ANNEX B: LITERATURE REVIEW AND ANALYSIS
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).
Supervision
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.
Introduction
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
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.
Screening
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
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.
Conclusions
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.
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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
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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
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Code of Conduct
"Protecting our Children" ASCR 24
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Tim Holgate, ed. (2001) Good Practice in Boarding
Schools BSA
Running a School Boarding House: A Legal Guide for
Housemasters and Housemistresses BSA & DfEE
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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
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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
Ibid. Back
700
Brigadier Evans Report, p. 3 Back
701
Haes Report, p. 12 Back
702
See http://www.boarding.org.uk 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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