Charlie Owen
29 Nov 2024 · Coroner Robert Simpson · Berkshire
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. risk of self-harm on return to unit
“army VRM guidance does not invite those attending case conferences to consider 'checking in' or meeting those assessed as posing a risk of self-harm on return to their unit”
2. insufficient suicide prevention training for welfare officers
“suicide prevention training is not mandatory for army welfare officers/welfare NCOs”
3. insufficient focus on reducing risk and preventing suicide in VRM training
“insufficient focus in that training on the actual aim including reducing risk and preventing suicide”
4. information sharing challenges
“information sharing between medical and command personnel poses challenges”
5. lack of detail in case conference notes
“lack of detail contained within the case conference notes hindered this inquest's ability to establish precisely what risk information was shared”
6. information not shared with Chain of Command
“information contained about relevant protective factors and safety actions is not necessarily shared with the Chain of Command”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.”
This report
“The lack of detail contained within the case conference notes hindered this inquest's ability to establish precisely what risk information was shared.”
Closely relatedConfidence 0.92 · high
Earlier report
“The medical care provided to service personnel through the DCMH is not truly independent, in that personal medical information may be disclosed to Chain of Command where substantial public interest demands disclosure”
This report
“I was concerned to hear that when a risk management and safety plan has been prepared by the Defence mental health services the information contained about relevant protective factors and safety actions is not necessarily shared with the Chain of Command.”