Source · Prevention of Future Deaths

Charlie Owen

Ref: 2024-0665 Date: 29 Nov 2024 Coroner: Robert Simpson Area: Berkshire Responses identified: 1 / 1 View PDF

The army's vulnerability risk management process fails to ensure 'check-ins' for high-risk soldiers, and suicide prevention training for welfare officers is not mandatory. Inadequate information sharing and documentation between medical and command personnel further hinder support and risk reduction.

Date 29 Nov 2024

56-day deadline 24 Jan 2025 est.

Responses identified 1 of 1

Service Personnel related deaths Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

Vulnerability Risk Management (VRM) process I heard evidence that the 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. In this inquest no consideration was given to this possibility even though Charlie posed an elevated level of risk and had been initially placed under the VRM process whilst at home. This gives rise to a concern that the army does not know where soldiers who pose a risk are and does not facilitate additional support that may be necessary. I accept the evidence I heard that different units will have different requirements but this would not prevent them from giving consideration of this issue. Training I heard that suicide prevention training is not mandatory for army welfare officers/welfare NCOs. This gives rise to a concern that those specifically tasked to deal with people who are most likely to pose a risk of suicide or self harm are not best equipped to identify this and assist the individual. I heard evidence regarding the VRM process training. I am concerned that there is insufficient focus in that training on the actual aim including reducing risk and preventing suicide. A better understanding of risks and the purpose of VRM seems likely to assist those tasked with running it. Information sharing Witnesses for the army have noted that information sharing between medical and command personnel poses challenges. I am concerned that the VRM process does not require adequate documentation of the information shared. The lack of detail contained within the case conference notes hindered this inquest’s ability to establish precisely what risk information was shared. This gives rise to a concern that audits of effectiveness and potential learning points are being missed. 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. There is no prompt on the relevant template to remind of team of the potential benefit of sharing this information or requesting consent from the individual in question to do so which gives rise to a concern that this important information is not shared.

Responses

1 respondent

Ministry of Defence Central Government

7 Feb 2025 PDF

Action Planned

The Ministry of Defence is currently undergoing a comprehensive review of the policy that supports the Army’s VRM Process, with plans to reissue the policy by the end of March 2025. Additionally, record keeping and information sharing improvements will be factored into the policy review of the Army's VRM process. (AI summary)

View full response

Dear Mr Simpson,

REF: YOUR REGULATION 28 REPORT TO PREVENT FUTURE DEATHS DATED 29 NOVEMBER 2024

Thank you for your letter of 29 November 2024 to the Ministry of Defence enclosing your Regulation 28 Report following the sad death of LCpl Owen on 11 September 2023. My deepest sympathies go out to LCpl Owen’s mother and his wider family and friends.

The Secretary of State for Defence has asked me to respond, and I am grateful for your thorough inquest into LCpl Owen’s death. I would like to take this opportunity to reassure you that suicide prevention is taken very seriously by the Armed Forces, and is something which I am personally, very committed to. I have carefully considered your observations and the recommendations raised in your Regulation 28 Report to ensure that future deaths are prevented. I have tried to address each of your points below.

Matter of Concern 1: Vulnerability Risk Management (VRM) process

The policy that supports the Army’s VRM Process is currently undergoing a comprehensive review. The plan is to reissue the policy by the end of March 2025. I expect this to further improve the process, while also making it easier to understand and action.

The review of the VRM policy will reassure you that we seek to continuously improve our approach to suicide prevention and that caring for our vulnerable personnel is of paramount importance.

Matter of Concern 2: Training

Suicide prevention training is already mandatory for Army Welfare Officers. I am sorry that this did not come through clearly at the inquest. This is clearly a point of concern and therefore, a working group is being established to fully review all aspects of the training for mental health and wellbeing. I expect the recommendations to be published by April 25 to inform an update to training policy in the following quarter. Your comments concerning a greater focus upon suicide prevention; understanding risk, and the purpose of VRM, will be included within this review.

Matter of Concern 3: Information sharing

Your concern about the adequacy of record keeping and the sharing of the risk management plan will be factored into the policy review of the Army’s VRM Process and templates will be amended accordingly. Additionally, consideration will be given to directing units on what information should be captured, recorded, shared, and kept, during and after case conferences.

Regarding wider information sharing, particularly between Defence mental health services and the Chain of Command (CoC), it is clear we need to improve. Work has already been done by the Defence Medical Services (DMS) Clinical Reference Group (CRG) around information sharing practices. This work comprises a three-pronged approach:

• Better communication with patients, including obtaining patient consent for information sharing with the chain of command;

• Where appropriate, greater involvement of families (usually spouse or parents) in the delivery of specialist mental healthcare; and

• Wider sharing of best practice, including the Department of Health and Social Care’s Consensus Statement and the Zero Suicide Alliance’s guidance.

Of course this is not an end in itself, and we will continue to assess whether we are getting this right and where we can improve.

I hope that my response highlights the steps that the Ministry of Defence has and will continue to take to improve the Army’s VRM process and policy, suicide prevention and VRM training and information sharing. I appreciate your thorough investigation and challenge, both of which is essential so that the MOD can continue to learn lessons and ensure that this government provides the support our Armed Forces need. As ever, my thoughts remain with LCpl Owen’s family and all those affected by his very sad death.

*

Report sections

Investigation and inquest

On 15 September 2023 I commenced an investigation into the death of Charlie Anthony OWEN aged 25. The investigation concluded at the end of the inquest on 29 November 2024. The conclusion of the inquest was that: The deceased ended his life by suicide. The assessment of the level of risk posed was appropriate as was the overall plan to address this risk. However there was a failure to pass on all of the pertinent risk management information to those making decisions; the full purpose of asking the deceased to return to barracks was not communicated effectively to him, protective factors mitigating the resulting lack of proximity to family, including meeting him or assessing his welfare on arrival, were not considered. These factors taken together may possibly have contributed to his death on that day.

Circumstances of the death

On the 11th September 2023 Charlie Anthony Owen was found deceased in his room at the Combermere Barracks, Windsor. On the 5th September 2023 he had taken action to end his own life which he aborted and sought help from his lieutenant. This was the second time that he had made, and aborted, an attempt to end his own life; both of which occurred in the context of relationship breakdown. The army arranged a medical and mental health assessment and Charlie denied current intent to end his life in all subsequent conversations with medical and army personnel. Charlie was still assessed as posing a risk to himself and was called back to his battalion. This was for further assessment and treatment as well as a return to work. Not all relevant information was shared and considered when plans were made for his return. He left his family home in Wales on the 10th September; having prepared notes indicating an intent to end his life at some point prior to this. After returning to barracks he hung himself.

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Report details

Reference: 2024-0665
Date of report: 29 November 2024
Coroner: Robert Simpson
Coroner area: Berkshire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 24 Jan 2025 (estimated).

Sent to

Ministry of Defence

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.