Alexander Tostevin
6 Dec 2021 · Coroner Brendan Allen · Dorset
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of independence of DCMH
“The medical care provided to service personnel through the DCMH is not truly independent, in that personal medical information may be disclosed to Chain of Command where substantial public interest demands disclosure, particularly for the protection of the operational capability of the Unit and the safety of other Unit personnel. This is, of course, unlike mental health care provided in a civilian context. The evidence heard at the Inquest was that this lack of independence risks service personnel”
2. absence of composite risk assessment and care plan
“There is no single composite risk assessment and care plan for service users that draws tooether all the relevant information for 2 a service user and identifies the plan in place (care plan and risk management plan) at any given time. Such as document is often used in other care settings, including mental health trusts.”
3. lack of independence of DCMH
“The lack of independence of DCMH risks service users minimising and/or under reporting the risks they may pose to themselves for fear that information may be disclosed to the Chain of Command. If the true extent of the risk of is not known by DCMH, an effective risk management plan to mitigate the risk of cannot be formulated.”
Linked reports
Closely relatedConfidence 0.78 · moderate
Earlier report
“Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour.”
This report
“There is no single composite risk assessment and care plan for service users that draws tooether all the relevant information for 2 a service user and identifies the plan in place (care plan and risk management plan) at any given time”
Closely relatedConfidence 0.92 · high
This report
“The medical care provided to service personnel through the DCMH is not truly independent, in that personal medical information may be disclosed to Chain of Command where substantial public interest demands disclosure”
Later report
“I was concerned to hear that when a risk management and safety plan has been prepared by the Defence mental health services the information contained about relevant protective factors and safety actions is not necessarily shared with the Chain of Command.”
Responses
2021-0407-Response-from-Ministry-of-Defence_Published.pdf ↗· Ministry of Defence
Stated action
“case. I will address each area in turn. Disclosure of information between DCMH and the Chain of Command. DCMH operates as an independent organisation, which sits within Defence Primary Healthcare (DPHC), a Tri-Service organisation in UK Strategic Command. Although military DCMH staff2 are drawn from the medical services of the Royal Navy (RN), Army and Royal Air Force (RAF), DCMH is independent of all three Service chains of command. Mental health services play a vital Occupational Health role in”