Paper junior officer inquiries investigations into death or serious injury on operations scope for improvement and tri service harmonisation

21.11 StratSecDD; PJHQ-CJO; Land-Private Office - CinC; AG-HQ AG Personal; CGS; CNS 1SL-NA; CAS/PS Subject: VCDS/DCDS(Pers) STUDY INTO OP INQUIRIES - FINAL VERSION (for SPB 30 Mar) Importance: High - VCDS/DCDS(Pers) STUDY INTO OP INQUIRIES - FINAL VERSION (for SPB 30 Mar) I am most grateful for the comments received on the draft of this report, virtually all of which I have managed to weave in in one way or another. I believe that I am fairly safe now in assuming the requisite broad and informal consensus, on which basis I am now issuing it in final form. You will see that there are two attachments: they are identical, but one is highlighted to show changes from the draft. This report now forms the essential background for discussion at SPB next Tuesday 30th March, and PSs/MAs to Board Members might usefully substitute it for the draft form sent out by MA/DCDS(Pers) yesterday (her 241050Z). I am now producing a much shorter paper for SPB itself, which I intend to distribute tomorrow. Bol Study (Final) Bol Study (Final) 251600Z Mar ... (highlighted... DECLASSIFIED recording, dissemination and audit of recommendations and their implementation. BACKGROUND: Towards the end of 2003, VCDS asked the Services to identify improvements in the procedures and handling of investigations and inquiries concerning death and serious injury on Op Telic. His concern was driven primarily by the need to correct certain limited but nevertheless specific shortcomings in the processes themselves that had become manifest in the course of the Operation, and partly by the need to correct any public perception, real or imagined, that internal inquiries might be lacking in urgency or diligence with a lack of independent audit offering scope to cover-up embarrassments. This latter concern was reflected in the ministerial postbag, where shortfalls in succinct and timely briefing up to ministers had at times contributed to an appearance of our being on the back foot, even when there should have been a reasonable line to put - particularly in dealings with next of kin (NoK) and the media. 3. VCDS had been particularly keen to draw from best practice across the three Services and to achieve harmonisation wherever this was sensible and practicable, bearing in mind the essential differences in their roles and structures. The Services, led by their respective PPO 1-Stars, duly produced a joint list of recommendations under the overall co-ordination of DP&TPol'. I was then tasked by VCDS and DCDS(Pers) to take forward this helpful groundwork in the form of a quick study to draw out any further specific recommendations that might be instituted straight away, consistent with and informing ongoing work on the Tri-Service Act. The Terms of Reference are at annex A. I should say at the outset that I am no expert in the subject, but I have learnt a great deal from the many who are, and to whom I am most grateful for their time and patience. I cannot claim a great deal of original thought in the recommendations since they were for the most part already under consideration or emerged naturally from discussion with a comprehensive range of interested parties. I attach a list of those consulted at annex B, all of whom have had the opportunity to comment on my initial points list and SITREP? and on this report in draft, so whilst I take full responsibility myself for the report, I believe it fair to say that it reflects a broad basis of informal consensus at 1-Star/working level. 5. This short report does not set out to give a comprehensive description of the respective inquiry and investigation procedures in each Service. It makes a limited number of incremental recommendations, listed at annex C, building in turn upon the measures in the January DPT&Pol Report' which was itself incremental in approach. The 1 PTC/113413/DP&TPol dated 22 Jan 04 2 D/DSPPoISC/2/3/1/10 dated 27 Feb 04. 1 DECLASSIFIED with an SIB investigation was acceptable provided it met his other directions on timeliness, independence, transparency, keeping NoK informed, legal advice and the like. It seemed evident from this exchange that Hd PL(LS), or DC&LF&S) as the post was re-titled, was taking the overall lead on such matters of policy from within DCDS(Pers). The DC&LF&S) post has recently been merged with SEF Pol (following an NAO recommendation) under CESO(MOD), now renamed DS&C (Director Safety & Claims) who now has dual reporting lines to DCDS(Pers) for strategic direction and to Personnel Director for line management. DS&C was commissioned by 2nd PUS last year to produce a report on harmonisation and best practice of Bol for fatalities and serious injuries. The first draft of this Report (DESB P(04)3) was presented to DESB (The Defence Environment and Safety Board, chaired by 2rd PUS and with wide membership including VCDS and Service Chiefs) at its 12 January 04 meeting, and is now being revised in line with the ensuing broadly supportive discussion. The Report recognised that responsibility for disciplinary or 'chain of command' inquiries lay with individual Services, but sought harmonisation wherever possible, and recommended the establishment and BESO, who would presugate recommendatins and very to A reaid of that theith implementation was being audited by respective TLBs. The Tri-Service Act Team (TSAT) under DCDS(Pers) sees Bol improvement and harmonisation as part of their main effort and is already making good progress, as reçorded in a note to SPEG from DSPPoISC (currently in draft). I have taken up residence within TSAT for the duration of this study in order to ensure that my own work draws from their greater experience and is in turn reflected in their product - to the extent as might be agreed by VCDS, DCDS(Pol) and the Services. SCOPE: 9. The term "Boards of Inquiry (Bol) Study' has been used as a convenient shorthand for this study, and there are in fact aspects intrinsic to the internal Bol process where improvements could be achieved. However, it rapidly became apparent to me that the narrowly defined Bol process itself ran reasonably well once triggered, and the problems lay more with the associated issues of how, when and why they were set up; how their product was processed; linkages with other inquiries by police, coroner, specialists and the like; and reporting to ministers. I have been particularly concerned to identify quite how the overall grip and co-ordination of these closely related activities could best be achieved. 3 D/PL(LS)/619/4/1/9(163/97) dated 27 Jun 97; and DC&L(F&S)/29/5/5(223.97) dated 8 Oct 97. * D/MIN(AF)/JR/5/3/1 dated 22 Apr 98. 2 DECLASSIFIED fact been occasions when the process itself could have been better, both on the ground and further along in dealings with NoK and the like. There is scope for improvement, and the lay public who might have difficulty in understanding why deaths or injuries of Service personnel sustained under virtually identical circumstances could be dealt with in quite different ways depending on their Service. ANALYSIS: General. 12. I should start by mentioning a particularly important principle that has driven this study, and that should, I believe be equally applicable to others. It would seem vital to the ethos underpinning our operational effectiveness that junior commanders in particular, taking intrinsically high risk intuitive decisions in the heat of operations, should not feel unduly constrained by the prospect of investigation and litigation. This is not the place to set out arguments that can no doubt be articulated more eloquently and effectively by Service colleagues, but the legal concept of 'combat immunity' has become fairly well established, and it would be unfortunate, to say the least, if this were to be negated to some degree by over-zealous interpretation of HRA, HSE or other legislation in inappropriate or unnecessary circumstances. There would seem to be a balance to be struck here: it would be wrong to hold an inquiry into every 'combat death', but equally wrong for any life to be written-off without some competent authority determining that it was indeed a 'combat death', howsoever defined. There may also be vital lessons to be learnt and disseminated immediately. 13. It has been suggested that a definition of 'combat death' or 'combat injury' could clarify the applicability of inquiries or investigations. This may well be the case in principle, but there would seem to be difficulties in practice, quite apart from the obvious complexities of culpability, blue on blue and the like. A clear case of an attritive firefight might be seen as meeting the definition, but it is not difficult to envisage circumstances where an enemy pursuing our own doctrine of the 'manoeuvrist approach' (put simply: hit your enemy where, when and how least expected at the point most likely to erode his will to continue), but to extremes exceeding international laws and conventions, might cause casualties in a manner likely to arouse public demand for inquiry. One can think of instances on Op Telic where the concept of 'combat death' could be hotly debated. It is probably counterproductive to attempt a narrow definition involving, say, enemy fire, 3 DECLASSIFIED actually deter some witnesses and lead to less openness in revelation. Judgement needs to be exercised on a case by case basis, mindful that there have been occasions where early common sense briefing could have avoided unhelpful speculation and the appearance of eventually being forced reluctantly to divulge information that in fact was bound to come out anyway. 15. Rightly or wrongly, the public have gained the impression that casualties will be minimal, and will most likely be followed by inquiry and high profile personal ministerial attention. The vast majority of our investigations and inquiries run perfectly competently, but most of what we do comes under media scrutiny, and the impression has been gained that our internal inquiries can be less than entirely thorough or impartial, partly because on the odd occasion there have actually been shortfalls, but also because occasional inadequacies in our briefing of NoK in particular have left us on the back foot and appearing unduly defensive. At times our own terminology works against us. The term Bol has a formal ring to it, with a lay perception of being the only proper inquiry, so the fact that a Bol can be convened many months after an incident does not always present an image of diligence or urgency, notwithstanding that other processes have been running their proper course beforehand. Grip and Co-ordination. I am here looking at problems that can and have arisen as a consequence of the way in which the overall process of investigation and inquiry has been set up and handled rather than intrinsic nature of the incident itself. It would seem that the workings of individual elements are reasonably well defined (such as SIB(Special Investigations Branch) or LAIT (Land Accident Prevention and Investigation Team)), as is their routine sequencing. There are also competent individuals within those elements who are well aware of how their elements relate to one another. However, the key requirement here would seem to be for overall grip and co-ordination, both at the outset to determine quite what those key elements ought to be, and on an ongoing basis to make sure that they function in a timely, effective and joined-up fashion, conducting their work in parallel to the maximum extent possible - and with the perception and authority to question specialists (including police and liaison with external elements) and to effect any necessary changes in the process. The effective exercise of this generalist grip should of itself identify and resolve most of the problems addressed in the following recommendations. It is a recurrent theme and is thus perhaps the most important recommendation. 17. Responsibility for this overall grip rightly rests with the chain of command, meaning the individual command/TLB, though the Services differ in the degree to which they share this function between FLC and PPO. At Higher Authority level, the Army monitors 4 DECLASSIFIED forms of investigation and inquiry into onsity for continual pro-active monitoring of alli lated the into operational (and non-operational) deaths and injuries and all matters related therewith, such as NoK, media and briefing ministers - maximising and progressing concurrent activity, and with the competence and authority to spot and implement quick common-sense actions. This is not just routine progress chasing; it needs to be sufficiently competent, senior and authoritative to interrogate and direct or liaise with all specialist elements, and to follow through in ensuring dissemination and implementation of recommendations relating both to incident and to process of investigation. This would require close secretariat involvement, to which I turn next. Briefing Ministers/Secretariat Involvement. 19. I am here concerned primarily with the briefing process, which does indeed require attention, but the point has been made that Ministerial concern has been occasioned primarily by the issues relating to the investigatory process that necessitated the brief in the first place. There is a need to provide ministers not only with the reassurance that all inquiries and investigations and related issues like NoK and the Press are being handled competently, but also with timely and digestible summaries and advice on those aspects most likely to impinge upon them directly. A period of two months would seem about right for routine updates, with prompt ad hoc briefs on issues with potential to damage the Department. There is a difference between the service writing and format necessary in a comprehensive military report and the succinct, self-standing, brief presented in short, straightforward, lay terms to ministers. The latter is both selective in that it focuses on matters of particular concern, and comprehensive in that it identifies potential problems (and solutions) in the context of ministers' bigger picture. 20. The recent DP&TPol Report' for VCDS made useful headway in defining a common reporting format, but it is recognised that a thick wad of Bol updates would be unlikely to meet the ministerial requirement on its own, however timely, comprehensive and uniformly formatted they might be, without such a succinct brief to go with it. This is no criticism of the the individual updates which should still be attached to the guiding brief to provide precise detail as required. Such briefs used to be the province of the MODHQ secretariats, now largely devolved to TLBs, so the term "secretariat" is used here as shorthand for this form of high quality perspective and briefing, whether service or civilian. The need for such secretariat input, with the antennae to read the Department of State context and the competence to interrogate specialist advice would seem evident right from the outset of the Bol process, and the question of who might best provide that added value would seem germane to this Study. 5 DECLASSIFIED 22. I recommend that a mechanism be established for both routine and ad hoc briefing to ministers on investigations, inquiries and associated issues, with command/TLB secretariats providing the main added value and lead. Some central co-ordination would seem to be required, not only for the set up and operation of this mechanism, but also to provide a broader tri-Service policy overview and lead, where relevant. This role would seem to fall most logically to DCDS(Pers), who needs as a minimum to be aware of all such briefings going direct to ministers, and who ought in particular to be consulted by commands/TLBs in those cases where he might more appropriately take the lead himself. Whilst not wishing to sound in any way prescriptive on the relationships between TLBs within a Service, and their ownership of chain of command issues, there would seem to be a need for each Service to define a single point of contact (perhaps a lead command/TLB?) to provide a coherent single-Service input to DCDS(Pers) on those occasions when he is in turn required to present a tri-Service overview. DCDS(Pers) is currently considering where within his own organisation this secretariat function might best be focused, mindful that he also has functional responsibility for CESO, who is in process of concluding a related and more comprehensive study for DESB on tri-Service harmonisation of inquires into death and serious injury. Nature of Inquiry or Investigation. 23. I have already mentioned that my focus has been more on the circumstances under which a Bol might be set up than on the internal process of the Bol itself. Indeed, the main question drawn to my attention in early broad discussions was whether a Bol should invariably be convened right at the outset in all cases of death or serious injury. The RN and the RAF already do this, so the focus inevitably shifted mainly to the Army and to the alternative forms of investigation that might precede or supplant a Bol - primarily the SIB of the respective Service police or the LAIT. The Army also establish a unit LA (Learning Account) in order to facilitate early lessons and implementation. On operations like Op Telic, the only realistic police asset is the Service Police who do have jurisdiction but, unlike their Home Office or MOD Police counterparts, do not have independent constabulary powers. This means that notwithstanding the weight to be attached to professional advice from the Provost Marshal and the Legal Adviser, the decision on whether to deploy them is in theory for the chain of command. That said, the recent revision to QRs, issued by the Army with commendable alacrity following the recent DP&TPol Report' for VCDS in order to permit Inquiries to run concurrently with € D/DPS(A)/3/331/PS2(A) dated 9 Feb 04. 6 DECLASSIFIED operations) there is precedent for a common sense approach in the Lord Chancellor's Guidance® to the Police on giving precedence to inquiries when, for example, the urgent need to determine air crash lessons for potential grounding of similar aircraft is expected to take precedence over criminal investigation. 26. All three Services' Police investigate cases of sudden death within their jurisdiction, but whilst the RN and RAF Police will normally cease their investigations where there are no suspicious circumstances or evidence of a crime, the Army Police, RMP(SIB), will normally carry out a full investigation and report. This is one of the reasons why the RN and RAF invariably convene a Bol, whereas the Army wish to retain discretion for those cases where the SIB or some other form of investigation like LAIT has shown a Bol to be unnecessary. The SIB are professionally trained in criminal investigation, and are undoubtedly the best asset to apply for that particular purpose. There must also be attractions to a hard-pressed commander in using this ready-made trained investigative team for wider purposes instead of his other staff or teeth assets. However, such wider application may well bring problems of perception and approach. 27. I have been impressed by the professionalism of the RMP whom I have encountered a number of times on operations, but I am not in a position to judge whether the trained approach for criminal investigation is necessarily the best approach for more generalist work. It may well be, but there would still seem to be two aspects of perception to be taken into account. On the one hand, the erroneous image has been generated in some parts of the media that a Service police investigation can be an inside job with an implication of incompetence and cover-up; whilst on the other hand, Service personnel ificulties, md thus perhaps being less than entirely folationing under guestioning:. The practice of sending in the Police to investigate all deaths and serious injuries may well be appropriate in many cases, though perhaps counterproductive if thought to be the consequence of every combat engagement. I would simply recommend that rather than being an automatic reaction, wider factors be weighed in determining the most appropriate investigative resource in cases where there is clearly no criminal dimension. 28. The LAIT was set up largely as a consequence of the 97/98 Report® and Direction* and consists of a small permanent team, run by Retired Officers, including serving SIB, and co-opting subject matter experts as appropriate. It deploys quickly and acts in a semi-formal manner to glean evidence without oath, which it then draws upon to write a report representing its own opinion. The Bol draws on the LAIT report, attaching it to its 6 Disasters and the Law - Deciding the Form of Inquiry quoted in DTLR Guidance to Police and Emergency Services in Aftermath of an Air Accident, Nov 2001. 7 DECLASSIFIED and thoroughness. Indeed, I understand that consideration is being given to giving it more generalist enhancement - an idea that would appear to have some merit. However, enhanced or otherwise, it is still essentially a working level and somewhat specialised element in the chain of investigation and inquiry, and whilst on the one hand it can save the need for a Bol where it finds this not to be necessary, on the other hand it can be part of a considerable delay in the convening of a Bol when it is necessary. LAIT TOR® define 4 weeks for issue of report after return from investigation, and HQLAND Bol Standing Orders® define another 14 weeks after issue of final LAIT and SIB Reports before the Bol first sits. In other words, the target for the Bol to start is some 5 months after the incident, if everything goes to plan. Exceptional cases may actually require this much time, or more, but 5 months seems too long for a routine target. (I turn later to the general question of timescale, at paragraphs 38 & 39.) 31. A Bol carries a more formal and independent image, both internally and externally, consisting of three or more middle to senior ranking officers with specialist advice as appropriate. (I turn later to selection of presidents.) There is an understandable concern that the prompt convening of a Bol carries the risk that it might have nothing to do for some time, and then perhaps find that it was not required after all. One of the arguments advanced for avoidance of such nugatory commitment has been that the commander and his full staff are already there on the ground during an operation, and are better placed than any putative president to get on with preliminary SIB and LAIT investigations. The counter argument is that the Commander and his staff are busy fighting a war, and although they must take the initial critical decision, a promptly appointed president could do a great deal to apply the requisite grip and co-ordination over all the separate elements, including working out in decidedly less than 5 months (in most cases) whether there was any likelihood that he might not need to convene his board at all. 32. I believe that on balance there is merit in there being a presumption that a Bol president will be appointed promptly in all cases of unnatural death or serious injury on operations, in broadly the same timescale for all three services. This would have little practical effect upon the RN and RAF with their rapid appointments, but it would represent a shift in principle for the Army, though perhaps not so much in practice. A sensible approach that should accommodate the workings of all three services would be to require appointment within 48 hours of incident unless, exceptionally, within that time the convening authority produced clear written justification (with further authorisation as necessary under single Service procedures) for not doing so. For the Army and Navy, 7 LAIT TOR Annex A to LAND/TS/2/1/2 dated Oct 03. 8 LANDSO 3207 dated Aug 03. DECLASSIFIED oraination, but it mignt userully reature as an additional term in the Bol TOR to cover some measure of influence over those elements subordinate to the chain of command, and liaison with any external bodies like the Coroner's Court. The president could play a major role at convening authority level in exercising a similar form of grip and co-ordination over specialist elements as advocated above for the higher authority, including the drafting or fine tuning of his own TOR, quick determination of quite what can be done in parallel with police or other investigations so as to maximise and progress concurrent activity, and the antennae to flag up early any tricky issues that are likely to attract media and political attention. That said, he should not have prime responsibility for related activities like NoK and media, though he would be mindful of them and could tender advice. 34. The Army had previously required the convening of a Bol to be deferred until police or disciplinary proceedings had concluded. Its recent revision" to QRs changed this to allow an inquiry to run in parallel with criminal or disciplinary investigations and proceedings, subject to there being no tainting of the latter (see paragraphs 24 & 25). The recommendation of a 'presumption' of parallel activity would take this a step further in principle, though perhaps to a lesser degree in practice because it would still leave the essential decision with the chain of command, subject as ever to legal advice, higher authority and DPS(A) authorisation, though there would be a need for written record of the reason for any decision not to convene a Bol. This is in line with current work on the TSA. 35. The main circumstance when a Bol might be deemed unnecessary would be where the facts were perfectly clear and no useful purpose would be served, as might be the case in a straightforward road traffic accident - though even here there may be lessons to be learned and disseminated. Operational priority and sheer practicality might also be a factor in determining the timing of a Bol; there are currently 44 incidents of death and serious injury on Op Telic, and prospect of that many presidents and their support staffs crowding in to a small operational HQ would be both impracticable and counterproductive - assuming that many could be found in the first place (see Resources). Some degree of prioritised sequencing or shared duties might be looked at, though there are good reasons for not changing presidents mid-Bol and for a president to cover only one Bol at a time. 36. Combat death is an exception. There is no specific legislative or regulatory requirement for any form of inquiry into clearcut cases of combat death, nor is this envisaged in the tri-Service Act. The 97/98 Report® and Direction* addressed unnatural rather than combat deaths and injuries. However, the facility exists under general catch-all provisions for an inquiry to be conducted into virtually anything deemed appropriate, so the ° D/PJHQ/10/5341 dated 19 Feb 04. 9 DECLASSIFIED what is reasonable and atristica over-simplification, much would seem to hinge around circumstances where there are no other UK authorities operating, it is difficult to see what more could be done than is addressed here. It would be decidedly counterproductive to accept an obligation to conduct some form of formal investigation into every single combat death, but the pursuit of this argument lies beyond this short study. Timescale. 38. The 97/98 Report® and Direction* placed emphasis on commencing and concluding the process of investigation and inquiry as quickly as possible, and this is reflected in the wording of the various Service instructions. Nevertheless, the words and figure do not match, and it has to be said that the Army's target timescale? of some 10-11 months after incident looks somewhat excessive to the lay eye, particularly when only two months of that is the Bol itself sitting. The majority of the time seems to be taken up waiting for any successive comments from others. I have already touched on the excessive appearance of the 14 weeks allowed for legal advice between conclusion of LAIT and SIB reports and commencement of Bol (paragraph 30). The recent DP&Pol Report' reflected the target date agreed between the three Services and VCDS" of 6 weeks for post-Bol higher level staffing on most boards, but still reverted to 9 weeks for AOC staffing and 12 weeks for CinC staffing post-Air Board - though I understand that there is often a substantial amount of post-Bol technical staffing required for air accidents. 39, There may well be particularly complex cases where staffing actually takes this long, or longer, but defining these lengthy periods as the norm does not sit easily with the urgency of the words. I recommend that the staffing periods following each level of report be revisited with a view to meeting the target of a total of 6 weeks or less agreed with VCDS, and that renewed emphasis be put upon early commencement and conclusion of all phases and maximum concurrent activity. Dealings with Next of Kin. 40. I will not attempt to summarise the processes adopted by the three Services for the sensitive business of dealing with NoK, other than to note that they have developed along separate lines to suit their differing modes of deployment, and ought not to be changed simply for the sake of uniformity. There are, however, two particularly important areas of convergence which I list as recommendations, though they already seem to have broad support. 10 Operational Loss Inquiry - an Op Telic driven proposal staffed at FS/STC and currently awaiting approval. " D/VCDS/40/1 (10/749) dated 22 Dec 03. 10 DECLASSIFIED against arp-reeding imbalanced and potentially compromising Bol progress reports ahead of the main report, but frankly the other extreme of saying nothing until the Report is issued could be seen as insensitive, unhelpful and possibly giving rise to even greater counterproductive speculation. It must be possible to strike a sensible balance in briefing on the facts and interim outcomes without commenting on the evidence. Some of the poor press on Op Telic has originated from NoK perceptions. 43. We already work on the assumption that the full Bol report will be made available to Nok, complete with annexes from LAIT, SIB and other specialist reports, and that all this will probably find its way into the public domain. Detail of a particularly distressing nature is 'redacted' in an obvious and fully explained manner, though included if NoK request it. I note from recent RN exchanges 2 that the test of "relevance" might usefully be applied in the case of gratuitous interviewee comment of an offensive or defamatory and wholly unrelated nature - perhaps best achieved by phrasing Bol TOR to exclude irrelevant material in the first place rather than by more obvious deletions later. Existing disclosure policy is defined in JSP 400 and is to be reviewed by DS&C in the light of the Data Protection Act (DPA 98), the Freedom of Information Act (FolA 00) and possibly the Human Rights Act (HRA 98). There are some exemptions, and some duties of confidentiality in regard to personal information, particularly of the deceased, and to information given in confidence; but the overall effect of Fol in particular is likely to be towards greater access not only to reports, but also to processes and evidence. Consideration might usefully be given to definition of a robust and well understood disclosure policy that manages release and explains the process to external stakeholders in much the same way as for NoK. A robust and well-understood policy need not be overly bureaucratic but could go a long way towards countering current negative perceptions. I list this as one of my recommendations, recognising that thought is already being given to the issue. Permanent Presidents. 45. Arguments for and against permanent presidents have been put to me, by which is meant doing the job as a normal full and exclusive tour for a number of years. The obvious advantage would seem to be the establishment of a level of expertise and the avoidance of delay and inefficiency due to repetitive learning cycles and disruption to other jobs. There could also be advantage in grouping such an organisation with LAIT or with any other closely related facility, and having in effect a multi-disciplinary and truly independent team that was ready to go at short notice. On the other hand, the important 12 FLA 520/1 dated 26 Feb 04. 11 DECLASSIFIED that tnis would impose for all three Services, and make no specific recommendation. There would, however, appear to be merit in releasing them from other duties for the duration. Monitoring and Audit. I have already spoken at some length under 'Grip and Co-ordination' and 'Briefing' about the mechanism for monitoring the progress of live inquiries and investigations. Individual elements have their own internal monitoring mechanisms. The Service police, for example, each have a system of reporting up their own functional police chains, with reports being copied to legal branches and to the chain of command at various points. It is, of course, entirely proper that the police should have systems to monitor themselves, and that legal advice should be part of that, but considerations of efficacy and perception of independent audit would seem to indicate a bigger picture command input, perhaps going beyond scrutiny of routine reports provided by the police themselves. There is an important distinction to be maintained here between the chasing and prioritising of investigations; the independence of the police investigation itself; and the independent audit of the police. The main requirement would seem to be for overall independent monitoring and grip to be exercised at both convening level, where the Bol president's TOR might be appropriately extended, and at command/TLB level where in addition to staffing of routine reports, there might also be a clearly defined senior focal point gripping the overall process on a continual and pro-active basis, working closely with the secretariat, with well tuned antennae to spot potential sensitivities and to prod down and brief up accordingly. 48. On completion of the inquiry and investigation process, commands/TLBs clearly need a mechanism for auditing their own internal implementation of recommendations. However, the question of dissemination of recommendations to other relevant Services and TLBs seems largely to be a matter of subjective judgement, though some specialist organisations like LAIT seem to have an established system and a pretty sound idea of where else outside their own Service might have a similar need. There would seem on the face of it to be potential benefit in some form of intelligent central register and clearing house to discharge this wider obligation for the Department as a whole. 49. One of the main recommendations in the DESB paper was the establishment of a central register or library listing all inquires and their recommendations concerning death or serious injury, right across MOD, though intended mainly for non-operational accidents. This was to be set up by DS&C, who would be ideally placed with his dual Service and civilian reporting lines to DCDS(Pers) and Personnel Director, and his answerability to 2nd PUS, VCDS and Service Chiefs, inter alia, at DESB, to pass the requisite assurance up 12 DECLASSIFIED U1. Open las seen a signinicant increase in expectation and volume of investigations and inquiries. To some extent this is a consequence of our own success in that the relatively low number of actual casualties has led to public expectation that numbers will continue to be low on foreseeable operations and thus to merit individual investigation. (see paragraph 15). It would seem likely that an appreciable proportion of future operational casualties might continue to be seen as controversial in some respect, and this, allied with raised public expectations of both investigation and disclosure, has imposed a heavy load on the Services, including civilian secretariat support. They stress that although they are coping with the pressure at present, it would take very little by way of increase to pose serious problems. All were keen that ministers be made aware of this fragility. The Army in particular noted that much as they might need more SIB, and were already taking steps to increase establishment, within a finite headcount they were reluctant for this to be at the expense of other teeth assets. Reaction to demand was in any case limited by the length of time that it took to train such specialists. 52. Resources were certainly a factor when it came to investigation of near misses. In theory, a serious near miss could result in a full Bol, but in practice this was much more likely to be a lower level unit or one man flight safety investigation, if that, partly because of resources and partly because of the need not to discourage Service personnel from owning-up honestly to mistakes when there were wider lessons to be learned. Tri-Service Act. 53., The foregoing recommendations are consistent with ongoing work on the TSA, on which the TSAT will shortly be putting proposals to SPEG. In particular, the TSAT currently proposes that a statutory Inquiry should be mandatory in the case of unnatural death, serious injury or non-repatriated overseas death. This would be effected though secondary rules and regulations, with statutory provision simply allowing creation of such rules. Higher Authority would retain the discretion to dispense with such an inquiry when it is clear that no useful purpose would be served, but would have to record the reasons for that decision. CONCLUSIONS: 54. I have for the most part drawn conclusions as I have gone along in order to explain the reasoning behind the recommendations in a report that is already more discursive than originally intended. I will therefore not attempt a comprehensive summary. The report itself does not attempt to present a comprehensive description of investigation and inquiry procedures. It is incremental in building upon the good work recently produced by the PPO 1-Stars, and then only addresses areas where specific issues have been drawn to my attention. 13 DECLASSIFIED Crime vestigation, but in cases where there is no criminal dimension, consideration might be given to the most appropriate investigative resource, which might not necessarily be SIB. A mechanism might usefully be established to enable the local commander to instigate immediately whatever form of investigation he might consider appropriate, even though this might risk compromise of disciplinary or criminal investigations, in exceptional cases where the imminent and ongoing risk to life is such as to outweigh the latter. There are also recommendations concerning grip and co-ordination and independent audit of the overall process, which ought of itself resolve most other problems, and the briefing process for ministers. The 15 recommendations are listed in largely self-explanatory form, with paragraph references, at annex C. 57. Finally, I should emphasise that the Report is not intended to sound an unduly critical note. Quite the opposite. Over the few weeks of the study, I have clearly not had a chance to meet the many people involved out at the sharp end of the process, but I have gained the impression of good people doing difficult jobs in difficult conditions in an area that they understand much better than me. I must apologise for any misunderstandings or omissions and hope that they will find some of the recommendations useful. WAY FORWARD: 58. I am grateful for constructive and supportive advice from those listed at annex B. I cannot claim originality for all the ideas, many of which were already under consideration or implementation in places, so whilst I accept full responsibility for the report, I think it fair to say that it reflects a broad basis of consensus at 1-Star/working level. Building on this groundwork, and subject to any comment from VCDS or DCDS(Pers), VCDS may wish to circulate it to the Services for quick comment, on the basis of which I can prepare a much shorter paper for SPB (30 March) and subsequent submission to ministers by the end of the month. 14 DECLASSIFIED Areas to be addressed should include, but not be limited to: Timing and sequencing, particularly the merits of early appointment of the president of a board of Inquiry. Monitoring of the overall process, particularly progress structure and efficacy, including any police and specialist investigations and the linkages between them. Reporting to ministers, particularly format, frequency and mechanism, and especially the essential secretariat context. Mechanism for independent audit of completed investigations and the dissemination and implementation of lessons learnt, both subject matter and process. The need for proposals for the Tri-Service Act to be consistent with any recommendations flowing from this Study. Resource implications, for military police in particular. 27.03.04 15 DECLASSIFIED MEDI1 AFBT2 AFBT3 AFBT4 AFBT5 AFBT6 Martin Hemming MODLA Humphrey Morrison LA14AFBT LA6 Geoff Hooper DS&C ADSEFPOL CL(FS)L1 Hazel Rice DDDAS ADInfoAccess David Johnson D Iraq Sec Iraq Sec 3 IraqTelicRev CNJA DDNLS DPS(N) ADPolSecFLT ComdSec2SL Paul Hatt ComdSecFLT Mai Gen Bill Rollo DAG Brig Stephen Andrews DPS(A) Brig Stephen Vowles DALSAdv ColPS2(A) SO1Pol DCS AG HdAGSec SO10&PLand CH LAIT Air Cdre Dusty Amroliwala DP&Tpol(RAF) Air Cdre Alan Hudson DASC Air Cdre Lindsav Irvine DDLS(RAF) HdAMPSec FS STC Paul Flahertv CivSecPJHQ HdPolOps 1 16 DECLASSIFIED rote decelallat, then passing lo service command/ILD secretanats, working alrecty on ad hoc single service issues (consulting PJHQ and DCDS(Pers)) and through DCDS(Pers) on consolidation of routine reports and issues requiring tri-Service policy overview. (para 17, 18, 47) Action: PJHQ and single Service comds/TLBs with DCDS(Pers) lead for overall co-ord. 3. Each Service to define single point of contact for coherent single-Service input to DCDS(Pers) on investigation, inquiry and related matters. (para 22) Action: single Services. 4. Mechanism to be established to permit local commander to instigate whatever form of immediate investigation might be appropriate, notwithstanding the risk that it might taint subsequent criminal or disciplinary investigations, in urgent and exceptional cases where the imminent and ongoing risk to life of a repetition might outweigh other concerns. (para 24, 25) Action: DCDS(Pers), MODLA, Services. 5. Consideration to be given to most appropriate investigative resource in cases where there is clearly no criminal dimension. Use of SIB not necessarily automatic. (para 27) Action: single Services, Army in particular. 6. LAIT TOR to be amended to make explicit the requirement to disseminate urgent lessons as early as practicable rather than at end of investigation and report. (para 29) Action: Army. 7. Establish presumption that Bol president will be appointed promptly in all cases of unnatural death or serious injury, unless confirmed within 48 hours as not necessary (e.g. uncontentious road accident) or delayed by serious operational or practical constraints. (para 31-35) (Combat death exception. (para 36)) Action: DCDS(Pers). 8. TOR for Bol to include a term requiring president to exercise grip and co-ordination over all Service investigative bodies, and liaison with non-Service bodies, as appropriate. (para 33) Action: single Services. 9. renewed emphasis to be put on earliest commencement and conclusion of all phases of investigation and inquiry process. Standard target timescales to be reviewed and tightened, particularly time allowed for advisers and senior officers to comment, where the total time should be 6 weeks or less in accordance with earlier agreement with VCDS. (para 30, 38,39) Action: single Services. 17 DECLASSIFIED dearerood disclosure policy to be establisned in the light of recent legislation (DPA, Fol, HRA) and criticism. (para 44) Action: DCDS(Pers) (DS&C) 14. Bol presidents to be released from other duties for the duration. (para 45, 46) Action: single Services. 15. Central register of all Bol and their recommendations to be established, along with mechanism for dissemination of recommendations to all relevant parties throughout MOD, and mechanism for independent audit to verify to DAC that recommendations are being implemented both in command/TLB of origin and in all other relevant parts of MOD. DS&C mechanism proposed in DESB paper to be adopted, recognising command/TLB prime responsibility. (para 48,49,50) Action: DCDS(Pers) and single Services. 18 DECLASSIFIED