Soldiers' rights

Verdict in inquest of two young soldiers says MOD must do more to support troops suffering mental distress

Posted on 27 Feb 2019

The Coroner examining the deaths of two young soldiers found hanged at their base has said he intends to write to the Head of the British Army.

The Coroner examining the deaths of two young soldiers found hanged at their base has said the Army can and must do more to encourage soldiers suffering mental distress to come forward for help. He has said that he intends to write to the Head of the British Army with various recommendations and observations.

Her Majesty’s Senior Coroner for Northern Ireland, Mr Joseph McCrisken, has today delivered his verdict in the inquests into the deaths of Lance Corporal James Ross and Rifleman Darren Mitchell. He has recorded that Rifleman Mitchell ended his own life, and has returned an accidental verdict on the death of Lance Corporal Ross.

Carol Mitchell, mother of Rifleman Darren Mitchell, said: “Darren always wanted to join the Army and he was a brilliant soldier. Everybody loved him. As one of his colleagues said at the inquest, ‘if we had an Army of Darrens we would be undefeatable’. But the Army failed him. Instead of Darren receiving the help he needed after returning from a difficult tour in Afghanistan, he was left isolated, exhausted and with nowhere to turn, even after his behaviour had noticeably changed. But this evidence has been overlooked.

“This inquest also showed beyond doubt that the culture in the Armed Forces stops soldiers from asking for help. This has to change. My family and I will always be devastated.”

Linda Ketcher, mother of Lance Corporal James Ross, said: “James was happy in his army career and it is difficult to understand him not being here today. But his inquest has exposed serous failings within the Army processes.

“The Armed Forces must become much more sympathetic towards military personnel who are struggling. It is clear that soldiers do not feel they can ask for help and mental health concerns are stigmatised. This has to be addressed urgently so incidents like this become fewer and eventually non-existent, and no more families go through what we have.”

The Coroner’s verdict comes in the same week as the publication of the House of Commons Defence Select Committee’s report on the provision of mental health care for serving personnel and veterans.

The report concludes that “serving personnel, veterans and their families who need mental health care are still being completely failed by the system”, and highlighted the continuing stigma around mental health in the Armed Forces and the fear that careers may be damaged by asking for help.


Lance Corporal James Ross, 30, from Leeds, and Rifleman Darren Mitchell, 20, from London, died within three months of each other at Ballykinler barracks, Co Down, in 2012 and 2013. Both men were found hanged.

An additional eight incidents of serious self-harm involving other soldiers on the same unit were recorded over the six-month period within which the men died.

Following their deaths, the Army conducted its own internal inquiry. The Service Inquiry took well over a year to report and found a number of serious failings, including inadequate measures for dealing with soldiers who were vulnerable and in need of help at an isolated base where self-harm was a serious concern. It was revealed at the inquest that the Service Inquiry’s recommendations were lost.

Evidence of systemic failings and bullying

The right to life, contained within Article 2 of the Human Rights Act, required the Coroner to not just consider how the men died, but to also examine the wider circumstances of their deaths.

The inquest lasted for three weeks and heard shocking evidence that: The “post-operational stress management” documents – which show what, if any, post-deployment support Lance Corporal Ross and Rifleman Mitchell had received on return from Afghanistan – were either incomplete or completely non-existent.

The base’s “suicide vulnerability and risk management register” for 2 RIFLES – which stored the details of all potentially vulnerable soldiers on the unit – went missing in 2013. The Army’s explanation was that it had been accidentally deleted.

There were only two active welfare staff on a base populated by 650 soldiers and their families.

Neither the nurse nor the camp doctor had received post-traumatic stress disorder training. Rifleman Mitchell visited the nurse four months before his death. He was anxious, tearful and withdrawn. The nurse passed the information to his chain of command who disciplined him for being late for work. There was no medical follow up and neither the camp doctor nor the psychiatric nurse were notified.

The families had been promised a post-tour briefing to teach them about the signs and symptoms of PTSD and what other concerns to look out for in their sons – but the meeting was never arranged. They learned through the inquest that a decision higher up had been made that the meetings ought to be cancelled.

Mental health stigma – and fear of the impact on their career – remains a serious problem. One soldier remains convinced that the Army’s response to a request for help is to “ridicule, then punish”.

Neither Lance Corporal Ross nor Rifleman Mitchell was being paid correctly at the times of their deaths. Rifleman Mitchell had not been paid correctly for two years and was struggling financially, having taken out a number of pay-day loans. Rifleman Mitchell was paid over £3,600 in back-pay after his death.

The police launched an investigation into alleged bullying at the camp after a vulnerable Rifleman disclosed that he had been burnt on the chest with aerosol fluid and burnt with cigarettes the same month Rifleman Mitchell died. The chain of command had known of the allegation and had not notified the police. The allegation only emerged months later at the Service Inquiry.

Rifleman Mitchell’s body was discovered by three close friends. They were described as distraught and traumatised, but were mocked on parade by someone in their chain of command as ‘grief groupies’, and asked “who’s going to be next?”. Their Company Sergeant Major (CSM) also threatened them with disciplinary action if they were ‘bluffing’ their reactions to Darren’s death. Two of the soldiers later self-harmed, one of whom was hospitalised. When he returned from hospital, he was held in the guard room for a week where he was visited again by his CSM who called him a ‘stupid dick’ for self-harming.

The Service Inquiry held into the deaths and eight self-harm events made a number of recommendations meant to be disseminated and acted upon across the wider Army. The recommendations were not logged correctly, were lost and not acted upon.

Emma Norton, Head of Legal Casework for Liberty and solicitor for the families, said: “This inquest has revealed a great deal the MoD would prefer to have remained hidden and failure after failure – missing paperwork, deleted documents and a shocking disregard for the need to have good and robust systems in place to help and support soldiers on their return from deployment. Even the Army’s own internal inquiry’s recommendations were lost.

“We echo the concerns expressed this week by the House of Commons Defence Committee that the MoD is not providing the quality mental health provision that soldiers deserve and that much more needs to be done to fight the stigma suffered by service personnel and described by so many witnesses to this inquest.

“By all accounts, Darren and James were both excellent and committed soldiers, yet both took their own lives on a lonely, isolated barracks in circumstances that their families still struggle to comprehend. It is vital that real improvements are made now, so that more families do not have to go through what the Ross and Mitchell families have endured.”

Liberty has a dedicated helpline for any current and former service personnel or their families who are in need of legal advice to enforce their rights.

Thanks to the generosity of the players of People’s Postcode Lottery, the ARMED FORCES HUMAN RIGHTS HELPLINE is open 10AM – 4PM Monday to Friday on 02031029313.


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