety in Mental Health - Suicide in 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.
c. The Veteran Friendly NHS GP Practice Initiative. Defence is now collaborating with the 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 6
, 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. AGAI 110 Vulnerability Risk Management dated Aug 20 (PDF)
2. JSP 950 Leaflet 2-7-1 Mental Health and Wellbeing Briefing Before, During and After Deployment dated Oct 20 (PDF)
3. Home Coming and Mental Health Brief dated Aug 13 (PPT)
4. AGAI 99 Command and Care of Wounded Injured and Sick Service Personnel dated Apr 22(PDF)
5. JSP 950 Leaflet 1-3-4 Healthcare Transition Arrangements for Military Personnel Leaving Defence Medical Services Care dated Sep 21 (PDF)
6. JSP 950 2-7-2 Section 11 Defence Mental Health Services dated Aug 22 (PDF)
7. JSP 950 Leaflet 2-7-5 Structured Mental Health Assessment dated Dec 20(PDF) 7
------------ --- - 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 ofbeing physically and mentally resilient. The debrief orrecovery process in itself appeared to centre more around the consumption ofalcohol 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"
1. Addressing Stigma. In court, you were informed about the mutually supporting policies of 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.
3. Furthermore, following a complete review of the underpinning evidence, TRiM policy and 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.
6. The Armed Forces carries out considerable research into the health and wellbeing of Armed 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.
7. Decompression. You make reference to a lack of 1-to-1 sessions and a focus on the 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). 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) 2
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 ofthe 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 ofthe mental health and/or wellbeing of those leaving the Army. I can see no justification for some elements ofre-settlement/re-integration being mandatory whilst others remain purely optional. I believe that there should be some assessment and coordination ofthe 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"
8. Your second and third matters of concern are fundamentally linked and therefore we will 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 regularly reviewed. All WIS personnel continue with self-development activities, training 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. 11 . In addition to the core Resettlement Programme, a bespoke service is also provided for the 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) 3
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:
a. Op COURAGE. In March 2021, NHS England launched Op COURAGE The Veterans' 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 million11 . (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} 4
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. (c) Care navigation - helping veterans and their carers find the local services best suited to their needs. (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. 5
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 ofthe rising figures and statistics, ex-military (predominantly men) who suffer from poormental health as a result ofactive 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 Affairs (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. Published 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:
a. The National Confidential Inquiry into Suicide and Safety in Mental Health - Suicide in 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.
c. The Veteran Friendly NHS GP Practice Initiative. Defence is now collaborating with the 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 6
, 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. AGAI 110 Vulnerability Risk Management dated Aug 20 (PDF)
2. JSP 950 Leaflet 2-7-1 Mental Health and Wellbeing Briefing Before, During and After Deployment dated Oct 20 (PDF)
3. Home Coming and Mental Health Brief dated Aug 13 (PPT)
4. AGAI 99 Command and Care of Wounded Injured and Sick Service Personnel dated Apr 22(PDF)
5. JSP 950 Leaflet 1-3-4 Healthcare Transition Arrangements for Military Personnel Leaving Defence Medical Services Care dated Sep 21 (PDF)
6. JSP 950 2-7-2 Section 11 Defence Mental Health Services dated Aug 22 (PDF)
7. JSP 950 Leaflet 2-7-5 Structured Mental Health Assessment dated Dec 20(PDF) 7
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Source: Courts and Tribunals Judiciary
Report Sections
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 medical cause of death being 1 (a) toxicity with a finding 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 Zl: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". CIRCUMSTANCES OF THE DEATH Neil had joined the military when he was 30 (2007). He remained with the Army until he was medically discharged 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 anxiety. He had an inpatient admission between 12th - 20th July 2017 with the 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 which 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.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.