Investigation into suicide and attempted
suicide
Reporting Suspected Suicides—Psychological
Autopsy Checklist
0001. The suicide of service personnel has
a traumatic impact upon the family of the deceased and upon the
morale, and therefore the operational effectiveness of the serviceman's
unit. The Army is committed to reducing suicide and to identifying
its underlying causes amongst service personnel. The Adjutant
General has established an Army Suicide Management Working Group
(ASMWG) comprising specialists from the medical authorities and
the Service Police whose terms of reference include the identification
of psychological causes for individual suicides and trends across
the Army.
0002. In order for the ASMWG to examine
the causes and trends of suicide it requires information about
each case. Information is gathered from numerous sources including
RMP, medical authorities and the person's unit and a Psychological
Autopsy Checklist has been developed by the ASMWG to record the
information required. RMP investigators attending the scenes of
suicides are best placed to gather first hand and accurate information
to benefit the investigation and the ASMWG's research. RMP investigators
attending the scenes of suspected suicides should complete as
much of the checklist as is possible and if necessary conduct
enquiries within the person's unit or with his or her family in
order to assimilate the information required. A copy of the checklist
is at Annex 34D which, when completed and at the earliest opportunity
should be forwarded to:
Reporting Attempted Suicides—Guidelines
for Commanding Officers
0003. It is a requirement that all cases
of Attempted Suicide reported to or discovered by the Service
Police should be properly investigated to determine the underlying
causes ie bullying, relationship breakdown etc, and whether any
offences have been committed. Usually the Service Police will
report the circumstances to the subject's commanding officer by
means of an INCAREP, and take no further action. Because of the
duty of care that must be provided to personnel by the MoD, and
to ensure that appropriate action is taken to try to avoid such
persons re-attempting, a flyer entitled "Guidelines for Commanding
Officers following an Incident of Self Harm" should be attached
to the copy of the INCAREP sent to the subject's commanding officer.
A copy of the flyer is at Annex 34E, and the need to attach the
flyer is contained in the guidance on recording and reporting
at Provost Manual Volume 5 Chapter 32.
Investigation into Suspected Suicide (Self Inflicted
Death)
0004. In the current climate of accountability
and public awareness, investigations by the Service Police into
cases of sudden death where suicide is suspected have become more
exacting and require a co-ordinated approach. In reality sudden
deaths of servicemen where suicide is suspected are not commonplace,
and therefore the Service Police should exercise best practice
by assuming the worst-case scenario, thereby viewing cases as
murder until proved otherwise. It follows that all such cases
should be treated as major incidents from the outset, with consideration
given to establishing a Major Incident Room (MIR), albeit that
within UK the Service Police should be included in the civil police
MIR. In all such cases a Policy Book must be maintained in which
all decisions made concerning Service Police investigative activity
are recorded—see Major Incident Procedures at Provost Manual
Volume 5 Chapter 36.
Police Primacy and Responsibility
0005. Within the United Kingdom the civil
police have police primacy and responsibility for all cases of
sudden death, and therefore the Service Police act in a supporting
role to both the civil police and HM Coroners. The situation concerning
the death of servicemen serving abroad is clearer, with police
primacy usually being exercised by the Service Police in accordance
with the various Status of Forces Agreements (SOFAs) and Memorandums
of Understanding (MOUs). Clear procedures for contact with HM
Coroners concerning the repatriation of bodies have also been
established—see Coroners Procedures at Provost Manual Volume
5 Chapter 69. To better co-ordinate Service Police procedures
in the United Kingdom, protocols on a national basis between the
Service Police and all United Kingdom police forces, Ministry
of Defence police and HM Coroners are currently being developed.
In the meantime, interim Service Police procedures have been developed
to better co-ordinate investigative activity with the civil police
and HM Coroners in the United Kingdom, including guidance to investigators
dealing with such cases. Although the investigative guidance,
which has arisen as a result of several recent cases, is inclined
towards the investigation of cases in the United Kingdom, most
is equally applicable to Service Police investigations abroad.
Investigative Guidance
0006. Attendance at the Crime Scene.
In addition to the SIB/SIS duty investigator, a SIB/SIS senior
investigator, preferably at WO level or above should attend the
scene of any sudden death. The section Scenes of Crime NCO (SOCO)
should also attend and from the outset a log to record all visitors
is to be maintained until the scene is declared clear.
0007. Initial Case Conference with Civil
Police. At the earliest opportunity, the OC SIB/SIS or his
nominated deputy should hold a case conference with the supervising
civil police officer that has primary responsibility for investigating
the case. All decisions made concerning Service Police investigative
activity throughout the enquiry should be recorded in the Policy
Book—see Major Incident Control at Provost Manual, Volume
5 Chapter 36.
0008. HM Coroner Case Conference.
Where there is need, a case conference should also be held with
the Coroner or his officer, and again all investigative decisions
should be recorded in the policy book.
0009. Crime Scene Examinations, Recovery
of Bodies, Weapons and other Exhibits. It is imperative
that the scene of death is thoroughly examined, searched and items
recovered to a very high standard. General guidance is as follows:
(a) Action before the Arrival of Service
Police. Unit and medical personnel are usually first on the
scene of any death and need to be aware of crime scene preservation
requirements. Notwithstanding their initial obligations to save
life, ideally the body and any weapons or items connected with
the death should be left in situ and untouched. However, in such
situations soldierly skills become automatic and weapons are usually
unloaded and made safe. In such cases it is imperative that a
statement is immediately recorded from whoever cleared the weapon,
outlining the exact condition it was found, location, safety catch
on/off, round in breach etc.
(b) Command. The first investigator
or policeman to arrive at the scene must take control and ensure
an adequate cordon is established. A qualified SOCO, either Service
Police or civilian equivalent should then examine the scene under
the clear command of a nominated Senior Investigating officer
(SIO) or deputy.
(c) Attendance by Forensic Pathologist.
In all suspicious fatalities where the body is still at the scene,
the attendance of a forensic pathologist should be sought.
(d) Body Removal. This must be co-ordinated
by the Scenes of Crime officer. Clothing should be searched by
the SOCO at the first opportunity.
(e) Shooting Incidents—Attendance
of a Ballistics Expert. Although it may take some time to
arrange, the subsequent attendance of a ballistics expert at the
scene to determine projectile trajectories and other technical
matters should be considered.
(f) Recovery of Items Connected with the
Death, Weapons and Ammunition. Such items ie ropes used for
hanging with knot intact, hose pipes, weapons etc must be recovered
by the SOCO. Although it may be important for safety reasons that
firearms are "cleared", due regard should be taken to
subsequent fingerprint examination. Such weapons must never be
cleaned and must be submitted for ballistics examination. Once
this is complete, the weapon is to be retained as an exhibit.
(g) Photography and Video. Sufficient
photographs and video should be taken of the scene covering all
angles and including a wide or anal view. Coverage should extend
to the route taken by the deceased and any other connected scene.
(h) Sketch Plans. A sketch plan of
the scene and any known routes should be meticulously compiled
by the SOCO, having due regard to the inclusion of immovable fixed
points.
(i) Search of Scene. It is vital that
the crime scene is thoroughly searched under the supervision of
the SOCO. A fingertip search of the immediate scene to locate
items such as empty cases, bullet heads, suicide notes, human
bone or other fragments etc should be conducted. Such searches
should extend where necessary to routes taken by the deceased,
and back to any place of work, residence, guardroom or place of
duty as appropriate. The use of specialised search teams should
be considered.
THE INVESTIGATION
0010. In all suspicious deaths the case
should be initially investigated as if it were a murder until
the evidence shows this is not so. In all suspicious deaths, including
suspected suicide cases, investigative priorities must be readily
identified thereby ensuring that key witnesses are interviewed
without delay and that exhibits such as clothing are retained
and submitted for forensic examination. It is vital to quickly
recover key documentary evidence regarding the issue of weapons,
guard rosters etc as otherwise such records may be destroyed or
lost. The following actions should be considered:
(a) The Post Morten Examination. In
suspected suicide cases a Forensic pathologist should conduct
the post mortem examination, with a SOCO in attendance to provide
adequate photography of injuries, take latent fingerprint impressions,
hand swabs etc and to recover the deceased's clothing. The recovered
clothing and any gloves/hand swabs should then be submitted for
forensic examination as necessary. In such cases clothing and
other exhibits, albeit biohazards, should be retained indefinitely.
(b) Interview of Key Witnesses. As
a matter of policy, a clear strategy should be determined early
in the inquiry to interview and record statements where necessary
from key individuals. It is crucial that such witnesses are located
and interviewed quickly, otherwise their varying accounts will
be clouded by time and confused with accounts they have heard
from elsewhere. Crucially, in cases were suicide is suspected,
it will be necessary to formally record in individual statements
whether the witness can provide any reason for the deceased's
course of action, including whether or not any bullying is apparent.
The full military background of any deceased soldier, including
copies of pertinent orders, training records etc should be thoroughly
researched. Interviews should extend to colleagues, close friends
and military supervisors.
(c) Background Medical Factors. It
will be necessary to recover a deceased's medical documents from
the medical officer civilian doctor concerned, and record any
material evidence such as any previous self-harm or psychiatric
assessments. This should extend to any significant behavioural
or medical factors prior to joining HM Forces; the parents of
the deceased should also be visited.
(d) Families Liaison Officer. It is
vital that the bereaved are given accurate and timely information
at the outset of enquiries, as well as providing important witness
information to the Service Police. Whereas in the United Kingdom
the civil police may carry this out, there is no real substitute
to having a Service Police Family Liaison Officer able to provide
accurate factual information and support both from a police and
"Army" perspective. A trained Families Liaison Officer
(FLO) should be appointed in all cases, and services offered to
the bereaved through the civilian police and PS4(A) Cas/Comp.
It is imperative that any visit by a Service Police FLO is thoroughly
co-ordinated, a joint civil/service police being the favoured
option in the United Kingdom. Once cleared, consideration should
be given to allowing the bereaved an escorted visit to the scene
of death.
(e) Other Investigative Considerations.
Depending on the circumstances, specifically where evidential
gaps appear, the following actions, which are not exhaustive,
should be considered:
(1) Searches of the deceased's room,
place of work, vehicle, combined with the recovery of any mobile
telephone or computer belonging to or used by the deceased.
(2) Determine the whereabouts of all
people in the area.
(3) Consider house to house enquiries.
(4) Consider media appeals for information.
(5) Produce customised witness proforma
when it is necessary to deal with large numbers of potential witnesses,
such as in a barrack area.
(6) Consider a "reconstruction"
of route taken by deceased prior to death.
REPORTING PROCEDURES
0011. At the conclusion of a Service Police
enquiry into the suspicious death of any serviceman, it is necessary
to draw all the material facts together into a full Investigation
Summary. Copies of statements and other documentary evidence should
be attached for entitled addressees only—see Recording and
Reporting of Incidents at Provost Manual, Volume 5, Chapter
32.[18]
18 Not printed. Back
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