Select Committee on Defence Third Report


Executive Summary

This report has been commissioned by the House of Commons Defence Committee as part of its inquiry into the duty of care regimes in initial training establishments in all three services of the armed forces. It is a review of five reports produced by the Ministry of Defence (MoD) in the period between 1995 and 2002 and dealing with duty of care provision in the British Army. Brigadier Evans' report is a review of Phase 2 training and was prompted by two deaths and ten self-harm incidents at the Deepcut Barracks, Royal Logistics Corps (RLC). The Walton Report is a study of suicide in the British Army, and the Hawley Report looks at instances of attempted suicide. The Haes report reviewed duty of care and supervision in the Army Training Recruitment Agency (ATRA) and finally, the Deputy Adjutant General (DAG) opened an investigation into the role of the training structure in the deaths of four soldiers at Deepcut.

This literature review analyses the reports from the point of view of seven issues relating to duty of care: supervision; recruitment and selection; training structure; welfare provisions; information-handling and accountability; access to firearms and guard duties; and dealing with specific issues (bullying, sexual harassment, self-harm and other).


The issue of supervision has two aspects: the supervisory ratios and the quality and motivation of supervisors. Most reports recognise that resources have been scarce and that insufficient numbers of supervisory staff can potentially heighten risk in the discharge of duty of care. Although the quality of instructors as soldiers is not in doubt, there are problems in terms of their training for the welfare aspect of their roles and issues concerning the suitability of some instructors for this role.

Recruitment and Selection: Screening and Monitoring

The importance of carefully selecting future soldiers is not lost on the authors of the surveyed reports. The need to screen recruits at the entry phase and to monitor them throughout the training period is crucial to the provision of duty of care in terms of suicide prevention and self-harm. Screening methods were however found to be of dubious effectiveness throughout the period surveyed.

Training Structure

The structure of Initial Training, consisting of basic training (Phase 1) and technical training (Phase 2), has been found to provide a negative environment for duty of care discharge. Phase 2 in particular was found to increase risks to trainees, as it features long periods of inactivity with no structured and meaningful training, programme or supervision and a turbulent environment where firearms are accessible.

Welfare Provisions

Soldiers in Initial training establishments can seek support within the Chain of Command and from voluntary staff. In several cases, a lack of coordination between military and voluntary staff, as well as negative attitudes of some military staff to the welfare aspects of their role have hampered the discharge of duty of care.

Access to Firearms and Guard Duties

The recognition that all four of the Deepcut deaths involved the use of service weapons prompted concerns that the safeguards in place were failing. By extension, the guard-duties setup, whereby trainees are issued with live ammunition and posted as guards, was acknowledged as undermining the duty of care for recruits and the security of the premises. The MoD reports all recommend the discontinuation of the use of trainees in guard duties.

Information Handling and Accountability

The lack of a uniform system of recording duty of care incidents, and self-harm in particular, is acknowledged as a weakness in the provision and discharge of duty of care and supervision. Recommendations seek to create a more accountable reporting mechanism, which would also help improve the policy of suicide prevention.

Dealing with Particular Issues: Bullying, Sexual Harassment, Suicide Prevention

MoD reports have mostly ignored the issues of bullying and sexual harassment, prompting concern that these and other related problems are not fully recognised.


The present report is a literature review of submissions by the MoD and other institutions. Its aim is to review past MoD reports on duty of care as to provide a background to the Duty of Care inquiry conducted by the House of Commons Defence Committee (HCDC). It also reviews a number of submissions made to the HCDC by institutions that deal with individuals of similar characteristics (in terms of age) or in similar circumstances (in terms of stress and work involved) as those likely to be part of the armed forces' Initial training regime. The objective here is to provide an overview of how the MoD has tackled duty of care issues since 1995 and the first Deepcut Barracks deaths and to establish whether the recommendations from the various reports have been implemented. In addition, the report draws upon the submissions from bodies such as the Metropolitan Police, the Health and Safety Executive and the Boarding Schools' Association (BSA) to provide a benchmark for comparisons of practices relating to duty of care.

The report is organised around the issues identified in the literature analysis as the most relevant to the provision of duty of care. Many of these figure prominently in most of the MoD reports and are highlighted for action. Some are also central to the submissions from other bodies. There are seven key areas that have been addressed by either the MoD or institutions dealing with duty of care issues: supervision; recruitment and selection process; training structure; welfare provisions; information-handling and accountability; access to firearms; dealing with some specific issues (bullying; sexual harassment; self-harm and other).

Duty of Care

The MoD definition of duty of care distinguishes between the concept's moral and legal components. The latter, referred to as 'duty of care', is 'the legal duty to take care in a limited number of circumstances [where]… a breach… would lead to successful proceedings for damages'.[658] Examples include health and safety at work, and the MoD memorandum states that the Courts would use a three-stage incremental test in considering the question of duty of care: a) reasonable forseeability of injury; b) proximity; c) whether it would be fair, just and reasonable to impose duty. The MoD is keen to point out the difference between the legal and the moral aspect, described below, and advises its staff to avoid using the term 'duty of care' except in cases when a legal duty of care is believed to exist.[659]

The moral component is referred to as 'supervisory care' and is used to describe the MoD's duties as a responsible employer, 'including the provision of an appropriate military, pastoral and welfare regime that goes beyond the mere delivery of military, technical or specialist training and education'.[660] The supervisory care regime is based on the Unit Commander's Risk Assessment and aims 'to provide appropriate levels of support, assistance or advice to trainees throughout the time spent at any training establishment'.[661]

As the Haes Report notes, the armed forces are an unusual employer in that their initial training regime features duty of care both for employees (instructors, supervisors etc.) and for trainees. However, for the purpose of the HCDC inquiry into duty of care provision, this report will concentrate on the duty of care to trainees in Initial training establishments (Phase 1 and Phase 2).

The Literature

This report is based on MoD submissions and accompanying documents that relate to duty of care issues since 1995. These are analysed sequentially in separate thematic sections. The report also draws on submissions from organisations that discharge duty of care in situations similar to the armed forces' Initial training regime. However, the following MoD reports form the backbone of the study:

Brigadier Evans' Review[662]

The Review of the Phase 2 Training System within Deepcut, conducted by Brigadier P.A.D Evans, was prompted by the deaths of Pte Cheryl James and Pte Sean Benton and ten self-harm incidents at the Deepcut Barracks. The aim of the review was 'to identify any underlying reasons for the suicides and attempted suicides within Training Regiment and Depot RLC… [and] highlight procedures and working practices which may have a bearing on the attitude and motivation of both soldiers and instructors serving within B Squadron'.[663] Brigadier Evans conceded that 'it is possible that the unit regime had, in some way, contributed to the unhappiness of these young soldiers'.[664]

As the Surrey Police report into the deaths at Deepcut points out, the Review indicates that it had not been recognised that 'the risks associated with Army recruit training at Deepcut had potentially systemic properties,'[665] that is to say that they were indicative of wider trend within the armed forces. The review resulted in external recommendations for the Chain of Command and internal recommendations targeting the Training Regiment. The MoD refused to accept the seven external recommendations, as they had not been commissioned by the Chain of Command, and could hence not be adopted. Five of the internal recommendations were sent to the HQ RLC Training Group for action, and 18 to the Training Regiment and Depot RLC. Out of the first five recommendations, the MoD claims to have implemented or acted upon four. All 18 recommendations of the second group were acted upon.[666]

Walton Report[667]

The Walton Report was commissioned by the Director of Personnel Services (Army) in 1996 to look into suicide in the Army. It takes as a sample all Army suicides from 1990-1996 and incorporates work from both military and civilian sources in the UK and elsewhere. The Walton Report undertook a comparative study of existing suicide-prevention methods and tailored the recommendations to the needs of the British Army. The content of the report is narrow, as Suzy Walton deals with only one particular duty of care-related problem (suicide prevention). Thus, other aspects and problems are sidelined, and the report is not a review of duty of care provisions per se. It is nonetheless wide in its treatment of the Army as a whole, rather than just the training establishments (the subject of the HCDC inquiry). It also provides significant insights into the work done by the MoD on one of the duty of care-related issues and through its extensive study of suicide-prevention policies, it highlights a number of issues relevant to this report. Suicide prevention is a distinct and integral part of duty of care provision and the Walton report approaches issues of supervision, welfare provisions, screening, and information-handling and accountability.

Among its recommendations, the report advocates a more scientific approach to the identification of self-harm cases and future suicide prevention. During the final stages of the research, the Army Suicide Management Working Group (ASMWG) was established to carry forward the results of the work. The report makes ten recommendations, some of which seem to have been implemented (as will be seen below).

Hawley Report[668]

The Hawley report is based on the study conducted by Colonel A. Hawley, a member of the Faculty of Occupational Medicine, on the nature and scope of self-harm incidents in the British Army. The study looks at the 1,620 recorded cases of attempted suicide between 1987 and 1996. The report acknowledges the Army's duty of care as well as the potential effect of 'DofC&S' on operational and combat readiness. It makes four recommendations, one of which - the training of instructors - is also consistently mentioned by the other reports surveyed.

Haes' Report[669]

The Chief of Staff ATRA commissioned a report on DofC&S aimed at providing an objective analysis of duty of care and to assess Op Div capability to deliver legal duty of care and adequate levels of supervision for staff and trainees. The aim of Colonel Haes' paper was to identify areas of risk within ATRA resulting from inadequate DofC&S and to recommend options that would maintain the legal duty of care and a minimum necessary level of supervision. In addition, the report was meant to provide the basis for the Army Welfare Committee discussion of ATRA needs and brief Haes' successors on how to develop and improve the system of ATRA G1 performance.

Haes' report sought to highlight that ATRA duty of care and supervision resources were stretched to breaking-point and that it lacked a coherent or measurable DofC&S policy. Haes stressed the need for a policy to govern priorities and demarcate clear responsibilities for staff. Although Haes did provide ten broad recommendations, each with a number of sub-paragraphs, the report was dismissed by the Chain of Command as an inadequate analysis on the grounds that it failed to provide practical solutions.

Deepcut Investigation - DAG's Final Report

On 13 September 2002, DAG began a supporting military investigation to assist the Surrey Police investigation into the Deepcut deaths. The purpose of the report is to provide the findings and recommendations of the investigation, as well as the lessons learned. Departing in nature from previous reports, it adopted a larger system approach and compared Deepcut with a number of other Army training establishments. The report adopted a risk-management methodology, assuming that the risk of suicide is influenced by a combination of interrelated factors. The report is primarily concerned with these environmental factors.

DAG's Final Report contains six recommendations: the revision of the supervisory ratios; the revision of performance targets; changes to the guarding provisions; changes to the security provisions; the training of instructors and supervisors; and the implementation of the detailed observations of the Joint Learning Account. Notably, many of these recommendations were made in some of the previous reports.

Other Material Surveyed

Contributions from a number of organisations submitted to the HCDC proved relevant for this report. In particular, the submissions from the Cadets Forces, the Metropolitan Police, the Commission for Social Care Inspection (CSCI), the Youth Justice Board (YJB) and the BSA brought insights into how other institutions dealing with a similar type of population as the armed forces Initial training establishments discharge duty of care.

Two particular organisational approaches merit special attention and should be applied in Initial training establishments. The Cadets Forces seem to have much higher DofC&S standards than the MoD Initial training establishments. Also, the BSA's standards and experience in providing boarding education could be highly useful in the improvement of provisions in the armed forces' training establishments.


Supervision has been identified by most of the literature as one of the central issues relating to duty of care. For the purpose of this inquiry, the centrality of supervision is further heightened, as the target group consists of young men and women at the initial stages of their careers in the armed forces. A large proportion of these recruits (40-50% according to the Haes report) are under the age of 18, and hence the armed forces act in loco parentis, adding a further dimension to the responsibility of the services for the individuals in their care.[670] The armed forces receive a group of young people who have to deal with significantly altered lifestyles at one of the most sensitive period of their lives (late teens). For many, the Initial Training Phase 1 will be the first prolonged time away from home, and exposure to a military regime and discipline warrants considerable adjustment. The need for adequate levels and quality of supervision is therefore paramount in enabling a healthy environment and providing the opportunity for the recruits to achieve their full potential.

The surveyed MoD reports all recognise the issues relating to supervision and their impact on the capacity to discharge effective duty of care. It is also something noted by the Surrey Police report and their chronological review of MoD actions and assessments of duty of care provision. However, there seems to have been no meaningful improvement in the quality and ratio of supervision between 1995 and 2002.

Ratios: The Problems of Staff Over-Stretch

As noted above, the ratios of supervisors to trainees have been highlighted as one key problem for the armed forces' ability to discharge duty of care for recruits in Initial Training (Phase 1 and Phase 2). As will be seen in this section, and in the section dealing with the training structure, the problem is more acute in Phase 2 and more pronounced in the Army than in the Royal Navy (RN) and Royal Air Force (RAF) training establishments. It is also worth noting that whereas the problem of ratios is highlighted by the Army reports (Evans, Haes, DAG), it is not really discussed by Walton and Hawley (nor was this issue within their remit).

Brigadier Evans' Review

As a response to the deaths of two soldiers and ten cases of attempted self-harm in Deepcut, the Review of Phase 2 Training System within Deepcut, compiled by Brigadier Evans in 1995, had a narrow scope of inquiry, concentrating on only one of the two phases of Initial Training and in only one establishment of the Army Training Regiment (ATR).

Regarding ratios of staff to trainees/recruits, Brigadier Evans notes in his report that 'as a matter of urgency the Regiment should review the instructor to soldier ratio and make recommendations for any increase to the establishment'.[671] In his internal recommendations to the Training Regiment and Depot RLC, Brigadier Evans asks for a review of the instructor-to-soldier ratio and for results and recommendations to be made to the SO2 G2/G3, HQ RLC Training Group.

Brigadier Evans identifies another issue concerning supervisor ratios, namely the proportion of female instruction staff. According to Evans, 'steps must be taken to establish the correct gender balance amongst staff, to reflect more closely the 3 to 1 ratio of male to female trainees'.[672] He recommends a female quota of at least 20-25% of instructors and one troop commander.

The MoD admitted that due to shortages in manpower, the instructor-to-soldier ratio was not acted upon until some years later. According to the summary of action taken in response to the internal recommendations provided by the MoD, the military manpower remained under pressure and no cover was provided until August 2002, when a 'very small enhancement to Guardroom staff was authorised'.[673]

Haes Report

The Haes report makes the strongest case for an increase in staff levels. It states that the expectation of military staff to deliver DofC&S is verging on being unrealistic; the burden falls on the same few people and the system is failing because of insufficient troops to task or it is achieved at the expense of staff working time/quality of training/private life… a majority of ATRA permanent staff are working 110% or more above WTR.[674]

Haes also notes that though they constitute the first line of duty of care provision in some units, guardroom resources are being stretched and suffer from significant female understaffing, which is particularly important vulnerability in terms of supervising accommodation. This last point confirms the concerns of Brigadier Evans' 1995 review (see above).

The Haes report argues for a reduction in non-core activities for ATRA along with either a reduction of a through-put of trainees and/or level of training; or, more radically, for ATRA to adopt a more minimalist approach to duty of care and supervision. According to Haes, instructors do not get sufficient contact with trainees, 'an estimated 80% of whom are "grey faces" who pass through ATRA without being known' while the other 20% take up most of ATRA's welfare capacity.[675] As a result, Haes argues, problems go unnoticed; the report gives several examples,[676] including that of an under-18 female with a history of alcoholism as well as the example of a suicide case that lay undiscovered for a number of days.

Haes appears particularly worried about the use of Phase 3 trainees to supervise Phase 2 students, especially when under-18s are involved. He states that the former are not qualified for the task and asks for legal advice to be taken on the policy.

Deepcut Investigation - DAG's Final Report

The investigation into the deaths at the Deepcut Barracks, led by the DAG's office, concluded that the level of supervision at Deepcut was completely inadequate. With a supervisory ratio of 1:60 at the time of the deaths, the Deepcut Barracks compared badly to similar establishments, such as Catterick and Larkhill, where the figures were 1:12 and 1:40 respectively. DAG's Report also notes that the quoted supervisory ratio applied only to working hours and when the establishment was fully manned. The out-of-hours figure for Deepcut was close to 1:200 or more. The review concluded that an increment of some 12 officers and 50 NCOs was necessary.

Thus, the first recommendation of the Deepcut Investigation report was for an increase in the supervisory ratio at the barracks to 1:38, while supervisory ratios across ATRA should be reviewed and brought to appropriate levels in line with a clearly defined and endorsed policy for all training establishments. Overall, the Army input into the Learning Account, developed with Surrey Police, states that the policy on supervisory ratios should be overarching and take into account factors such as the scale, nature and duration of training; trainee quality; cohort cohesion; gender ratios; accommodation architecture and site-specific issues. As a matter of urgency, sufficient supervisory manpower for out-of-hours periods should be provided.

Other Institutions' Experience and Standards

Although it is clear that the armed forces are fully aware of the risk associated with sub-standard supervisory ratios and though the problem is one of resource rather than attitude (to the contrary, evidence suggests that most trainers often try hard despite lacking in resources), it is still useful to look at how other institutions have approached the issue.

The submissions from the Sea Cadet Corps (SCC) and the Air Cadet Organisation (ACO) do not deal with the ratio of adult supervisors for the cadets, although they do show comprehensive steps to ensure the protection of all cadets, especially those under the age of 18. HM Inspector of Prisons found that on the MoD site they were inspecting, the level of supervision appeared to be much greater than that found by Surrey Police in Deepcut Barracks, implying higher ratios than those listed in the Evans, Haes and DAG reviews. The Metropolitan Police recommends that the ratio of instructor to students during the physical part of its Officer Safety Training should be 1:8, although for other parts of the curriculum, ratios could vary and are dependent on specific factors, including the experience of staff and trainees, space and environment.[677]

The Boarding Schools Association's (BSA) 'Good Practice in Boarding Schools' offers the most comprehensive recommendations and assessment of staff needs. MoD's training establishments, especially those with a high proportion of under-18s, could learn much from the practice of boarding schools.[678] The core National Boarding Standard is that 'staff supervising boarders outside teaching time should be sufficient in number and deployment for the age, number and needs of boarders, and the locations and activities involved'.[679] It is obvious here that an effort is necessary to meet a similar standard within the Initial training establishments, especially since out-of-hours supervision has been identified as a particular problem.

Quality and Motivation:

This section deals with the training and selection of instructors and their motivation to perform their job. It questions whether the instructors have been properly inducted and equipped to deal with welfare issues as well as duty of care in general. Supervisors need to be equipped for their roles and able to act as first in line in terms of welfare provision, but they must also be selected on the basis of their suitability and motivation for the welfare role. This in turn will have a positive effect on both the quality and satisfaction of soldiers, the operational readiness and quality of the British Armed Forces as well as the ability to discharge the duty of care and supervision.

Brigadier Evans' Review

Brigadier Evans devotes great attention to the issue of recruit management and welfare. Central to both is the capacity of instructors to deal with their supervisory duties and overall, Evans notes the need for the instructors to see themselves as the first link in the welfare chain. Evans admits that the instructors are not always aware of the welfare aspect of their jobs. Hence, Evans argues that because 'the demands placed on the military staff in B Squadron require not only instructional ability but a keen awareness of welfare and counselling… welfare training for the Squadron staff must be introduced'.[680] In addition, the review recognises the need for suitable people for the role and clearly expresses the need to improve the selection of instructors.

In terms of training, Evans suggests that instructors attend relevant training prior to taking their appointments, including the roles of other elements of the welfare provision (see section below) such as the Medical Officer, the Padre or Women Royal Volunteer Service (WRVS). Noting that instructors are expected to undertake their duties without appropriate introduction to the unit, Evans recommends the introduction of an induction course for instructors as a matter of priority. Among the internal recommendations to the Training Regiment and Depot RLC, Evans includes the need to review existing induction procedures for newly arrived instructors, make recommendations regarding the content of the induction course to the Training Executive and review the procedures for the selection of instructors.

Responding to the Evans review, the MoD claimed that all newly arrived permanent staff were given a one-week induction course before working with recruits, and that this training was intensified for those staff who had close daily contact with recruits. Regarding the selection of instructors, the MoD stated that the system was being continuously improved and that increased liaison visits by COs to monitor the filling of instructor posts were taking place..

Hawley Report

Although Colonel Hawley's study into suicide attempts in the British Army between 1987 and 1996 deals specifically with self-harm incidents, it nevertheless recognises the importance of supervision in terms of the Army's duty of care and the role that instructors and supervisors can play in identifying the individuals at risk. Hence, one of Hawley's recommendations is to train Commanding Officers in identifying individuals at risk. Like Brigadier Evans, Hawley emphasies the continuous need for officers and NCOs to monitor recruits.

Haes Report

Although the Haes Report insists on the problem of manpower shortage in the discharge of duty of care and supervision, it does highlight some problems regarding staff training and motivation. Haes acknowledges that the selection of instructors in Phase 2 training is not based on their ability to provide suitable DofC&S, and that there is a need to train ATRA instructors and supervisors to cope with the legalities and practicalities of delivering duty of care. In specific, Haes recommends that a Commanders' Guide on how to deal with self-harm be issued to all ATRA supervisors.[681]

Deepcut Investigation - DAG's Final Report

Whereas the investigation report emphasises supervisory ratios and the conditions that might lead to suicide at Deepcut (stimulation, means), it downplays the problem of staff quality and motivation. According to the report, 'the training, supervisory and welfare staff are well led and motivated, despite the magnitude of the challenges that are beyond their power to resolve… they make every effort to counter the adverse factors described [in the report] but an established military staff:trainee ratio of 1:60 is a pervasive handicap on their effectiveness'.[682] With this comparatively upbeat assessment, the report claims that the Army's polices in terms of welfare provision matched all reasonable benchmarks of quality: the 'only area of concern identified was the quality of induction training to instructional staff in ATRA Phase 2 training establishments, which is now being addressed'.[683] The report recommends that a common induction training package for ATRA Phase 2 instructors and supervisors be implemented in order to raise standards towards those prevailing in Phase 1. Hence, it seems that despite being noted as a problem in 1995 by Brigadier Evans, the induction for instructors remains an issue for the ATRA.

In terms of lessons learned, the report's input in the Joint Learning Account states that supervisory staff should receive training to ensure that they can better detect signs of possible self-harm or suicidal intent.

Other Institutions' Experience and Standards

The quality and motivation of the supervisory staff are particularly important aspects in terms of the provision of duty of care. The experience of other organisations in meeting this challenge can be insightful.

Particularly interesting is the experience of the Cadet organisations. These are voluntary, community-based organisations promoting personal and social development of young people.[684] They are sponsored by the MoD and emphasise that they follow the same safety procedures as their parent services. The MoD states that regulations are developed through benchmarking against other youth organisations and, where possible, against the best practices of the Department for Education and Skills (DfES) and Local Education Authorities (LEAs). Regarding supervision, the Air Cadets Organization (ACO) maintains that its primary responsibility is to discharge its duty of care to cadets by 'ensuring that unsuitable adults are not placed in charge of them'.[685] Among the particular steps, the ACO sites the vetting of all adults, the imposition of a probationary period, suitable formal instruction, training and information on duty of care provision, and the issuing of regular repeat orders drawing attention to duty of care issues. Similarly the SCC seeks to protect its cadets through the careful selection and appropriate training of supervisors.[686]

The CSCI National Minimum Standards for welfare provision in Further Education Colleges states that all staff with responsibilities for supervision or provision of welfare for under-18s are expected to have relevant qualifications or experience, clear job descriptions, induction training, continuing training opportunities, and a regular review of their supervisory and welfare practice. The CSCI calls for the production of a staff handbook with details of practice in supervising residential students and safeguarding their welfare (including child protection, countering bullying, use of sanctions etc.).[687] Another institution, the Interactive College, states that its staff attends several inductions outlining their special responsibilities with under-18 students, and that all staff must be familiar with procedures and policies.

Finally, the submission by the BSA illustrates how properly qualified, vetted, trained and motivated staff can minimise risks relating to duty of care provision.[688] Among the recommended procedures are criminal records checks, identity checks, references, a personal interview, and a verification of qualifications. The BSA also maintains that its schools are committed to the professional development of its members of staff in all aspects of boarding-school education and provide 'opportunities for in-service education in pastoral care, counselling and other aspects of boarding life'. A similar practice would be beneficial to trainers/instructors and supervisors in the armed forces, especially those dealing with under-18s.

Recruitment and Selection Process: the Need for Screening

Since the armed forces are a voluntary organisation, the recruitment and selection process is perceived as a particularly important stage in the process of maintaining combat readiness. It is also the point at which the armed forces should be able to assess the potential of future soldiers. With regard to the problem of duty of care, the recruitment and selection process has been seen in light of its potential to improve the screening of recruits. Meanwhile, the provision of information prior to trainee induction remains crucial in increasing the quality of the training, as it provides potential recruits with an early chance to gauge their suitability for the programme. As none of the material surveyed dealt with the provision of information to potential recruits, the matter will not be included in this report. However, it is worth noting that other institutions, such as the Metropolitan Police, have a scheme for providing information to recruits in the pre-joining period and a 'Marketplace' programme that provides trainee officers with career options and an opportunity to discuss possibilities and choices.[689] It is not clear from the material reviewed here to what extent the armed forces offer such opportunities.


Most of the reports surveyed seem to agree that some sort of screening process should be implemented in order to reduce wastage and disruption, improve the quality of the trainees and reduce the risk of self-harm or other duty of care-related problems. There is no evidence that improvements recommended by the various reports have been implemented.

Brigadier Evans' Review

In the summary of his report, Brigadier Evans concludes that the soldiers that attempted suicide should not have been allowed to graduate from Phase 1 and that they did so 'casts a doubt on the effectiveness of screening methods'.[690] Brigadier Evans' review notes the instructors' belief that an increasing number of Phase 1 graduates seem poorly motivated, unwilling to respond to discipline and determined to be disruptive. More importantly, the report states that 'medical and psychological difficulties must be identified during the enlistment process… screening would help to ensure that soldiers with a prior record of attempted suicide, never enter training'.[691] The report calls for direct contact with a recruit's GP in order to obtain medical records. Evans also notes that the responsibility does not end with enlistment, and that even without any diagnosed psychiatric condition, military judgement must be exercised as to determine a recruit's suitability for continue training.

The external recommendations call for a review of the screening procedures prior to enlistment as to minimise the number of unsuitable recruits entering training and a review of the assessment procedures within ATRs to ensure that soldiers are not only physically fit but also mentally and psychologically capable of coping with the rigours of Army life. As both recommendations were made to the Chain of Command, they were not implemented because, as Minister Adam Ingram explained, they had not been commissioned by the Chain of Command.

Walton Report

Though aimed at suicide prevention in particular, Dr Walton's study has some useful recommendations and observations regarding screening. It suggests the adoption of a psychological autopsy technique: a retrospective investigation by a qualified professional to learn more about the nature and causes of suicide. According to Dr Walton, the technique can be particularly useful in closed communities since it can generate valuable information about organisational processes and structures that may accentuate or attenuate a suicidal tendency.[692]

The Walton report also advocates the 'tagging' of vulnerable soldiers through the Suicide Vulnerability Questionnaire developed in her study (Part 3 and 4). This system would alert the commanding officer of a new unit to the vulnerability of a soldier. Walton recognises the need to establish a system by which such tagging could be removed once the soldier is no longer considered at risk.

Hawley Report

The Hawley report demonstrates that self-injury rates in the British Army are lower than in civilian life, and attributes this partly to the medical, educational and societal selection criteria. According to Hawley, the preferred method of dealing with suicides and para-suicides (attempted suicides)[693] 'is to select appropriate individuals at the outset[694] a claim he backs up with examples of low para-suicide rates among Royal engineers, the Royal Electrical and Mechanical Engineers and the Gurkhas. Among its recommendations, Colonel Hawley's study emphasises the need for a review of the selection criteria for entry into the Army in order to help select individuals appropriately. There is however no evidence that this has been implemented.

Deepcut Investigation - DAG's Final Report

In terms of screening, DAG's investigation concludes that the inbuilt turbulence and unpredictability of Phase 2 training led to increased vulnerability among trainees. The risks are concentrated amongst the weaker and less competent, and especially among those with underlying problems, which may be exacerbated in such a psychological environment. However, the staff ratios make screening and monitoring during training very difficult. Hence, DAG's Report concludes that trainees judged to be vulnerable and at risk on psychiatric grounds should be identified, subjected to close supervision, and, if appropriate, excluded from all armed duties.

DAG's Report concedes that the selection process is unable to identify all risk categories and that, as a result, more research should be conducted in terms of AMD and Human Factor. Interestingly, it does not mention the need to improve screening at the enlistment stage.

Other Institutions' Experience and Standards

In terms of screening, most institutions agree that it is a process that continues throughout a student's/trainee's/individual's time with the organisation. Organisations like the Cadets do not have their trainees in care for long enough for this aspect to be particularly relevant. However, organisations such as the YJB and the BSA have interesting insights to share.

The YJB states that among the key standards in terms of duty of care provision, screening and assessment of young people coming into its care are crucial in reducing risk, especially in terms of self-harm and suicide prevention. It recommends that children and young people entering youth justice systems should be assessed for mental-health needs and substance abuse in order to determine whether there is a risk of the person committing serious harm to him/herself or others. The assessment information should be received by the establishments on reception of the young person. The YJB recommends that procedures to identify and manage those at risk of self-harm and suicide should exist in all establishments and that they should be 'regularly monitored, reviewed and updated'.[695]

The YJB approach can be particularly useful for the Initial training establishments. Initial screening would help remove those at risk from training at an early stage, while the transfer of results between institutions (from Phase 1 to Phase 2) would allow welfare workers, supervisors and instructors to follow trainees and be aware of any worrying medical history.

The BSA provides further insights into the screening of staff, dealt with in the previous section. As mentioned, the BSA insists on a high standard of checks to be performed on potential staff, and the armed forces should consider more stringent screening, especially of the staff put in charge of under-18s.

Training Structure

According to the MoD, initial training in the armed forces focuses on providing the core single-Service competencies to give recruits a sense of their Service's ethos and the confidence to function in the operational environment. Initial Training is structured in two phases. Phase 1 Training is delivered on a single-Service basis and is aimed at equipping the recruit with basic military skills and immersing him/her into the single-Service ethos required by all personnel. Phase 1 lasts on average 12 weeks, during which time the transition from civilian to service life is achieved. Phase 2 usually follows directly from Phase 1 and varies in time from a few weeks to over a year for highly technical training. In Phase 2, recruits receive initial specialist training, giving them the skills for their first employment.

It is widely recognised that the most pronounced problems in the discharge of duty of care and supervision occur during Phase 2. Recruits are at this point under less supervision and tend to have more free time. The nature of the trade-training courses that some of the trainees have to take results in recurring waiting periods, leaves sometimes long intervals of inactivity, leading to skill fade and boredom.

This section looks at how the MoD reviews assessed the impact of the training structure itself on the ability to fulfil the obligations of duty of care. The Evans review focuses most heavily on the training structure. The Walton, Hawley and Haes reports do not deal with it in a separate capacity and are not reviewed in this section. In addition, this section deals with the particular structure of training in the armed forces, an area where other institutions have little to contribute. The usual section on other institutions has therefore been omitted.

Brigadier Evans' Report

The Evans review concentrates on Phase 2 training, although some observations are also made regarding Phase 1. Overall, Evans notes the impression that soldiers B Squadron are poorly informed on the content and development of their specialist training and frustrated by the lack of programmed training and the overuse of fitness training. Trainees also complained of skill fade during the trade training, especially regarding weapons handling. The report acknowledges that the time spent in the barracks during Phase 2 in between postings or awaiting trade training can sometimes be long and calls for the provision of a progressive and imaginative training programme. It also acknowledges the need to provide trainees with meaningful and progressive training. Both of these issues are dealt with in the recommendations, where Evans calls for the introduction of a system that minimises time spent with the RLC Training Group. According to the MoD, the review of the programme was conducted and a new programme of sending recruits off to field units if they are likely to be awaiting training for longer than two weeks has been put in place. Similarly, the MoD states that low-level ad hoc military training was introduced on a 'as time and resources permit basis' to counter boredom and skill-fade complaints.

Brigadier Evans' review regrets the lack of opportunity during Phase 2 for trainees to develop unit identity in 'stark contrast to the tightly knit fraternity of basic training'.[696] The report goes on to note that the trainees arriving at a Phase 2 establishment have greater personal freedom than in Phase 1 and less group identity but 'all too often, insufficient self-discipline to stay out of trouble'.[697]

There is a recognition that the uneven output of recruits from Phase 1 creates some problems for course scheduling in Phase 2. The report laments the inability to distribute evenly the outputs of soldiers from Phase 1, as this would enable better planning of courses (such the driver training) and would facilitate the organisation of worthwhile activities for trainees during training gaps.

In his recommendations, Brigadier Evans calls for a reconsideration of recruiting procedures in order to even out the distribution of recruits as far as possible.

The report recommends the review of the programme of Phase 2 training courses against the output at ATR Pirbright and a reduction of the gap between the completion of the Induction Course and the commencement of Phase 2 training. There seems to have been no real improvement in dealing with this issue.

Deepcut Investigation - DAG's Final Report

In terms of the training structure, DAG's Report makes it clear that the scale and complexity of the task faced by the Defence Logistics Support Training Group (DLSTG) is at or beyond the limits of feasibility.[698] The pressure from manpower shortages, the complexity and size of the training operation as well as the input of trainees from Phase 1 make the task extremely difficult.

DAG's investigation found that soldiers awaiting trade training (SATT) were a particular problem in the training organisation. The report found that in the absence of coherent and credible training activities, soldiers become bored, de-motivated and increasingly prone to indiscipline as time passes. Such a psychological environment increases the stress of weaker individuals, who had previously been well supported by the tightly structured basic training.[699]

It also recognises the turbulence of the Phase 2 training where recruits might change three or four bed spaces with different people and are effectively denied the stability of private space. Although DAG's Report states that this is normal in combat situations, it does concede that it is unnecessary and destabilising in the context of basic training, which should aim at reducing the strain of transition from civilian to military life.

What is evident from these findings is the fact that problems identified by Brigadier Evans in his review remain central issues in DAG's investigation seven years later. The problem of a lack of coordination between the output of Phase 1 and the training schedules in Phase 2 seems to be causing concern but no solution was proposed by DAG's Report.

Welfare Provisions

It has already been noted that recruits and trainees have particular needs when adjusting to military life. Apart from being away from home and adapting to a new and specific way of life, some of the trainees are under 18, adding an extra dimension to the duty of care regime. Hence, a crucial part of the armed forces' duty of care provision is the welfare support and counselling that they offer to recruits. It has been noted in the section dealing with supervision that some reports found that the instructors were not qualified, and hence less able to deal effectively with trainees at risk or provide the initial level of support. In addition, a number of surveyed reports have noted deficiencies in the provision of welfare support and some of them offer recommendations in order to improve that situation. This section outlines the findings of those reports and looks at the recommendations and improvements that they have highlighted.

Brigadier Evans' Review

A considerable section of Evans' review deals with the provision of welfare support within the ATR. Accordingly, a large number of his recommendations centre on improvements to the provision of welfare-related services. The report notes the existence of a number of welfare and counselling institutions available to the trainees. The Padre, a WRVS representative and the Medical officer (able to refer patients to a Community Psychiatric Nurse and Consultant Psychiatrist) were all accessible, but there was no officer in the Regiment dedicated to the welfare of soldiers under training, where the responsibility follows the normal sub-unit chains of command Evans therefore recommends the creation of such an officer post.

Brigadier Evans states that his investigation revealed a 'lack of awareness amongst some staff, particularly JNCOs and SNCOs, of the role of the welfare agencies and concerns amongst others, the welfare professionals, that they are not sufficiently involved in the management of soldiers'.[700] In addition, Evans notes the potential for much closer liaison between instructors and the welfare staff. The report found that instructors were often perceived to 'treat welfare support as an unnecessary irritation' and he recommends that instructor courses stress the need for a maximum use of all welfare provision within the barracks. It also noted the support among the Padre, Medical Officers and WRVS representatives for more regular meetings between them and the instructors to discuss individual cases. In his recommendations, Brigadier Evans calls for the development of existing Phase 2 management procedures to involve the military welfare agencies more often and increase the awareness of the role amongst military staff. In addition, the report recommends the establishment of a welfare group comprising all interested agencies, which would meet regularly, review welfare cases and coordinate support.

Recognising that unqualified instructors are often expected to provide welfare support, the Evans review recommends that the instructors attend appropriate courses (see the section on supervision) prior to taking their appointments. The review highlights the need for instructors to see themselves as first in line in the welfare chain and recommends reviewing the welfare training for instructors.

As one possible way of improving welfare provision, Brigadier Evans' report recommends examining the feasibility of making information on and the services of local civilian welfare services available to soldiers.

The lack of information available to soldiers regarding available support was also identified as a potential issue, and the report recommends that the Soldiers Induction Course programme be used to rectify the problem. The report also recommends the establishment of a single focus for the welfare of all soldiers undergoing training.

In response to the recommendations, the MoD stated that a major review was undertaken and more extensive use of WRVS and Padres made possible. In addition, posters with details of confidential help-lines were more clearly displayed in the barracks. In 1996, an Induction Training week was introduced for all arriving soldiers, where they were made aware of the Padres and WRVS facilities available to them. In response to the need for a focal point, the Regiment established the Unit Welfare Officer post.

Walton Report

The study by Dr Walton into suicide in the British Army provides an interesting and very detailed account of welfare provisions available to recruits. Overall, the Walton Report concludes that there is a good availability of staff, both military and voluntary, with whom to share problems. Dealing with the particular case of suicide, it acknowledges that all soldiers have access to psychiatric assessment as well as to a whole range of chain of command and other welfare support provisions. It is, however, the particular recommendations for a more effective system of suicide prevention that is the most central and interesting issue of the Walton Report. It is taken here that suicide prevention is a distinct and important part of the welfare system within the armed forces, one that relies on different techniques as well as the military and voluntary support staff and services.

In terms of recommendations for welfare provisions, Dr Walton suggests that the Suicide Prevention Aide-Memoir developed by the Army personnel, should continue to be distributed and 'trained in' through briefings. The aide-memoir should be checked annually and revised if necessary.

Dr Walton commends the work of the Confidential Support Line, which offers immediate telephone access to trained counsellors for soldiers in the UK, Germany and Cyprus. The report recommends that staff manning the help-line should be retrained after every year of operation in order to avoid complacency and updated on the current status of problems such as suicide.

Dr Walton further recommends that the Chaplains Character Building talks include materials specifically dealing with suicide prevention.

Hawley Report

The Hawley report makes no recommendations for the provision of welfare support other than to emphasise the aforementioned need for officers and NCOs to monitor soldiers continuously as part of a suicide-prevention strategy.

Haes Report

The Haes report makes a number of recommendations for the improvement of the welfare provisions. Overall, Haes supports the conclusion that 'welfare delivery in the Army is currently ill defined, fragmented in delivery… and delivered in a decidedly ad hoc fashion'.[701] His main suggestion to enhance the provision of welfare includes the development of a system of monitoring and assessment by creating a DofC&S risk-assessment committee at HQ ATRA and formalising the DofC&S working group, which would meet bi-annually to look at causes, effect and outcomes. The working group would produce an annual risk assessment with recommendations.

Haes also recommends the creation in each Op Div of a welfare forum including the CO Support Regiment, Padre, WRVS, AWO, SMO, UWO and DoC&S working-group representative. The welfare forums would feed the ATRA working group. In addition, Haes recommends that each Op Div has a welfare centre of excellence and an alcohol-free leisure environment involving church charity groups and with personnel of relevant expertise present.

Finally, Haes recommends a better use of the Padre network, including the issuing of mobile phones or pagers so as to improve accessibility. The material surveyed does not offer any evidence of change in this respect.

Deepcut Investigation - DAG's Final Report

DAG's report on the investigation does not mention welfare-support provision other than to say (as has been mentioned above) that all staff, including instructors, supervisors and welfare staff, are highly skilled and motivated, but face pressure from lack of resources and imbalanced supervisory ratios. The lessons learned recognise the importance both of the sub-unit chain of command and of information received from trainees on the psychological state of their peers judged to be at risk.

In the Annex to the report (the Joint Learning Account input) however, several entries cover duty of care discharge and welfare provisions. In terms of support to bereaved families, the DAG Report seems to have taken into account the complaints from the families of soldiers that have died at Deepcut. The Annex calls for policies on how to deal with families in the immediate and long term to be reviewed and redrafted. It also recommends that the requirement for additional training of CVOs be examined including family access to information, and recognises that immediately following a death, the Army needs to engage with the family at an appropriate level as to express sympathy and condolences without admitting any form of legal liability.

The recognition that insensitive handling of the victim's belongings have led to increased suffering for families prompted the recommendation to review disposal procedures for military equipment and packaging instructions for personal effects.

Other Institutions' Experience and Standards

Welfare provisions form an important part of most of the submissions and the experiences highlighted could prove useful in setting standards within the armed forces' Initial training establishments. The standards of the Boarding School Association (BSA) are extremely comprehensive and deal with all sorts of welfare issues and the provision of support to students.[702] It is obvious that the BSA places heavy emphasis on meeting standards such as the Children Act of 1989[703] and the National Boarding Standards.[704] Although a number of standards could be a good basis for change in some of the Initial training practices, it is also important to recognise that individuals in BSA care are different and in different circumstances than Army recruits.

The BSA submission devotes considerable space to issues relating to pastoral care and discusses the recognition of symptoms of problems such as eating disorders, alcohol and substance abuse, a change to family circumstances, sexual abuse, pregnancy or self-harm. The BSA states that 'effective pastoral care is delivered through an effective web of human relationships which exist around a pupil to support him/her and which are built up with him/her directly'.[705] In an article relating to the management of pastoral issues, the role of the housemistress/master is recognised as being distant from the students, which further underlines the importance of and reliance on staff. The BSA emphasises the positive impact of 'building an atmosphere of trust and a sense that the care given is unconditional'.[706] It underlines the need to listen and support those pupils with problems in order to help them thrive.[707]

It is worth noting that the Metropolitan Police is in the process of setting up its 'Welfare Information and Guidance Unit' (also known as the 'Pastoral Care Unit', although the name is under review as it is felt that Pastoral had Christian connotations). The Metropolitan Police's current Student Officer Care and Support relies on instructional staff (as first line managers with responsibility for study support, welfare, discipline, sickness and personal issues, and acting in liaison with support units and other advice providers) and on intake managers, who refer matters of welfare and discipline to the Head of Foundation Training (the Chief Inspector or Head of Recruit and Probationer Training (Superintendant). Officers undergoing weapons training have access to an instructor-mentor and the duty officer is available after hours to discuss welfare issues.

Information-Handling and Accountability

The investigations into the Deepcut deaths highlighted problems with the approach of the armed forces and the MoD in recording incidences relating to duty of care provisions. Throughout the period surveyed, a mechanism for recording incidents of self-harm or bullying appeared to be missing, with no system in place for how the reported information gets handled within the immediate chain of command. This has led to problems in conducting investigations as well as recording patterns of behaviour and monitoring trainees.

In terms of accountability, it is obvious that the issue relating to responsibility over the provision of duty of care needs to be clarified. A number of reports have called for responsibility to remain with the Chain of Command, although the Haes report in particular seemed very concerned with the lack of clarity in defining legal duties for Commanders and others involved in the provision of duty of care and supervision.

Brigadier Evans' Report

The Evans review pays scant attention to the problem of information-handling when recording instances of self-harm or other duty of care issues. In the first part of the report, Brigadier Evans suggests that it would be useful to examine the records of other Phase 2 training organisations in order to put the Deepcut Barracks incidents into context. He does however note that statistics should be viewed with reservation, as 'not all units appear to report such events, especially where they consider there was no serious threat to life'.[708] The report suggests that 'Land Command instruction should be clarified to ensure uniform reporting across the Army; if only to highlight incidence of bullying'[709] as that there is an 'inconsistency within Land Command in the reporting of attempted suicides or self-harm incidents'.[710]

The recording of minor punishments was also identified as an area where improvements could be made. Brigadier Evans states that 'instructors should record the award of a minor punishment within a register kept by the Squadron', and that such punishments should be administered with discretion.[711] A recording system would have helped trace potential bullying incidents or at least imposed a degree of accountability on the instructors, thus improving the system of duty of care provisions. According to the MoD, such a system is in place and records are kept within Squadrons. The question remains whether and how all instances are recorded, a matter that deserves further clarification.

One of the external recommendations of the report is for Land Command to revise instructions on reporting suicide attempts in order to ensure uniform reporting standards. This recommendation, along with the other external recommendations, was not implemented by the Chain of Command.

Walton Report

Although the Walton Report concentrates on the particular issue of suicide prevention (discussed below in the final section), it has also made a number of important observations and recommendations that could benefit the organisation as a whole and the Training Regiment in particular.

The study conducted by Dr Walton recommends measures aimed at improving the collection and handling of information as to strengthen the suicide-prevention regime. It also gives a clear recommendation on where responsibility for suicide prevention should reside. The Walton report's first recommendation is that the 'focus for suicide prevention should remain a Command responsibility with professionals such as Chaplains or MOs/Psychiatrists under remit to deliver particular prevention or management packages'.[712]

It is however the recommendation and findings regarding the collection, gathering and storing of information that are the most interesting. Dr Walton suggests that collation of data relating to all prevention or management packages should be undertaken by the DPS(Army). She goes on to advocate the use of the ISI death data management system developed by Human Sciences (Army) in order to facilitate the data-collection on suicide trends across the whole Army, and hence improve prevention measures. Her report stresses the importance of a uniform system of data-collection and data-management for the establishment of an effective prevention of self-harm policy.

Finally, Dr Walton raises the idea of 'tagging' soldiers at risk by including their Suicide Vulnerability Questionnaire (SVQ) scores in their personal notes, which follow him/her on any unit move or training course. Such tagging should be discontinued when the soldier in question is no longer considered at risk.

If implemented, this final recommendation in particular might go some way towards alleviating the above problems of training structure and the passage between Phase 1 and Phase 2. It may also increase the ability of Phase 2 instructors to care for all trainees, not just those who appeal for help. If managed properly and applied as detailed by Dr Walton, the 'tagging system could significantly improve the ability of supervisors to monitor recruits at risk'.

Hawley Report

The Hawley report does not devote much space to the problems dealt with in this section. It does however note that the manner in which data was collected and recorded made data-interpretation problematic.[713] Similarly, Hawley complains about the quality of the hospital notes (his primary data) and states that it was difficult to make meaningful sense of much of the data. Hence, data-collection and handling seem to have been a recurring problem.

Haes Report

Haes' report identifies some problems relating to accountability and information-handling. It calls for a greater clarity in the MoD definition of duty of care in armed forces by better delineating the gap between the legal duty (duty of care) and the moral obligation (supervision). This recommendation is in line with the overwhelming scepticism in the report regarding the quality of DofC&S provision.

In terms of information-handling, Haes recommends changing the system of recording trainee discipline so that only Regimental entries are carried forward to the Field Army on posting. In addition, Haes notes that medical reports were incomplete.

Deepcut Investigation - DAG's Final Report

Although the report itself does not deal with the handling of information, Annex A to the report (Joint Learning Account, Army Input) recommends means of facilitating the conduct of investigations. These recommendations are a direct consequence of the problems faced by the soldiers' families and the Surrey Police in establishing the events surrounding the Deepcut deaths as well as the deficiencies of the records regarding guard duties and access to weapons (dealt with in the next section).

The first recommendation calls on the unit in which a serious incident occurs to establish a list of potential witnesses and to track subsequent postings and locations. A further recommendation calls for all information-handling and processing, including media relations, to be dealt with by a single lead HQ, which should be established at the onset of an investigation. This should lead to the issuing of more precise information.

As access to firearms has been identified as a potential risk, the report recommends that an officer or NCO be present and record all weapons handed over between trainees. In addition, NCOs should also record the transfer of guard duties. These measures, if implemented, would reduce risk and facilitate any subsequent investigation into incidents by providing a detailed record.

Finally, in terms of responsibilities, the Army input states that Police investigating officers must take control and give clear allocation of tasks to RMP/SIB acting in support.

Other Institutions' Experience and Standards

The submission from the Health and Safety Executive is in the context of information-handling particularly noteworthy given the MoD's failure to implement a uniform policy of recording incidents. In light of the problems encountered by the Surrey Police investigation, it is worth considering changing the practice under which members of the armed forces on duty are exempt from The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) do not apply to members of the armed forces on duty. RIDDOR require employers to report accidents at work that result in death, major injury or incapacity for normal work for three or more days. Imposing that requirement on training establishments would help boost uniform and consistent reporting policy and improve DofC&S provisions.

The practice of Student Officer Care and Support, implemented by the Metropolitan Police, places accountability for student officers on instructional staff (as first line managers with responsibility for study support, welfare, discipline, sickness and personal issues, and acting in a liaison with support units and other advice providers) and on intake managers, who are responsible for the management of all staff and student officers within their own intake.

The BSA submission contains an interesting section on confidentiality and deals with the handling of information in difficult situations (see section on welfare provision).[714] The standards employed by the BSA regarding confidentiality are stringent and establish the few cases when confidential information can be disclosed. These standards should be examined in more detail. The BSA for example states that 'information should be passed on a need-to-know basis' so that those who need to know something in order to perform their role successfully are able to so.[715]

Access to Firearms and Guard Duties

Access to firearms is part of the norm of military training and the military profession. This aspect is virtually unique to the training of soldiers and creates a particular concern and need in terms of duty of care provision. The availability of firearms to groups of young men and women, often under 18 years of age, places an increased requirement for safety provisions to avoid both accidental harm to oneself and to others. The problem of access to firearms is in many ways related to, on one hand, issues of supervision, screening and welfare, and, on the other, to the quality of training. In terms of supervision, the welfare system must (through screening and action by supervisors and welfare officers) be able to detect any individuals at risk and restrict their access to firearms. In term of quality of training, soldiers must be trained to handle firearms competently and responsibly before gaining access to weapons, especially if called upon to do guard duties in remote or isolated locations.

Hence, among the most important issues highlighted by the reports is the access to weapons afforded to recruits and whether the system in place has enough safeguards to prevent accidental misuse and self-harm. It can safely be concluded that access to firearms has been one of the most problematic areas in terms of duty of care and supervision, and the fact that all deaths investigated in relation to the Deepcut Barracks were caused by gunshot wounds leaves considerable cause for concern.

Among the problems that the Army reports deal with in particular, guard duties seem to be causing the most concern. As one of the reports states 'guard and sentry duties are the highest risk activity, accounting for some 60% of suicide cases…those on singleton or detached duty are most at risk, and especially at night'.[716] Hence, most Army reports call for a re-think of the setup under which trainees in Phase 2 are called upon to undertake guard duties, often without supervision or proper training in weapons-handling. Failure to deal with guard-duty setups is a particular problem for the safety and security of the trainees, and must be addressed.

Brigadier Evans' Report

Brigadier Evans' investigation is silent on the access to firearms but discusses the problem of the guard-duty system within Deepcut as well as its impact on morale and training effectiveness. The Report seeks to provide some recommendations in order to alleviate this pressure. Evans acknowledges that though not new, the guard problem had been accentuated by a lower input of trainees in the period leading to the investigation.

The review found that Deepcut was running a complicated security system, which required up to 22 military personnel at State Black. The low input of Phase 1 trainees in the period leading to the investigation resulted in a higher load of guard duties per trainee. Evans acknowledges that the measures he had authorised to alleviate the problem were not sufficient and calls for the substitution of soldiers by for example the Military Guard Service. Hence, one of the recommendations of Evans' review was for increased funding for a higher number of MGS at Deepcut, along with other security measures. As for the internal recommendation, Evans' review requests a review of guard duties as a matter of priority and encourages work towards the further reduction of military manpower requirements.

In short, Evans found that the load of guard duties is an additional factor 'undermin[ing] the unit's ability to run the progressive and imaginative training programmes to which the staff and their soldiers clearly aspire'.[717] Hence, guard duties as described by Evans were clearly perceived to hamper the training provision within Deepcut and, by extension, also the overall welfare of the trainees.

The MoD submission regarding the implementation of Evans' recommendations seeks to show that most of the problems were dealt with. In terms of reviewing the guard commitment, the MoD claims that steps were taken in the wake of the Pte Sean Benton Board of Inquiry recommendations. Accordingly, guard procedures were reviewed for relevance and a number of orders were promulgated concerning guard responsibility, the issuing of weapons and ammunition and the safeguarding of such weapons whilst in an individual's charge. In addition, the MoD claims that it had implemented a number of additional steps such as the banning of singleton prowler patrols; the handing over of weapons only under the direct supervision of an appointed NCO; the review and reduction of some 11 guard posts and the issuing of specific instructions where they had not existed beforehand.

Haes Report

Although the MoD submission presents a promising picture of 'problems solved', the findings by Colonel Haes in 2001 show that a number of key improvements did not take place and that the pressure on resources continued to pose a threat to the Army's ability to discharge the duty of care and supervision in its training establishments. The Haes report clearly identifies the risk associated with overstretch of Guardroom resources and the use of Phase 2 trainees (including SATT and soldiers awaiting discharge (SAD)), stating bluntly that 'security may be in the hands of dissatisfied, disinterested or unqualified soldiers'.[718] This is particularly dangerous when it applies to SAD. In addition, Haes notes the increased risk of under-qualified soldiers being issued with live ammunition for their guard duties.

In line with the Evans review, Haes recommends that to deal with the problem of under-staffed guardrooms, Military Provost Guard Service (MPGS) should as a priority measure be employed on all ATRA sites.

Deepcut Investigation - DAG's Final Report

The DAG investigation into the deaths of Privates Benton, James, Gray and Collinson acknowledges that all were caused by the use of a service weapon, although access varied from case to case. Nevertheless, all four soldiers had either direct access to the firearms or obtained a weapon with ease.[719] The realisation that within training establishments, firearm use accounted for eight out of 14 soldier deaths within the categories of suicide or open verdict between 1982 and 2002 prompted the investigation to look more closely into the risks related to the use of firearms.[720] Among the eight cases, six occurred whilst on guard duty (all four cases in Deepcut), indicating an Army-wide trend. For this reason, guard and sentry duties were identified as the most risk-prone activities.

Following the risk-management approach, the report states that in cases involving firearms, the opportunity for self-harm/suicide is usually characterised by isolation, and the investigation centres on whether the Deepcut procedures contributed to the circumstances that led to death. It found that the 'frequency, size and limited supervision of guards at Deepcut created those circumstances'.[721] In particular, one of the most significant factorS in the four deaths investigated might have been the unusually large number of soldiers (26) employed on guard duty at the highest risk periods (night/weekend) and with inadequate supervision.

The report identifies a similar problem to the one highlighted by Haes regarding guard duties performed by SATT. DAG's Report is however more concerned with the fact that SATT carried out more guarding duties than other soldiers and the opportunity risk that this generates. Predictably, the report recommends among other things that the routine security of the Deepcut site should be taken over by MPGS as soon as practicable and at a cost of £1.7 million.

The learning account input shows that the Army has taken in the full scale of the risk surrounding guard-duty setups and access to firearms. In terms of learning account input, a whole section of DAG's Report was devoted to the control of access to lethal weapons, followed by a section on the provision of armed guards and threat level.

DAG's Report recommended that soldiers should hand weapons over between themselves only on the direct order of an officer or NCO and in his/her direct presence, and with the transfer duly recorded by serial number on a weapon-issue sheet. In addition, a prohibition of unauthorised handover of weapons is to be included in orders issued at each posting and relief of detached guards. The frequency of guard duties was recognised as a problem, and DAG's Report recommends that these should be spread as widely as possible across the soldier population and that the allocation be controlled by sub-unit SNCOs. The report further recommends that sub-unit NCOs be present at and record guard-duty transfers.

In terms of access to weapons, DAG's Report concludes that decisions on the arming of trainees should be based on their Phase 1 report, their age and maturity and their Phase 2 induction interview. Trainees should not be employed on guard duty until that assessment is complete and signed off by their troop/platoon commander. This recommendation echoes some of the fears expressed by Haes over the competence and ability of some of the guards.

The recommendations for the provision of armed guards include a tighter application of risk-assessment methods in estimating guarding requirements, in particular an assessment of the risk posed to trainees. Regarding the organisation of guard duties, it is recommended that where prowler patrols on detached location are required, the guard should be composed of a minimum of four soldiers. If composed of trainees, such a guard should be supervised by a JNCO and all singleton patrols are to be prohibited. Finally, detached guards should be visited regularly by the duty officer and NCOs.

Other Institutions' Experience and Standards

In terms of weapons-handling, only a handful of institutions have experiences to contribute, in particular the Cadet Organisations and the Metropolitan Police. The ACO states that 'it follows the same procedure used in the Regular Forces by use of the Safe System of Training, i.e. safe rifles and ammunition, safe ranges, safe planning and conduct of training, safe cadets and investigation of incidents'.[722] Among the safety measures, cadets are tested regularly to ensure their competence in handling rifles and ammunition.

The Metropolitan Police screens officers applying for firearms training, and according to the submission, officers in training are given full access to protective equipment and weapons and ammunition are drawn from storage by qualified instructors. Officers in training do not have any unsupervised access to firearms.

Dealing with Specific Issues: Bullying, Sexual Harassment

So far the report has dealt with general issues relating to the armed forces' ability to discharge the duty of care in their Initial training establishments. The final section deals with some of the specific issues that have been mentioned throughout the report but that, due to their importance, need to be addressed separately. These can be encountered in any organisation but the armed forces' Initial training establishments need to be particularly aware of them. Principally, they need to be ready to deal with instances of bullying and sexual or other harassment.

At this stage it is worth noting that this report is merely analysing the literature mentioned in the introduction and providing an overview of how the different reports have dealt with duty of care issues. DAG's Final Report in particular has omitted theses issues as the Surrey Police investigation was still ongoing at the time of its writing. The report states that: the examination of specific factors that may have led each individual to [take their own life], such as bullying, harassment, personal problems or psychiatric disorder, remains part of the continuing Police inquiries, and so was outside the scope of this military investigation.[723]

Since most of the reports pay little or no attention to theses issues, the bulk of this section looks at the experiences of other institutions.


Bullying seems to be a more serious problem than the armed forces acknowledge (at least according to the Surrey Police submission to the HCDC), and most of the reports fail to address the issue as one relevant to duty of care and supervision. This section will outline experiences and standards of institutions that have sent submissions to the HCDC.

Brigadier Evans' Report

Brigadier Evans' report states that there was no suggestion of mistreatment in the deaths of either Private Benton or James, and that none of the self-harm incidents were the result of intimidation or bullying. No indication of mistreatment of any kind existed within Training Regiment and Depot RLC. As seen, the report does however recommend that reporting of self-harm incidents be harmonised throughout Land Command if only to highlight incidents of bullying. There is at this point no indication that this recommendation has been implemented.

Other Institutions' Experiences and Standards

Bullying is recognised as a serious matter by most institutions, including the armed forces. The BSA is particularly concerned with reducing bullying in its establishments, and claims that bullying is 'more common than many schools realise or are prepared to admit'.[724] The BSA calls on schools to formulate a definition of bullying understood by all, and recognise the full extent of a case, which can begin by simple exclusion from a peer group to physical abuse. The BSA believes that the most important preventive measure is to have a clearly stated and effective anti-bullying policy that is wholeheartedly supported by all staff.

The BSA is adamant that all allegations of bullying must be dealt with seriously and rapidly, though whether to deal with it as a public or private matter remains at the discretion of the authority. The response nevertheless has to be sensitive and consideration for the victims is paramount. Overall, the BSA suggests several ways to counter bullying: improving the environment; peer counselling; assertiveness training; support groups; complaints procedures etc. Finally, the BSA sees the training of staff and the raising of awareness as crucial steps in tackling bullying.

The SCC established similar level of standards in order to prevent child abuse, whether physical, emotional, sexual, or due to neglect and bullying. Since their policy is presented holistically - covering all aspects at the same time - it will be dealt with in the next sub-section, which looks at problems relating to harassment (sexual and other sorts).

Sexual (and other) Harassment

It is interesting to note that despite the findings of the Surrey Police investigation regarding the sexual harassment of trainees, none of the MoD investigations found anything to add on the subject. As a consequence, sexual harassment does not figure among the problems explicitly highlighted by Evans, Haes or DAG's reviews. Both Evans and Haes do however raise the problem of inadequate female staff ratios, and Haes does recognise the potential DoC&S-related risk for ATRA emanating from the lack both of sufficient female supervision for female accommodation and of female RPs.

Other Institutions' Experiences and Standards

The BSA submission provides interesting insight regarding standards and recommendations. It is obvious that the BSA has a particular concern and duty to ensure the safest possible environment for its pupils and its standards are a reflection of best practice. With regards to sexual abuse, the BSA states that each school has a very clear child-protection policy (see above). Sexual abuse and rape need to be handled with extreme care and discretion.[725] In all cases, police and social-service involvement are seen as necessary.

As noted above, the SCC has very high standards in child protection. Its policy for protecting children in the SCC provides its supervisors with a list of 'dos and don't', which covers the most important ways of dealing with abuse.[726] It also establishes that the responsibility to protect lies with those in direct contact with the cadets. Furthermore, the guidelines establish the proper ways of responding to child abuse, including reporting allegations; suspicions or concerns; follow-up action and what to do when a cadet confides in an instructor. It prescribes the immediate suspension of any officer, instructor or unit assistant against whom allegations are made. This is also prescribed for cases in which adult members are involved.


This report has provided a review of five MoD reports outlining reviews and investigations into duty of care-related issues since 1995. The report by Brigadier Evans reviews training provision at Deepcut Barracks and was prompted by two deaths and ten self-harm incidents occurring there in 1995. The Walton Report makes recommendations for an effective suicide-prevention policy for the British Army. The Hawley Report is a study of self-harm incidents in the British Army during a ten-year period (1987-1996). The Haes report is a review of duty of care and supervision in the ATRA facilities. Finally, DAG's Final Report into the deaths of four soldiers at Deepcut Barracks provides an account of how the training environment factored into the decision to commit suicide.

The Evans, Haes and DAG reports fall into the same category of Army reviews of training practices, identifying similar problems and making recommendations that then fail to be implemented and are therefore repeated in the next review. In a similar vein, the Walton and Hawley reports identify crucial problems in terms of effective suicide-prevention policy, but their recommendations were not fully implemented in the following years.

From the different reports, this report has distilled seven key areas concerning duty of care discharge and provided an analysis of each report's solutions to the problem. It is noteworthy that the areas are interrelated, as for example the nature of the training structure and supervision affects the efficient implementation of screening and monitoring as well as the provision of welfare and support.

Effective supervision - a product of balanced supervisory ratios and qualified and motivated staff - was identified as particularly problematic but central to the discharge of duty of care. All three MoD reviews (Evans, Haes, DAG) stress that the problem of staff levels is a significant risk and that inadequate level of staffing leaves an important gap in the capacity to secure duty of care standards. It seems that recommendations to increase numbers of staff, especially female and out-of-hours cover, have fallen on deaf ears, as this same problem was also evident between 1995 and 2002.

In terms of supervisors' quality and motivation, all reports have identified the need to improve the training of instructors as to equip them for the welfare roles inherent to the posts. Problems with staff inductions and actual training were evident throughout the period, as was the need to change the instructor-selection process as to ensure that only suitable members of staff assume a post within Initial training establishments.

The second area identified in this report deals with the screening of recruits/trainees and the recruitment process itself. Screening has been identified, in one form or another, as essential to the ability of the training establishments to track trainees most at risk. Screening is important both at the entry stage, where its improvement has been continuously recommended, and throughout the soldier's life in the armed forces. However, Phase 2 soldiers are believed to be particularly at risk, as the quality of monitoring in those establishments is below the standards needed to implement successful prevention and support policies.

More emphasis needs to be placed on informing potential recruits of army careers and on improving entry-level screening. It is felt here that the problem of information provision has not been sufficiently dealt with by the surveyed reports. This is an area where progress needs to be made in order to ensure that recruits are well aware of the full extent of demands that are going to be placed on them as well as the nature of military life.

The training structure is particularly problematic, as the quality and level of supervision and training in Phase 1 are far superior and therefore less prone to risk (in terms of duty of care) than the equivalent in Phase 2. This problem has been highlighted by both Evans and DAG and seems to be the single largest unresolved issue. The nature of Phase 2 poses particular risks in terms of its turbulent environment and the fact that recruits are under less supervision and considered trained, resulting in a level of freedom that is disproportionate to the soldiers' maturity. The structure of Initial Training seems to be a root-cause of a number of problems and feeds into difficulties relating to supervision, screening, access to firearms and welfare provision.

Welfare provisions seem to suffer from a lack of resources and staff training. Regarding the former, the facilities and support services have improved between 1995 and 2002, but remain under-funded. The lack of training in welfare roles available to supervisors, and the negative attitude of some military staff to voluntary and welfare services need to be addressed. It seems that the coordination of welfare support has not been successfully implemented and further evidence of improvement of the policy towards bereaved families should be sought.

The nature of the military profession and its initial training establishments bring young people into direct contact with firearms. This unusual professional characteristic increases the risk of harm to self and others and is exacerbated by the guard-duties system in Phase 2 establishments. This risk was identified by all three MoD reviews, especially with regards to trainees who are either not fully trained, soldiers awaiting trade training (SATT) or, worse, soldiers awaiting discharge (SAD). The system as such was recommended for revision, but due to resource constraints, the preferred option of introducing the Military Provost Guard Service (MPGS) was not met between 1995 and 2002.

Finally, the lack of a uniform system of reporting and logging incidents is worrying, even more so since it has been identified as a problem by Evans, Haes and DAG. It is obvious that the system as described by those reports hides the true extent of duty of care problems. In addition, proper handling of information is essential in establishing an effective suicide-prevention policy, as the effectiveness depends on properly assessing the causes of suicide.

In conclusion, the review produced here shows that he MoD's approach of reviewing the Initial training duty of care-related problems has failed to improve significantly the ability of its establishments to discharge DofC&S in an efficient manner. A number of findings and recommendations are present in more than one report suggesting that despite claims to the contrary, implementation of key improvements has been sporadic and inefficient.


Ministry of Defence Documents

ATRA Duty of Care and Supervision (DofC&S) Report 98-01(including annexes) by Headquarters Army Training and recruiting Agency (Haes Report)
Deepcut Investigation - DAG's Final Report
DOC Appraisal of Initial Training Departmental Progress Report - July 2003
Re-Appraisal of Initial Training by Directorate of Operational Capability
Care for Service Recruits and Trainees, Memorandum by the Ministry of Defence
Additional submission by MoD (Document 1b, D/Parliamentary/21/47)
Individual Training and Education in the Armed Forces Paper no.6(2004) by the Ministry of Defence Policy Papers
Brigadier Evans A Review of the Phase 2 Training System Within Deepcut
Suzy Walton Suicide in the British Army (Parts 1-5)
Colonel A Hawley A Study of Attempted Suicide in the Army: 10 Years of Experience 1987 to 1996
Submission by Sandra Caldwell, Director of Field Operations, to Bruce George MP Chairman of Select Committee on Defence

Submissions by professional organisations, institutions and bodies

Surrey Police Deepcut Investigation Final Report

Memorandum by Surrey Police: Duty of Care Inquiry

Memorandum by the Religious Society of Friends (Quakers)

Memorandum by the Chartered Institute of Personnel and Development

Submission by Air Cadet Organisation

Submission by the Sea Cadets Corps

  Code of Conduct

  "Protecting our Children" ASCR 24

Submission by the Boarding Schools' Association (BSA)

  Tim Holgate, ed. (2001) Good Practice in Boarding Schools BSA

Running a School Boarding House: A Legal Guide for Housemasters and Housemistresses BSA & DfEE

Boarding Schools National Minimum Standards: Inspection Regulations Department of Health

Dr Roger Morgan Safer Staff Recruitment Boarding Briefing Paper No1, BSA

Dr Roger Morgan Educational Guardians Boarding Briefing Paper No3, BSA

Dr Roger Harrington Medical Protocols and Practice Boarding Briefing Paper No4, BSA

Adrian Underwood Policies for Partnership with Boarding Parents Boarding Briefing Paper No6, BSA

Taking on a Boarding House Boarding Briefing Paper No7

Tim Holgate Job Descriptions for Boarding Staff Boarding Briefing Paper No8

Tim Holgate Effective Welfare Policies Boarding Briefing Paper No9

Adrian Underwood The Boarding Handbook Boarding Briefing Paper No10

Tim Holgate More Welfare Policies Boarding Briefing Paper No11

Submission by the WRVS

Submission by the Commission for Social Care Inspection (CSCI)

Submission by Roger Morgan, Children's rights Director, to Bruce George MP Chairman of Select Committee on Defence

Submission by the Interactive College

Submission by Youth Justice Board

Submission by Anne Owners, HM Chief Inspector of Prisons to Bruce George MP Chairman of Select Committee on Defence

Memorandum by PAPYRUS

Memorandum by the Centre for Hazard and Risk Management (CHaRM)

Memorandum by Institution of Occupational Safety and Health (IOSH)

Further Memorandum from IOSH

Evidence from the Health and Safety Executive by Paul Wusteman, HM Principal Inspector

Submission by David Sherlock, Chief Inspector Adult Learning Inspectorate

The Metropolitan Police Service Duty of Care to Students Training, a submission of written evidence to the Defence Committee Duty of Care Inquiry by Commander Shabir Hussain

Memorandum by the Independent Monitoring Boards' Secretariat

Submission by SSAFA Forces help to HCDC Inquiry

Other submissions

Letter by Geoff & Diane Gray to Bruce George MP Chairman of Select Committee on Defence

Letter by Lynn Farr to Bruce George MP Chairman of Select Committee on Defence

Memorandum by James and Yvonne Collinson

Memorandum by Mrs Elaine Higgins

Memoranda by James Mckenna, Helen Mckenna and Stuart Mckenna

Memorandum by Lembit Opik MP

Statement of Evidence by Mr & Mrs D. James to Defence Select Committee

Submission b Lieutenant Colonel (Retd) Richard Haes OBE

658   DCI Gen 2006 Annex D, cited in the Haes Report, p.2 Back

659   See DCI 260/00 Duty of Care (U) (Annex D to Haes Report) Back

660   Individual Training and Education in the Armed Forces, Ministry of Defence Policy Paper, no. 6, p. 16-7 Back

661   Ibid Back

662   The Review of the Phase 2 Training System within Deepcut, conducted by Brigadier P.A.D Evans Back

663   Brigadier Evans' review, p. 1 Back

664   Ibid, p. 2 Back

665   Surrey Police Final Report, p. 12 Back

666   Letter by the Rt Hon Adam Ingram to the HCDC, Reference D/Min(AF)/AI/1567P&1571P&1572P, 15 June 2004 Back

667   Suicide in the British Army by Suzy Walton  Back

668   A Study of Attempted Suicide in the Army: 10 Years of Experience 1987 to 1996 by Colonel Hawley Back

669   ATRA Duty of Care and Supervision (DofC&S) Report 98-01 by Colonel Haes Back

670   Haes Report, p.12 Back

671   Brigadier Evans Report, p. 6 Back

672   Ibid., p. 9 Back

673   Annex A-3 to the Letter by The Rt Hon. Adam Ingram D/Min(AF)/AI/1567P&1571P&1572P, 15 June 2004 Back

674   Haes Report, p. 4 Back

675   Ibid.  Back

676   Ibid., p. 13 Back

677   Ev 438ff Back

678   Ibid. Back

679   Ibid., p. 263 Back

680   Brigadier Evans Report, p. 9 Back

681   Haes Report, p. 16 Back

682   Deepcut Investigation - DAG's Final Report, p. 10 Back

683   Ibid., p. 11 Back

684   MoD letter, D/Parliamentary/21/47, 5 July 2004 Back

685   Ev 472ff Back

686   The Sea Cadets Corps, 'Protecting our Children', Child Protection ASCR 24 Back

687   Ev 479ff Back

688   See Dr Roger Morgan, Safer Staff Recruitment, Boarding Briefing Paper, no. 1, The Boarding Schools Association Back

689   Ev 438ff Back

690   Brigadier Evans Report, p. 8 Back

691   Ibid. Back

692   Walton Report (Part 5), p. 7 Back

693   Hawley defines para-suicide as 'a non-fatal act in which an individual deliberately causes self injury or ingests a substance in excess of any prescribed or generally recognized therapeutic dose', p. 12-13 Back

694   Hawley Report, p. 2 Back

695   Ev 428ff  Back

696   Brigadier Evans Report, p. 6 Back

697   Ibid. Back

698   Deepcut Investigation - DAG's Final Report, p. 9 Back

699   IbidBack

700   Brigadier Evans Report, p. 3 Back

701   Haes Report, p. 12 Back

702   See Back

703   See Tim Holgate, ed. (2001) Good Practice in Boarding Schools Boarding Schools Association, ch. 3 Back

704   Ibid., pp. 243-82 Back

705   Ibid., p. 185 Back

706   Ibid., p. 186 Back

707   Ibid., p. 69 Back

708   Brigadier Evans Report, p. 2 Back

709   Ibid. Back

710   Ibid., p. 8 Back

711   Ibid., p. 5 Back

712   Walton Report, p. 31 Back

713   Hawley Report, p. 36 Back

714   Ibid. Back

715   Tim Holgate, ed. (2001), Good Practice in Boarding Schools, Boarding Schools Association, p. 194 Back

716   Deepcut Investigation - DAG's Final Report, p. 7 Back

717   Brigadier Evans Report, p. 9 Back

718   Haes Report, p. 5 Back

719   Deepcut Investigation - DAG's Final Report, p. 10 Back

720   Private Collinson, who at the time of the report's publication was still awaiting the coroner's report, is the 15th case. Back

721   Deepcut Investigation - DAG's Final Report, p. 11 Back

722   Ev 472ff Back

723   Deepcut Investigation - DAG's Final Report, p. 1 Back

724   Brian FitzeGerald, 'Reducing Bullying in Boarding Schools' in Tim Holgate, ed. Good Practice in Boarding Schools, The Boarding Schools Association, pp. 88-103  Back

725   Ibid., p. 191 Back

726   Ev 288ff Back

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