Select Committee on Defence Third Report


366. The Surrey Police Final Report provides evidence that the Army chain of command was made aware of significant weaknesses in its training system at various times between 1995 and 2002 but failed to act to address them.[588] During this period, four internal Army reports and an internal working group, repeatedly identified welfare and supervision issues and made recommendations to rectify them. These were:

  • Brigadier Evans Report—Review of phase 2 Training System at Deepcut—December 1995
  • Suicide in the British Army—Dr Suzy Walton Parts 1-5—December 1996 onwards
  • In 1998 the Army Suicide Management Working Group (ASMWG), an internal Army working group, was established as a result of recommendations arising from Dr Walton's Suicide in the British Army Report
  • A Study of Attempted Suicide in the Army: 10 years of experience 1987-1996—Colonel Hawley October 1998
  • ATRA Duty of Care and Supervision (DoC&S) Report 1998-2001—Colonel Haes April 2001

However, these issues were neither considered nor acted upon in a coordinated manner. The Surrey Police report found that:

    there does not seem to have been any over-arching mechanism to risk assess the findings of these reports and determine, direct and monitor a credible and effective organisational response. Because the reports were never considered together, the first convincing evidence of the recognition of the systemic nature of these risks, and of a coherent practical response to them, was in October 2002 when the Deputy Adjutant General produced his report.[589]

367. Both the Surrey Police final report and the independent literature review we commissioned found several common issues concerning welfare in initial training establishments identified by these reports but that, between 1995 and 2002, the Army consistently failed to address them.[590] These issues were: supervision of recruits; recruitment and selection; training structure; accountability of ATRA command and firearms and guarding.

Reasons for failure

368. It is clear from the evidence we heard that, during the period 1995-2002, ATRA lacked an appropriately integrated structure through which welfare issues could be highlighted, solutions found, and responsibility for implementation acknowledged. As Chief Superintendent Craig Denholm, the officer in charge of the Surrey Police investigation, told us:

369. When the issues raised in these reports were addressed by the Army chain of command, they did so in a fragmented and piecemeal way with scant consideration given to wider implications for the training regime as a whole. For example, following the death in 1995 of Pte The survey is administered by training staff, but run and analysed by MORI.[592] All trainees have the opportunity to fill in the survey when they leave training, even if they are leaving before completing the course.[593] There have been individual surveys in the past which were described to us as 'snapshots' that could not be used to make comparisons.[594]

370. Following the deaths of Pte Cheryl James, and four months later of Pte Sean Benton at Deepcut barracks, the Commanding Officer, Brigadier Evans, conducted a review of phase 2 training at the RLC Deepcut barracks. Brigadier Evans made 30 recommendations, 23 of which he considered applicable solely to the Deepcut training regime and therefore actionable under his command. The remaining seven recommendations he believed had relevance for the wider ATRA training regime. We have received no evidence that any of these recommendations which related to supervision, screening, welfare, and pipeline management were assessed for relevance to other training establishments. As Surrey Police noted, 'Evans' external recommendations provided an opportunity to promulgate the Deepcut lessons across the Army. This opportunity was missed'.

371. When, six years later, Colonel Haes wrote his report 'ATRA Duty of Care and Supervision' he was unaware of the existence of not only the Evans report but also the 1996 Walton Report 'Suicide in the British Army', commissioned by the Army's Director of Personnel, and the 1998 thesis 'Attempted Suicide in the British Army' by Colonel Hawley. This was despite the relevance to Colonel Haes' study of some of the recommendations contained in these reports on issues such as supervision, screening, and welfare. Colonel Haes told us that 'Until I read the Surrey Police report that was the first time I became aware that other people had written the same kind of report that I had done'.[595]

372. This lack of institutional memory was compounded by ATRA's complacency when presented with evidence of weaknesses in its initial training system. This complacency was illustrated by the experience of Colonel Haes who, when describing the process of formulating his 2001 'ATRA Duty of Care and Supervision Report 1998-2001', told the Committee:

    I briefed the main board [of ATRA] in July 2000 with the findings I had got to at that point, and I think it was indicative that one of the two star officers present, as soon as I had finished, basically said "Thank you for that but I don't believe the picture is as bad as the boy has painted".[596]

373. When asked to account for the shortcomings in its duty of care regime between 1995 and 2002 MoD cited the demands on manpower experienced by the Armed Forces under the twin pressures of operational commitments and reduced levels of recruitment. A direct consequence was that the training system suffered as resources were moved to the Field Army. General Palmer told us that:

    As you will appreciate well, over that period the Army was very heavily committed and for the most part it was very under-recruited. So there were big gaps in the Field Army and they were at that time undertaking major operations: 1995 Bosnia, then there was Kosovo, Sierra Leone and on top of that there were firemen, foot and mouth, etcetera. So the context is significant over-commitment and a lot of under manning. There was significant risk operationally in the Field Army at the time. In order to look at these risks and how to mitigate their effects, a study was undertaken to see whether or not the support organisation—and that includes the training organisation—could help to reduce the under manning in the frontline and close some of these gaps. The view at the time—at the time and hindsight is all very well—was that the under manning in the Field Army was creating a significant operational risk. I cannot remember the exact date but about 250 people were moved out of the training organisation into the frontline. In addition to that there were attempts to see whether or not some private contracts could be let to undertake some of the training which was previously done by soldiers to try to relieve the pressure in the frontline. That happened as well.[597]

374. We recognise the pressures on resources experienced by the Army training system throughout the 1990s. However, we do not accept that this fully explains the Army's failure to provide the necessary organisational structure to expose problems in its training system at that time or to identify solutions and successfully implement improvements. Rather these failures were the result of an organisational culture that too readily transferred risk to its training regime when faced with operational demands. This is illustrated by ATRA Headquarters' dismissive response to the key recommendations in the Haes report, that a significant and rapid increase was needed in the number of ATRA instructors on the grounds that, 'the extra staff required was impractical in a climate where resources were over-stretched and functions were therefore under-manned'.[598]

375. For far too long in the past the Armed Forces, and the Army in particular, failed to grasp the nettle of duty of care. Arguments about the level of resources available and the need to divert resources to the front-line should not have been used to mask the Armed Forces' failure to tackle these issues in that period.

Developments since 2002

376. It was not until the summer of 2002, some five months after the death of Pte. Geoff Gray whilst on guard duty at Deepcut, that a significant and coherent attempt was made by MoD and the Army to address duty of care issues in its initial training establishments. These developments included:

377. The joint Police/Army Learning Account was established by Surrey Police with the Adjutant General's agreement in August 2002.[599] Its aim was to provide Surrey Police with a means to 'report to the Army issues that required timely and appropriate remedial action'. It also provided the Army with an auditable tracking and implementation process. By March 2004 the Learning Account contained 27 recommendations relating to risks identified in the training regime at Deepcut. These risks included: supervision policy, screening, dissemination of best practice and firearms/guarding. The Army has told us that these specific risks have been addressed.

378. In September 2002 the Adjutant General tasked the Deputy Adjutant General (DAG) to 'assist the Surrey Police by conducting a supporting military investigation in order to identify further lessons to be learned from all four (Deepcut) cases and to make recommendations'.[600] The resulting review compared the training system at Deepcut with that of other Army training establishments with the intention of identifying best practice and applying any resulting recommendations across the training regime. The review identified several areas of significant (and familiar) risk.[601] These were: supervision levels; screening; the number of Soldiers Awaiting Trade Training (SATT) and firearm/guarding; all of which had been previously identified in reports since 1995. The DAG review was the first occasion in which the Army applied recommendations in a coordinated way across the Army training regime. For example, changes in regulations on access to firearms, the introduction of the Military Provost Guard Service to take over routine security and guarding at training establishments and a recognition that SATT levels were too high. In particular, DAG's recommendation for an indicative instructor: trainee supervision ratio throughout ATRA led to the recognition by the Army that the numbers of supervisory personnel needed to be increased to levels very similar to those recommended by Colonel Haes and rejected by ATRA HQ only eighteen months previously.

379. The welcome decision by Mr Adam Ingram MP, the Minister for the Armed Forces, on 3 October 2002 to task the Directorate of Operational Capability (DOC) to conduct an appraisal of the initial training of non-officer recruits of all three Services (including initial and basic specialisation training) represented a significant change in attitude by MoD in that, for the first time, it had initiated an assessment of its three training systems.[602] The aim of the appraisal, which reported directly to the Minister, was to provide a health check of training regimes and examine possible issues of morale, motivation, training practices and culture. The autumn 2002 appraisal was followed by reappraisals in the summer of 2003 and the autumn of 2004 to check progress against the recommendations identified in the original appraisal.[603] All three appraisals were based on the outcome of questionnaires and personal interviews with thousands of recruits and trainees as well as instructors and commanding officers.

380. DOC (1), whilst assessing that 'the department has a lean hard worked initial training system in which it can have considerable confidence', found that the training system due to the high volume of throughput of trainees and too few supervisors, was 'inherently fragile'.[604] In general terms DOC (1) called for a rapid increase in supervisor numbers, improved management of recruit numbers through the training system and improved accommodation for trainees and instructors. This should be underpinned by 'additional investment in the initial training pipeline or adjustments to intake flows…This has the potential to transform radically the Initial Training environment and reverse years of under-investment in this key area of operational capability'.[605]

381. DOC (3) recognised that although 'It was evident that considerable energy, imagination and leadership are being applied in an effort to improve the regime in which phase 1 and phase 2 trainees are trained', further progress needed to be made particularly in the areas of management of SATT, out of hours supervision and accommodation.[606]

382. We welcome the evaluation work that the DOC team has carried out in its three appraisals. However, questions remain over whether an internal MoD audit team whose 'primary purpose was to provide a strengthened ability to assess defence-wide operational capability through a process of operational audit' was the most suitable agency for assessing welfare systems in initial training teams.[607] The Director of Operational Capability, Brigadier Mungo Melvin, told us that, in his opinion, his team was suitable for the task because they:

    have all got command experience and a lot of operational experience and… they have all been selected for their analytical skills and are people with a good deal of intellectual rigour, and they are prepared to go in and look behind what they are presented with, so it is the overall balanced professional skills which they bring to bear that provide them with the capability, in my opinion, to do the job that you have outlined.[608]

383. We recognise the commitment and integrity with which the Directorate of Operational Capability has approached its three evaluations of initial training. We also recognise that these appraisals have successfully brought to the attention of MoD and the Armed Forces' chain of command the need for a focus on welfare and supervision issues in initial training. This has resulted in MoD providing extra resources for more supervisory personnel and to improve accommodation. We also welcome DOC's highlighting of areas of good practice, particularly in the management of SATT. The internal audit role of DOC is important and clearly has credibility in MoD. We recommend that DOC appraisals of initial training should be regular and ongoing.

384. The appointment of the Director General of Training and Education (DGT&E) in September 2002 was the first time that there had been a single joint focus in MoD for training and education policy.[609] The DGT&E is responsible for identifying and promoting the sharing of training and education good practice. In addition to developing and implementing training and education policies across the Services DGT&E is responsible for implementing the recommendations of the DOC appraisals. The DGT&E, Rear Admiral Simon Goodall, told us that:

    Hitherto the activities of the single Services were all relatively silo­ed in this respect and so with this focal point at the centre of MoD, we now have an individual who can direct the implementation of recommendations. I have created, in essence, within my organisation a smaller clone of the DOC in the Directorate of Individual Training Capability, and I intend to use that aspect of my organisation to keep the pressure on and the momentum on with revisits by DOC and, in conjunction with the ALI, keeping our foot to the pedal. I think that is a significant change in the last two years.[610]

385. We welcome the establishment of the post of Director General of Training and Education as an important step in the development of a coordinated joint approach to training and education. We recommend that his remit be expanded to include responsibility for developing policies, priorities and targets for welfare across the three Services' training establishments. This would include the identification and active promotion of good practice across the Services.

Improvements since 2002

386. In its Final Report, Surrey Police acknowledges that the Army has made significant progress since 2002 (a "watershed" year). However they state that they:

387. In earlier chapters of this report we have described and commented on that progress. Admiral Goodall, DGT&E, told us that 'in implementing DOC, we have gained resources to implement, up to date, 48 of the 58 recommendations… this year £23.25 million were given to implement some key recommendations…'.[612] Tangible outcomes from extra investment have included: the re-establishment of 179 instructor posts previously moved to the Field Army in the late 1990's; the establishment of train the trainers courses at the Defence Centre for Training Support; changes to regulations pertaining to the supervision of guarding by trainees and evidence of some better management of SATT.

388. We are concerned however that MoD cannot guarantee resources in the future for the initial training regime. When we asked the Minister whether DOC's reports were the driver for ensuring extra resources now and in the future the Minister told us:

    The Treasury does not quite operate in that way with us. What happened was that I commissioned the report and I got those recommendations and said "I am now going to implement them" and you can imagine what happened next, "Where does the money come from"? You have to find out what the problem is and then you have to find the resource, and that was what was done. DOC gave us the platform on which to do that but I would just say that everyone else within the decision making chain are also seeking additional resource and this is something that has to be addressed.[613]

389. We welcome the fact that MoD has provided the necessary funds for the implementation of many of the DOC report recommendations. We recommend that MoD commits itself to providing the necessary additional resources for the full implementation of the DOC report.

390. As we have noted the Army does not historically have a good track record of committing the necessary resources to its initial training system. For that to change permanently in the future will require not just adequate resources but also a change of attitude. As Colonel Haes told us:

    Yes, there has been a sea change in attitude to duty of care and supervision. It is now flavour of the month, to use that phrase. I do have some cynicism from long years of experience as to whether it will be sustained.[614]

391. In essence MoD needs to ensure that the chain of command drives through a permanent change in attitude in the Army from one that accepts unnecessary risk in its training regime to one that considers effective welfare and training as vital to producing operationally effective Servicemen and women. As DOC himself stated: is not in our view a contradiction, it is part and parcel of operational capability that we have the right training regimes and we provide the right trained and qualified personnel going into each of the three Services to provide the bedrock of professional expertise.[615]

392. Effecting the culture change which we recommended earlier in an organisation as large and complex as the Army will be a significant challenge. It will require the provision of a training system which has the care of recruits at its heart whilst at the same time including sufficient rigour to produce, in a relatively short time-frame, operationally effective Servicemen. We recognise the establishment of forums such as the DOC Appraisal of initial training and best practice working group as a positive step for sharing good practice amongst Commanding Officers across the Services. We also welcome the establishment of the Defence Centre for Training Support, under the command of the DGT&E, as a positive signal that MoD is committed to promoting good practice on its train the trainer course.

393. We believe, however, that more can be done to share best practice, particularly in the Army and with the other two Services. We recommend that regular conferences of Commanding Officers and expert welfare professionals be established, at which changes in policy would be discussed and good practice identified and shared. We recommend that such seminars should also be a forum for the consideration of future reports on the Army's training system. The output of those meetings should then inform the work of the Director General of Training and Education.

394. We recommend that MoD encourage development of a community of welfare practitioners. This could include instructors, the Army Welfare Service, chaplains and medical officers. Such a community of practitioners could be a vehicle for the exchange of information on areas such as changes in legislation or policy, approaches to particular welfare issues or the identification of good practice. The process might involve conferences, web-based groups or in-house journals. We believe that such measures would promote an integrated approach to welfare concerns across the three Services.

395. An example of how good practice and lessons learned can be widely shared across the Services is the in-house magazine 'Aviate' concerned with flight safety. This magazine, which also has a web site, promulgates good practice, enables the exchange of real-life flying and ground crew experiences and stimulates discussions on flight safety issues. Flight safety issues are explored in a full and frank manner even if they could be considered to be critical of the chain of command. There is a sense that the magazine is written by and for practitioners and not to serve any internal political purpose.

396. We recommend that MoD consider providing resources for the establishment of a similar forum for welfare practitioners in all three Services. An in-house magazine and website could provide instructors with the means to share experiences of providing welfare in training establishments, promulgate good practice and provide instructors with a means of discussing welfare issues. We believe that such a magazine could significantly contribute to the sharing of good practice within the three Services.

588   Surrey Police Final Report Back

589   Ibid, para 4.10 Back

590   Literature Review and Analysis of Duty of Care in Armed Forces, Ivan Zverzhanovski, King's College London, October 2004. Back

591   Q 669

The Review of the Phase 2 Training System within Deepcut, conducted by Brigadier Evans Back

592   Qq 42, 1326 Back

593   Q 43 Back

594   Qq 1326-1336 Back

595   Q 269 Back

596   Q 243 Back

597   Q 11 Back

598   Surrey Police Final Report, para 2.94. Back

599   Ibid, paras 1.17-1.18, 3.45ff Back

600   Ibid, para 3.5 Back

601   Deputy Adjutant General Report-Deepcut investigation final report December 2002. Back

602   DOC (1) Back

603   DOC (2), DOC (3) Back

604   DOC (1), para 104 Back

605   Ibid, para 106 Back

606   DOC (3), para 7 Back

607   HC Deb, 19 December 1995, col 1106WA. Back

608   Q 767 Back

609   Q 48 Back

610   Q 781 Back

611   Surrey Police Final Report, p 3. Back

612   Q 50 Back

613   Q 1366 Back

614   Q 288 Back

615   Q 775 Back

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2005
Prepared 14 March 2005