Minute palmer to ingram inquiries into unnatural death and serious injury on operations improvements in process and briefing

INQUIRIES INTO UNNATURAL DEATH AND SERIOUS INJURY ON OPERATIONS: IMPROVEMENTS IN PROCESS AND BRIEFING ISSUE 1. To update Minister(AF) on proposals for improvement in process and briefing for investigations, inquiries and related issues concerning unnatural death and serious injury on operations. RECOMMENDATION 2. Minister (AF) is invited to note the following areas of improvement: Process: - presumption of Board of Inquiry (Bol) common to all three Services, - higher command to have discretion in exceptional cases, - presidents to have overall co-ordination role and to be released from other duties, - priority to be given to determining cause when imminent risk of recurrence. Timescale: - emphasis on earliest commencement and conclusion of all stages, - target timescales to be shortened, maximum concurrent working, - urgent lessons to be disseminated and implemented ahead of main reports. Disclosure: - next of kin (NoK) communications to be routed through single point, - NoK to be briefed on realistic expectations from each stage of process, - NoK to be briefed on factual information, whenever practicable, ahead of final Bol report, - clear robust disclosure policy to be developed in light of recent legislation. Co-ordination and Audit: - senior focal point in commands/TLBs to exercise co-ordination of overall process, - effectiveness and timeliness to be ensured without compromise to independence, - processes to be defined for overall dissemination, implementation, audit and assurance. Reports to Ministers: - Routine comprehensive reports to ministers every two months. lus ad hor. TIMING 3. Routine DECLASSIFIED automato lot the milly mabdare wilore there was nothing to add to an SIB investigation - subject to the Minister's other concerns being met. 6. The current proposals are based on a recent Study and Report commissioned by VCDS, the 15 recommendations of which have found consensus with the POs. The main advance from the earlier Direction might be seen as the Bol presumption now being applicable to all three services. The presumption would be that a Bol president would normally be appointed within 48 hours in all cases of unnatural death or serious injury unless, exceptionally, judged and recorded as unnecessary or inappropriate by higher authority. This is in line with current proposals for the Tri-Service Act. The president would normally be released from other duties and would play a wider role in determining and co-ordinating the activities of any other necessary investigations, notwithstanding that he might decide not to convene his own board immediately. 7. 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. Operational priority and practicality would also have to be factors in determining deployment and timing. The local commander would be also be able, in exceptional cases, to give immediate priority to identification of cause when judged necessary to avoid imminent risk of recurrence 8. Combat death is an exception. It is subject to command scrutiny, as with any death ( or injury, but 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. It would be both impractical and damaging to operational effectiveness for junior commanders in particular to feel unduly constrained by the prospect of investigation when taking intrinsically high risk intuitive decisions in the heat of operations, and there is in any case a fairly well developed precedent of combat immunity. That said, there will no doubt at times be less clear circumstances that do warrant investigation, such as specific blue- on-blue incidents. Timing 9. The main recommendations are being implemented with immediate effect, recognising that some elements are already in effect in some places, but are listed here by way of best practice and tri-Service harmonisation, and that further development will be required in areas like disclosure policy and priority of investigations. D/MIN(AF)JR/5/3/1 dated 22 Apr 98 Inquirie s/Investigations into Death or Serious Injury on Operations: Scope for Improvement and Tri-Service lannenisation 0/DSPPolSC/2/8/1716 oaled 26 Feb 041 DECLASSIFIED: tulate al slages of investigation and inquiry process from determination of appropriate structure and sequence through to implementation and audit and related issues, including dealing with NoK and liaison with external bodies like Police and Coroner. A careful balance is to be maintained in the exercise of sufficient visibility and co-ordination of specialist activities to ensure effective and timely function whilst not compromising the independence and impartiality of Bol and SIB in particular. A central register for wider Departmental dissemination, independent audit and assurance is to be established. Reports to Ministers: 12. •Routine reports are to be submitted to Minister(AF) on progress and issues on all investigations and inquiries into unnatural deaths and serious injuries on current operations. These would take the form of a succinct covering brief highlighting issues of particular or potential concern, and annexed summaries of each current case. Current, non-operational, unnatural deaths and serious injuries would be included in this reporting structure for completeness, where appropriate, as would briefer record of combat deaths and serious injuries. Reports and briefs are also to be submitted ad hoc when pressing issues arise. 13. Prime responsibility for Inquiries and investigations lies with the chain of command so it would be the command secretariats in TLBs who would provide the main input for the regular reports to minister(AF). The Services would route these reports through their own would consult DCDS(Pers) on a case by case basis to agree the most appropriate routing, depending again upon the need for a wider overview. Further Work: 14. There are three main areas where further work is required. First, the balance between the protection requirements of DPA and the disclosure requirements and limited exemptions of FolA will no doubt take time to evolve, though for practical purposes it is already assumed that release of Bol reports to NoK effectively places them in the public domain, so this need not delay unduly the promulgation of a clear policy. Second, the proposal for a central register, dissemination, audit and assurance function operated by Personnel Director) is currently beind address reporting lines to both DCDS(Pers) and to barely Board, chaired by 2"* PUS and attended by VCDS and Service Chiefs.) And third. further legal consideration needs to be given to the balance between the need for the local DECLASSIFIED the processes themselves, and partly from improvements in NoK perception and consequent media coverage. A clear and robust disclosure policy should go some way to disabusing the media and the public of the erroneous expectation that virtually all deaths and injuries will be the subject of a Bol. DCDS(Pers) DECLASSIFIED