MILITARY FATALITIES AND THE BEREAVED

SECTION 16.3
MILITARY FATALITIES AND THE BEREAVED
The Report of the Iraq Inquiry
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Contents
Introduction ………………………………………………………………………………………………………77
Planning and preparing for fatalities …………………………………………………………………….78
Estimates of UK military fatalities …………………………………………………………………..78
Repatriation policy ……………………………………………………………………………………….79
Preparing to hold civilian inquests ………………………………………………………………….80
Support for bereaved families ……………………………………………………………………………..83
The Casualty Notification Officer and Visiting Officer ………………………………………..83
Immediate remedial action on bereavement procedures ……………………………………84
Joint procedures and a Joint Casualty Co‑ordination Cell ………………………………….89
Training and support for Casualty Notification Officers and Visiting Officers …..91
The experience of bereaved families ………………………………………………………………92
Early concerns about military investigations ………………………………………………………….94
Impact of a study on military inquiries and investigations, March 2004 ………………..94
Review of Service Police investigations, October 2004 ……………………………………100
Changes to MOD processes ……………………………………………………………………………..103
Creation of the Army Inquest Cell …………………………………………………………………104
Reducing the number of redactions in BOI reports released to families ……………..105
Creation of the Defence Inquests Unit …………………………………………………………..107
Introduction of Service Inquiries …………………………………………………………………..113
Efforts to reduce the backlog of inquests, 2005 to 2007 ………………………………………..113
Support for the Oxfordshire Coroner …………………………………………………………….113
Discussions on funding …………………………………………………………………………117
Progress in clearing the backlog of inquests …………………………………………….119
Efforts to transfer more inquests to local coroners ………………………………………….121
Support for the Swindon and Wiltshire Coroner ……………………………………………..125
Efforts to improve the inquest process, 2006 to 2009 ……………………………………………126
US participation in inquests …………………………………………………………………………126
Legal representation at inquests …………………………………………………………………..130
The Coroners and Justice Act, 2009 ……………………………………………………………..135

Fatal Accident Inquiries in Scotland ……………………………………………………………… 137
Honouring the dead ………………………………………………………………………………………… 142
Repatriation ceremonies …………………………………………………………………………….. 142
Royal Wootton Bassett …………………………………………………………………………. 144
Letters of condolence ………………………………………………………………………………… 144
Commemoration in Parliament ……………………………………………………………………. 147
Memorial services ……………………………………………………………………………………… 148
Armed Forces Memorial …………………………………………………………………………….. 149
The Elizabeth Cross ………………………………………………………………………………….. 151

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Introduction
1. Between 2003 and 2009, 178 British Service Personnel and one Ministry of Defence (MOD) civilian lost their lives serving on Operation TELIC.1 A breakdown of those fatalities by year is shown in the table below.

2. This Section addresses:

• the preparations made for repatriating the bodies of those who lost their lives
on Op TELIC, and for investigating their deaths;

• changes to military investigative processes and to the civilian inquest process;

• the support offered to the next of kin and bereaved families; and

• how the Government honoured those who lost their lives.

3. This Section does not consider other UK citizens who also lost their lives in Iraq, in a variety of different roles and as the result of hostage‑taking.

4. The provision of welfare support for Service Personnel is addressed in Section 16.1.

5. The provision of medical care, in particular for seriously injured personnel, and the support provided to their families, is addressed in Section 16.2.

6. The problems caused by deployments consistently exceeding the Defence Planning Assumptions in respect of the provision of military equipment are addressed in Sections 6.3 and 14.

7. The decision to deploy to Helmand province in Afghanistan, and the implications of that decision, are addressed in Section 9.
Table 1: Service Personnel and MOD civilian fatalities serving on Op TELIC, 2003 to 2009
Year               Fatalities
2003               53
2004               22
2005               23
2006               29
2007               47
2008                4
2009                1

Total               179

Footnote

1 GOV.UK, 12 December 2012, British Fatalities: Operations in Iraq.

 

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Planning and preparing for fatalities

Estimates of UK military fatalities

8. Sections 6.1 and 6.2 describe military planning for operations in Iraq.

9. In early September 2002, the MOD estimated that between 31 and 48 Service
Personnel would be killed in action during the initial combat phase of operations of an
attack on Iraq (and that between 157 and 241 Service Personnel would be admitted
to Role 3 hospitals).2,3 Those figures excluded possible casualties from chemical and
biological warfare.

10. The MOD regularly updated its casualty estimates as the military plan developed.
The estimates did not consider casualties beyond the initial combat phase of operations.

11. Mr Geoff Hoon, the Defence Secretary, wrote to Mr Blair on 16 January 2003,
recommending that the UK agree a US request to provide a large scale ground force
for operations in southern Iraq.

12. Mr Hoon’s advice did not include the estimates of UK military casualties (including
fatalities) that had been developed.4

13. Mr Blair agreed Mr Hoon’s recommendation the following day.5

14. On 3 February, the MOD produced a Casualty Estimate paper for the Chiefs of Staff
meeting later that week.6 The paper stated that:

• There could be between 30 and 50 fatalities in the Land Component.

• There could be between 5 and 9 fatalities in the Air Component.

• No simple estimate could be made of fatalities in the Maritime Component, given
the high impact/low probability nature of incidents.

• Fatalities from a “single small‑scale but well executed” chemical attack could be
between 0 and 96 fatalities, depending on a range of factors including the target,
the chemical agent used, and the weather.

• No useful estimate could be made of fatalities from a biological attack in the
absence of more specific information about the circumstances of any attack.

15. The Chiefs of Staff concluded on 5 February that the Casualty Estimate paper would
need to be shown to Ministers before any decision to commit UK troops was made.7

 

Footnotes

2 Role 3 (Echelon 3) medical support is generally provided at field hospitals and on hospital ships.
3 Minute MOD [junior official] to Iraq Inquiry [junior official], 22 June 2010, ‘Iraq Inquiry – Request for Evidence’.
4 Letter Hoon to Blair, 16 January 2003, ‘Iraq: UK Land Contribution’.
5 Letter Manning to Watkins, 17 January 2003, ‘Iraq: UK Land Contribution’.
6 Minute Fry to COSSEC, 3 February 2003, ‘Casualty Estimates – Op TELIC’ attaching Paper MOD, 3 February 2003, ‘Casualty Estimates for Op TELIC Based on Operational Analysis’.
7 Minutes, 5 February 2003, Chiefs of Staff meeting.

 

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16. On 20 February, in response to the publication of a paper, Iraq at the Crossroads: State and Society in the Shadow of the Regime, by the International Institute of Strategic Studies (IISS),8 Mr Blair asked for advice on a number of questions, including: “What is our military’s assessment of the likely consequences of an attack on Iraq; i.e. how many casualties; how quickly the collapse?”9

17. On 24 February, Mr Peter Watkins, Mr Hoon’s Principal Private Secretary, wrote to Mr Matthew Rycroft, Mr Blair’s Private Secretary for Foreign Affairs, advising that the MOD estimated that there would be between 30 and 60 British and between 500 and 1,200 Iraqi “land battle” fatalities.10 Mr Watkins also advised that work to estimate Iraqi civilian casualties continued.

18. Lord Boyce, Chief of the Defence Staff from 2001 to April 2003, told the Inquiry that Ministers would have been informed of the MOD’s casualty estimates, as part of the routine briefing process.11

19. By 1 May, when President Bush declared that major combat operations in Iraq had ended, 33 British Service Personnel had died serving on Op TELIC.12

20. Both Lord Boyce and Sir Kevin Tebbit, MOD Permanent Under Secretary from 2001 to 2005, told the Inquiry that the actual number of casualties had been fewer than the MOD had estimated.13 Sir Kevin commented: “… as far as casualties are concerned, the assessment was that they would not be any higher than we faced in the Gulf war 12 years earlier. So the figures were relatively … modest. In the event, they were even lower than that. The uncertainty was … the possible use of chemical/biological weapons against us. I think the original assessment was that Saddam was unlikely – but we couldn’t rule it out militarily – unlikely to use them early … but he might use them, and we expected
him to use them, as a matter of last resort, which, of course, informed the nature
of military planning.”

Repatriation policy
21. Until the Falklands Conflict in 1982, Service Personnel who died on major operations were normally buried in theatre.14

22. After the Falklands Conflict, all bereaved families were offered the opportunity to have the bodies of their relatives returned to the UK, largely because of the difficulty

 

Footnotes
8 Oxford University Press for the International Institute of Strategic Studies: Iraq at the Crossroads: State and Society in the Shadow of the Regime – Adelphi Paper 354.
9 Minute Rycroft to McDonald, 20 February 2003, ‘Iraq: Political and Military Questions’.
10 Letter Watkins to Rycroft, 24 February 2003, ‘Iraq: Political and Military Questions’.
11 Public hearing, 3 December 2009, page 94.
12 GOV.UK, 12 December 2012, British Fatalities: Operations in Iraq.
13 Public hearing, 3 December 2009, pages 94‑96.
14 Paper DCDS(Pers), 14 March 2003, ‘UK Forces: Repatriation of the Dead’.

 

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of travelling to the Falkland Islands to visit their graves. In subsequent operations,
it became MOD policy to repatriate bodies to the UK in all but the most exceptional
circumstances.

23. The MOD’s policy on the repatriation of the dead was set out in a paper produced
by Lieutenant General Anthony Palmer, Deputy Chief of the Defence Staff (Personnel)
(DCDS(Personnel)), on 14 March 2003: “Repatriation to UK of the dead is to take place wherever possible and as soon as practicable.”15

24. If fatalities were suspected to have been caused by Chemical Biological
Radiological Nuclear (CBRN) agents, then repatriation should only proceed once the
presence of a CBRN agent had been confirmed or ruled out, and then on the basis of
a risk assessment. In certain circumstances, repatriation might require mitigating actions
(such as decontamination or special isolation of the body), or the body might need to
be officially cremated in theatre with the ashes repatriated. In exceptional circumstances,
the body might need to be cremated and permanently buried in theatre.

Preparing to hold civilian inquests
The legal frameworks for inquests

Coroners are independent judicial officers. They are appointed and paid for by the
relevant local authority and their officers and staff are employed by the local authority
and/or the police.
Coroners in England and Wales had a statutory duty, under Section 8 of the 1988
Coroners Act, to investigate deaths which are reported to them when the body is lying in
their district and there is reason to believe that the death was violent or unnatural, or was
a sudden death of unknown cause, or in some other circumstances.16 That duty applied
“whether the cause of death arose in his district or not”.
Section 14 of the 1988 Coroners Act provided that, if it appeared to the coroner for the
district where a body was lying that the inquest ought to be held by another coroner,
then he may request that coroner to assume jurisdiction.

The position in Scotland and Northern Ireland was different.
In Scotland, the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 required
the appropriate procurator fiscal to investigate (through a Fatal Accident Inquiry)
any death which occurred within Scotland in the course of an individual’s employment,
or in legal custody.17 The Act also provided for the Lord Advocate to instruct a procurator
fiscal to investigate a death if it appeared to him that an investigation would be in the
public interest.

 

Footnotes

15 Paper DCDS(Pers), 14 March 2003, ‘UK Forces: Repatriation of the Dead’.
16 Coroners Act 1988. The Act was replaced by the Coroners and Justice Act 2009.
17 Fatal Accidents and Sudden Deaths (Scotland) Act 1976.

 

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81

The Coroners Act (Northern Ireland) 1959 provided that coroners in Northern Ireland within whose district a dead body was found, or an unexpected or unexplained death or a death in suspicious and certain other circumstances occurred, “may” hold an inquest.18 The Act also provided for the Advocate General for Northern Ireland to direct that an inquest should be held in other circumstances.
In the case of military deaths overseas, civilian inquests usually took place after the internal military investigation had concluded, although this was not formally required.
The military investigation could provide evidence that would be extremely difficult for
a coroner to source elsewhere.

25. An MOD official wrote to Mr Nicholas Gardiner, the Coroner for Oxfordshire, on 17 January 2003 to advise him that the Services were currently considering the administration for “potential mass casualties in the event of war”, and that the majority of fatalities might be repatriated to RAF Brize Norton, which fell within his area of responsibility.19 The official asked whether “normal peacetime rules” would apply and specifically whether, if there were a large number of fatalities, he would expect to hold
an inquest into each case.

26. Mr Gardiner replied on 20 January, confirming that:

• If the cause of death appeared unnatural, then there would be an inquest.
This would normally be held in public.

• Normal practice where there was a single death was to transfer responsibility for the inquest to the “home town coroner”. Where there were a number of deaths in the same incident it was “clearly sensible” for the same coroner to hold those inquests; that would commonly be the coroner for the point of entry.20

27. Mr Gardiner and officials in the Home Office (the Department which was then responsible for coronial policy) and the MOD worked together during February and March to refine the arrangements for receiving UK fatalities.

28. Mr Gardiner advised a Home Office official on 20 February that he understood
that in “contamination cases”, the bodies of deceased Service Personnel would not
be returned to the UK.21

 

Footnotes

18 Coroners Act (Northern Ireland) 1959, as amended.
19 Letter MOD [junior official] to Gardiner, 17 January 2003, ‘Handling of Multiple Deaths as a Result of Operations Overseas’.
20 Letter Gardiner to MOD [junior official], 20 January 2003, ‘Foreign Deaths’.
21 Letter Gardiner to Home Office [junior official], 20 February 2003, ‘Service Deaths Overseas’. Mr Gardiner’s letter provides no further details on the nature of those “contamination cases”. The Inquiry believes that Mr Gardiner was referring to casualties from chemical and biological weapons.

 

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29. Mr Gardiner wrote to a Home Office official on 18 March, the day before military
operations against Iraq began: “There are a few matters outstanding but, generally, I think we are reasonably well prepared, although there are bound to be things we have not thought of.”22

30. The Home Office issued guidance to all coroners on handling deaths arising from
hostilities in Iraq on 26 March.23 The guidance stated:

• The MOD had advised that, while hostilities lasted, it would not be possible to
provide evidence of the incidents on the battlefield which led to injury. In those
circumstances, the Home Office recommended that coroners should adjourn
inquests pending the conclusion of hostilities. Coroners “could expect to receive
in due course advice on when it might be appropriate to consider the resumption
of such inquests”.

• Coroners should notify the Home Office “if the numbers of adjourned cases in
their jurisdiction seem likely to cause problems in terms of workload”.

31. A Home Office official wrote to Mr Gardiner on 2 April to advise that, while the
Home Office appreciated Mr Gardiner’s “willingness to undertake the handling of all
these cases”, the extra costs involved would fall to Oxfordshire County Council and they
should be invited to agree the commitment that Mr Gardiner was taking on.24

32. The official went on to suggest that, “wherever appropriate, it would be better for the
substantive inquests to be held by coroners local to the family concerned, as with any
other deaths overseas”. While that approach had not been adopted for the inquests into
the deaths caused by the 9/11 attack and the Bali bombing, in those cases the deaths all
arose from a single incident: “In the case of Iraq, the deaths are occurring in different places, at different times and in different circumstances. It seems to me, that unless there is good reason to the contrary, single deaths, and multiple deaths arising from the same incident and involving personnel from broadly the same place in England and Wales, ought to be subject to local inquests where the family or families involved can attend
conveniently. Inquests into multiple deaths involving individuals from different
parts of the country might properly be undertaken by you, unless there seems to
be a more appropriate local coroner (e.g. if the deceased were all from the same
military base).”

33. Mr Gardiner replied on 4 April, agreeing that it was certainly appropriate for some
inquests to be transferred to other coroners.25 Those would generally be single deaths,

 

Footnotes

22 Letter Gardiner to Home Office [junior official], 18 March 2003, [untitled].
23 Letter Cobley to Coroners, 26 March 2003, ‘Deaths Arising from Hostilities in Iraq’.
24 Letter Home Office [junior official] to Gardiner, 2 April 2003, ‘Section 14 and War Deaths’.
25 Letter Gardiner to Home Office [junior official], 4 April 2003, ‘Section 14 etc’.

 

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and multiple deaths where there was a “significant common factor” indicating that an inquest outside of Oxfordshire would be appropriate.

34. Mr Gardiner also agreed that there were “significant financial implications” for his office, and advised that he was copying the exchange to Oxfordshire County Council.

Support for bereaved families
The Casualty Notification Officer and Visiting Officer

35. Lieutenant General Sir Alistair Irwin, the Adjutant General from 2003 to 2005, described the role of a Casualty Notification Officer (CNO) for the Inquiry:
“It is the hope and expectation that those involved [CNOs] will be from the unit but sometimes, particularly if it was an individual based elsewhere, it had to be done by somebody else … The general principle was that it should be based on the family entity, the military family entity.
“Once the casualty has been identified beyond peradventure and all the details are correct … the CNO … has the unenviable task of knocking on the door and presenting the bad news.”26

36. Vice Admiral (VAdm) Peter Wilkinson, Deputy Chief of Defence Staff (Personnel) (DCDS (Personnel)) from 2007, told the Inquiry: “… it is the very first official contact that a bereaved family has with the MOD or the Armed Services that determines how the journey will go from there. If that official notification is carried out appropriately from all sides, then there is a chance that we may be able to help the family as they go through the grieving and bereavement process. If, for whatever reasons, that initial official contact doesn’t go well, then it is very hard to recover. Sometimes we never do.”27

37. Lt Gen Irwin described the role of a Visiting Officer (VO) for the Inquiry:
“… that person [the CNO] then stays with the family until the notified casualty Visiting Officer appears. The CNO, the one who has broken the bad news, then departs the scene and the VO then remains with the family……
“These people were trained … to hold the family’s hand through the awful aftermath of this. First of all, the realisation that it has happened, then the business of going to the repatriation ceremonies, then, in many cases, going through the whole of the coroner’s process, then the funerals, and then the gradual trying to piece together

 

Footnotes

26 Public hearing, 21 July 2010, pages 47‑48.
27 Public hearing, 19 July 2010, page 49.

 

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life again. Some families, of course, needed their VOs only briefly; others needed
them … for really quite a long time.”28

38. VOs were not generally specialists, but Service Personnel who were asked to
take on the role in addition to their regular duties because they were thought to be
suited to it.29

39. In December 2002, following a number of high‑profile cases, the Army
acknowledged that its procedures for supporting bereaved families “fell short of modern
expectations” and introduced a number of changes, including:

• CNOs and VOs were briefed to try to identify any issues that might affect
communications with the immediate and wider family (such as divorced or
separated parents). If necessary, a second or third CNO could be appointed.

• All Notifying Authorities were instructed to maintain a pool of CNOs and VOs
“who must have attended a seminar at Brigade or Divisional level”.

• Notification was to take place at any time of day or night, to avoid families
hearing the news from elsewhere.

• The VO would remain in contact with the family as the focus for all
communication, as long as the family wished.30

40. The Army refined that approach through 2003 and 2004, in the light of their
experience of supporting the families of Service Personnel killed in Iraq.
Immediate remedial action on bereavement procedures

41. The prospect of military operations against Iraq prompted the MOD to bring forward
plans to extend some benefits to unmarried partners.

42. Mr Hoon was advised on 26 February 2003 that, with conflict in Iraq looming, the
Government should end the uncertainty on whether unmarried partners of Service
Personnel were eligible for benefits in the event of their death.31

43. Unmarried partners were not entitled to benefits under the Armed Forces Pension
Scheme (AFPS) and only certain unmarried partners were entitled to benefits for death
attributable to service under the War Pension Scheme (WPS). The MOD advised that
the new Armed Forces compensation and pension schemes would extend benefits
to unmarried partners (both heterosexual and homosexual) for attributable and
non‑attributable injury and death, but the new schemes would not be implemented
before 2005/06.

 

Footnotes

28 Public hearing, 21 July 2010, pages 48-49.
29 Public hearing, 21 July 2010, page 50.
30 Paper MOD, [undated], ‘The Army Investigations and Aftercare Support Cell (AIASC)’.
31 Iremonger to PS/Secretary of State [MOD], 26 February 2003, ‘Unmarried Partners – Implications for the Gulf’.

 

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44. Ministers had already indicated that, in certain circumstances, the Government would extend benefits to unmarried partners on a “case‑by‑case” basis.

45. That position now needed to be clarified and formalised, by agreeing that AFPS benefits should be extended to unmarried partners for deaths attributable to service.

46. On 20 March, Dr Lewis Moonie, the Parliamentary Under Secretary of State for Defence, announced that, with immediate effect, where a member of the Armed Forces died as a result of service related to conflict, ex‑gratia payments equivalent to the benefits paid to a surviving spouse under the AFPS could be awarded to their unmarried partner, where there was a substantial relationship.32

47. In late March, the MOD’s Armed Forces Personnel Administration Agency (AFPAA) wrote to the spouse of a Serviceman who had been killed in Iraq advising that an overpayment of her late husband’s salary – relating to the period between his death
and formal identification – would be recovered from her benefits.33

48. The bereaved spouse also felt that the AFPAA was pressuring her to leave her Service Family Accommodation (SFA).

49. The MOD’s policy at that time was to allow spouses of deceased Service Personnel to remain in SFA for up to six months.34 That period could be extended in some circumstances.

50. The case attracted significant press attention.

51. The bereaved spouse wrote to Mr Blair on 26 March, setting out her concerns. Mr Blair replied on 7 April, stating that Mr Hoon would consider the detailed points raised in her letter, but assuring her that she would be given all the time she required to consider her future housing needs.35

52. Mr Hoon told Lt Gen Palmer on 15 April that he was “very uncomfortable” with the MOD’s handling of the case, including both the tone and content of the AFPAA’s letter.36 Lt Gen Palmer confirmed that the letter was “factually incorrect”, as there were no grounds for seeking repayment.

53. The following day, Mr Hoon tasked Lt Gen Palmer to oversee “a comprehensive review of the way in which all three Services handled bereaved families”.37

 

Footnotes

32 House of Commons, Official Report, 20 March 2003, column 54WS.
33 Minute Palmer to 2SL [MOD], 15 April 2003, ‘Op TELIC – Pay, Pensions and Allowances Issues on Death of Service Personnel’.
34 Record, 12 May 2003, ‘Record of Bereavement Policy Meeting Held in St Giles Court at 1330 on 7 May 2003’.
35 Letter Blair to [name redacted], 7 April 2003, [untitled].
36 Minute Palmer to 2SL [MOD], 15 April 2003, ‘Op TELIC – Pay, Pensions and Allowances Issues on Death of Service Personnel’.
37 Minute Cooper to CE AFPAA, 24 April 2003, ‘Assistance to Bereaved Relatives – Policy Review’.

 

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54. Lt Gen Palmer wrote to Mr Hoon’s Private Office on 17 April, confirming that work
was already in hand to conduct that comprehensive review (an initial report would be
available by 16 May), and reporting the “immediate remedial action” that had been taken
in response to the individual’s experience:

• Lt Gen Palmer had “declared” that all except one of the Op TELIC fatalities
to date were attributable to service. That declaration meant that the usual
assessment of attributability would not be required, and that families could
be notified now that the higher benefits associated with deaths attributable
to service would be paid.

• The letters used by the AFPAA were not appropriate. As of 16 April, all letters
dealing with Op TELIC had been “personally vetted” by the AFPAA’s Chief
Executive and checked by the appropriate Service Casualty Co‑ordination
Centre.

• Families of Service Personnel were now able to stay in their service
accommodation for “as long as they feel they need to in order to assess their
longer‑term housing requirements”. If pressed, VOs should “talk in terms of
nine months although stressing that each case will be examined on its merits”.

• The MOD had asked the deceased insurer’s to accelerate their procedures.38

55. Lt Gen Palmer was advised on the same day that the MOD was facing a new
challenge: “Policy … changing ‘on the hoof’”.39

56. Lt Gen Palmer provided his first report to Mr Hoon on bereavement procedures
on 16 May.40 It identified six recent, specific lapses in the MOD’s handling of
bereaved families (two of which pre‑dated Op TELIC), and three broader areas where
improvement was necessary:

• the volume, timing and style of correspondence between multiple MOD
organisations and bereaved families;

• a lack of clarity over the sources of specialist advice available to bereaved
families; and

• the “training/education” of CNOs and VOs.

57. Lt Gen Palmer reported the actions that had already been taken to prevent a
recurrence of those specific lapses, and restated the decisions of the previous month

 

Footnotes

38 Minute DCDS(Pers) to APS/Secretary of State [MOD], 17 April 2003, ‘[name redacted] – Follow‑up Action’.
39 Minute Cheadle to Palmer, 17 April 2003, ‘Op TELIC – Pay, Pensions and Allowances Issues on Death of Service Personnel’.
40 Minute DCDS(Pers) to PS/USoS [MOD], 16 May 2003, ‘Bereavement – Review of Procedures’.

 

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to relax the MOD’s policy on the retention of SFA and to improve the quality of AFPAA correspondence. Lt Gen Palmer also advised that:

• He had directed that all MOD correspondence should be routed through the deceased’s unit and the VO, and all MOD visits to bereaved families should
be co‑ordinated by the VO.

• Further work would be done to develop “simple and readable” guidance, to improve the tone of correspondence, and to develop a comprehensive guide to the sources of advice and support available.

• Further work would be done to assess the selection, training and education
of CNOs and VOs.

58. In March 2004, the MOD concluded a study to identify improvements to their investigative and Board of Inquiry (BOI) processes.41 While the study focused on the investigative and BOI processes themselves, it recommended that:

• Commands should establish a senior focal point with responsibility for pro‑actively monitoring all investigations and BOIs;

• all communication with families should be routed through a “single established and known contact”, who could explain the context of any correspondence and “head‑off any infelicitous or insensitive drafting”; and

• a “knowledgeable and consistent” officer should regularly brief families on the detail and progress of the entire investigation and BOI process.

59. On 24 June, Lt Gen Palmer reported to Air Chief Marshal (ACM) Sir Anthony Bagnall, Vice Chief of Defence Staff (VCDS), that each Service had now appointed a “Senior Co‑ordinator” to act as a focal point for monitoring investigations and Inquiries.42 Lt Gen Palmer also gave ACM Bagnall the “specific reassurance” that he had requested that each Service had undertaken to provide regular briefings to next of kin on process and progress. All communication with the next of kin would be routed through a single contact (normally the VO) who would “act as a sift” to filter out any insensitive or inconsistent drafting.

60. Lt Gen Palmer advised ACM Bagnall that a study into Services’ bereavement support procedures, including the training provided to CNOs and VOs, had now reported. The study had concluded that:

• While it might seem logical to adopt a tri‑Service approach to bereavement support procedures, it was reasonable for each Service to continue to use their

 

Footnotes

41 Paper MOD [junior official], 25 March 2004 [incorrectly dated on original as 24 February 2004], ‘Inquiries/Investigations into Death or Serious Injury on Operations: Scope for Improvement and Tri‑Service Harmonisation – a Short Study for VCDS/DCDS(Pers)’.
42 Minute DCDS(Pers) to VCDS, 24 June 2004, ‘Inquiries into Unnatural Death and Serious Injury: Improvements in Process and Briefing’.

 

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“slightly different” approaches given their differing geographical spread, unit
organisations and ethos.

• With the exception of the Royal Navy, which generally used qualified welfare
workers, “bereavement support personnel” were appointed on an ad hoc basis
from the junior officer cadre. While bespoke training for the entire cadre was
neither cost‑effective nor deliverable, it should be possible to provide “awareness
briefings” during general staff training, supplemented by “thorough briefings” by
specialist personnel when an individual was appointed to be a VO.43

61. Lt Gen Palmer advised ACM Bagnall that he supported those findings, but
commented that ACM Bagnall might wish to “revisit” the conclusion that it would not
be financially or practically viable to develop a bespoke training course for individuals
involved in bereavement support.44

62. ACM Bagnall accepted the findings, but commented that existing single‑Service or
tri‑Service courses could include some coverage of bereavement support procedures.45

63. On 30 June, Lt Gen Palmer provided Mr Hoon with an update on work to improve
the BOI process.46 The update also covered progress on improving communications
with families.

64. Lt Gen Palmer advised Mr Hoon that it was “clear that we are failing to meet
some families’ expectations in respect of the quality and quantity of information we are
providing to them”. A key step in improving communications between families and the
MOD would be the appointment of a Senior Co‑ordinator in each of the Services to
ensure that families were briefed, through their VOs, on the progress of investigations
and BOIs; the role of the Senior Co‑ordinator, and progress in improving the BOI
process, is described later in this Section.

65. Lt Gen Palmer recalled the steps that had been taken to improve the tone and
accuracy of the MOD’s correspondence with bereaved families and advised that,
as far as practicable, all routine correspondence now followed standard templates.
The production of a joint casualty procedures manual47 and the formation of a
Joint Casualty Co‑ordination Cell (JCCC) by January 2005 would further improve
communication with families. As a “final filter”, all communication with families was
now routed through a single point of contact, usually the VO.

 

Footnotes

43 Paper MOD, [undated], ‘Bereavement Support Training (Scoping Study) – Summary of Findings and Recommendations’.
44 Minute Palmer to VCDS, 24 June 2004, ‘Inquiries into Unnatural Death and Serious Injury: Improvements in Process and Briefing’.
45 Minute VCDS to Palmer, 1 July 2004, ‘Inquiries into Unnatural Death and Serious Injury: Improvements in Process and Briefing’.
46 Minute DCDS(Pers) to APS/SofS [MOD], 30 June 2004, ‘Boards of Inquiry – Improvements in Process’.
47 The first Joint Casualty and Compassionate Policy and Procedures (JSP 751) manual was published in March 2005.

 

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66. Lt Gen Palmer reported that the review of training for personnel involved in bereavement support had concluded that a bespoke training course would be neither “financially nor practically viable”, but had identified a number of ways in which they would be better supported. The “problems of picking VOs from a necessarily ad hoc pool” could be overcome by including VO duties in general staff training, ensuring that specialist advice was available when needed, and ensuring that the “often junior” VO was properly briefed and supervised. Lt Gen Palmer expected that senior commanders would take a close and personal interest in ensuring that this was done properly.

67. In April 2005, Lt Gen Palmer recommended that the MOD’s policy on the occupation of Service Family Accommodation by bereaved spouses should be changed to be “less prescriptive”: “… while bereaved spouses should be offered retention of SFA for two years we should acknowledge that there might be some … who seek to retain their SFA for
an indefinite period thereafter.”48

68. Mr Hoon agreed that recommendation, subject to a number of amendments, including that Ministers should be consulted before any decision was taken to withdraw housing entitlement beyond the two‑year period.49

69. Mr Adam Ingram, Minister of State for the Armed Forces from 2001 to 2007, recalled the exchange in his evidence to the Inquiry: “… the view [in the MOD] was, ‘Well, this is going to dislocate all the other arrangements, if you let this widow stay in the house’, and Geoff Hoon just said ‘So what? Fix it’, and it was fixed. I think, to the best of my recollection, we didn’t have a deluge of demand in that area. It may have been beneath the surface, but it never became a reality and, if it had been: yes, they can stay there, yes, we have to be sympathetic.”50

Joint procedures and a Joint Casualty Co‑ordination Cell

70. The Joint Casualty Co‑ordination Cell (JCCC) was established in early 2005 to provide a focal point for casualty administration and notification and requests for compassionate travel.51

 

Footnotes

48 Minute Palmer to APS/SofS [MOD], 11 April 2005, ‘Draft Revised Policy for the Occupation of SFA by Bereaved Spouses Following the Death in Service of the Service Licensee’.
49 Minute APS/SoS [MOD] to Palmer, 13 April 2005, ‘Revised Policy for the Occupation of SFA by Bereaved Spouses’.
50 Public hearing, 16 July 2010, pages 39‑40.
51 Ministry of Defence website, Casualty Procedures.

 

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71. Air Marshal David Pocock, the Deputy Chief of Defence Staff (Personnel) from 2005
to 2007, told the Inquiry that in 2004: “… there was clear dissatisfaction with the notification procedures because … it was a single‑service responsibility and we were required very quickly to set up a Joint Casualty and Compassionate Cell … and that took over getting the information from theatre, identifying a [Casualty] Notification Officer and setting the whole notification procedure in place … on a joint basis.”52

72. Lt Gen Irwin told the Inquiry that during his time as Adjutant General (from 2003
to 2005): “… I think [there were] 57 Army casualties … and I would think, looking back on
it, that I may have heard about issues in the notification process, and by ‘issues’
I mean either delays in doing it or calling on the wrong person, or the wrong sort of
words being said at the wrong sort of time, I think maybe I had cases of that kind
maybe between six and ten, so something of that order.”
“… as an individual, that family, there was nothing in the world was more significant.
So we had to keep asking ourselves, ‘Are we doing this right?’…
“So as each issue developed, we tried to close it off, but even after all this time and
even with the establishment of the new joint system, with the new central training,
even then, I am afraid I can guarantee that, in the future, there will be people who
have a bad experience with this for one reason or another, and it is because we are
all human beings.”53

73. The first version of the Joint Casualty and Compassionate Policy and Procedures
(JSP 751) was produced in March 2005 (policy and procedures had previously been set
and managed by the individual Services).

74. Lt Gen Palmer described the JSP as drawing together into one publication the best
practices and procedures currently in place across the three Services.54

 

Footnotes

52 Public hearing, 19 July 2010, page 50.
53 Public hearing, 21 July 2010, pages 52‑53.
54 Minute DCDS(Pers) to VCDS, 30 July 2004, ‘Inquiries into Unnatural Death and Serious Injury: Improvements in Process and Briefing’.

 

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75. Shortly after the JCCC was established, the Army established the Army Investigations and Aftercare Support Cell (AIASC) to improve and extend the Army’s support for families.55 The AIASC had two main roles:

• to maintain close contact with bereaved families on a regular basis for as long
as they wanted, including estranged family members. This included regular letters on the progress of Service Police investigations and BOIs; and

• on behalf of the Army’s Senior Co‑ordinator, to oversee the BOI process and ensure that delays were kept to a minimum.

76. The AIASC had a number of secondary roles, including developing and maintaining a formal, standardised training package for CNOs and VOs. The AIASC aimed to implement that package by the end of 2005.

TRAINING AND SUPPORT FOR CASUALTY NOTIFICATION OFFICERS AND VISITING OFFICERS

77. JSP 751 stated that CNOs should “if possible … have received some training or instruction such as in dealing with bereavement” and that VOs should “if possible … have received some relevant training or instruction”.56

78. Lieutenant General Mark Mans, the Deputy Adjutant General, wrote to senior Army commanders on 25 November 2005, to remind them of the importance
of selecting appropriate and experienced individuals to be VOs: “Although the majority do an excellent job, from time to time the wrong person is nominated and invariably significant difficulties follow. This happened again recently …
“The training of both Casualty Notification Officers (CNOs) and VOs is also most important and although JSP [751] says ‘if possible … should have received some training’, it should be exceptional for them not to have attended some sort of instruction.”57

79. Lt Gen Mans advised that a centralised training package based on an interactive CD and accompanying material should issue in early 2006 and would form the basis of all future training (divisions and brigades currently ran their own training). Training would become mandatory when this package issued.

80. Lt Gen Mans told the Inquiry that VOs had: “… a fairly comprehensive training programme in order to deal with a number of issues … and, indeed, as individuals, they need to be looked after as well because,

 

Footnotes

55 Paper MOD, [undated], ‘The Army Investigations and Aftercare Support Cell (AIASC)’.
56 Paper MOD, 11 July 2005, ‘JSP 751: Joint Casualty and Compassionate Policy’.
57 Minute Mans to Comd BFC, 25 November 2005, ‘Selection of Visiting Officers’.

 

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if you are a Visiting Officer, you can have a pretty traumatic time. Throughout a
period of a tour of duty, you might be looking after one or two or three families one
after the next, and they need to be monitored for stress … and we have a process in
place to do just that.”58

81. Lt Gen Irwin told the Inquiry that “there is no doubt about it that the training is better
now, the preparation is better now”.59

82. MOD Ministers returned to the issue of the training and support provided to Visiting
Officers in 2008.

83. In February 2008, Sir Bill Jeffrey, the MOD’s Permanent Under Secretary, provided
detailed advice to Mr Bob Ainsworth, Minister of State for the Armed Forces, on how the
BOI process could be improved and how the existing process could be accelerated.60
Sir Bill’s advice did not consider the role of the VO.
84. Mr Ainsworth held a meeting on 11 April to discuss that advice.61 The record of the
meeting reported: “The Minister raised the issue of interface with families. He recognised that the Visiting Officer role was very difficult … He also recognised the clear single Service
lead in this area … He, nevertheless, felt that more could be done in terms of the
resourcing and training of Visiting Officers. He felt that the cell [the Defence Inquests
Unit] should play a role in this area, focusing on ensuring the right training and
guidance is provided, sharing best practice between the Services and monitoring
performance.”

The experience of bereaved families

85. The experiences that family members have shared with the Inquiry suggest that
there was considerable variation in the quality of the notification process. Some family
members spoke positively about the sensitive and prompt way in which the news was
delivered. A smaller number reported negative experiences, including:

• insensitive delivery;

• an impression that details were being withheld (particularly in ‘friendly fire’
incidents or where there was a possibility of equipment failure);

• release of names to the media before official notification;

• circulation of names amongst the families of others deployed in Iraq before
official notification; and

 

Footnotes

58 Public hearing, 19 July 2010, page 45.
59 Public hearing, 21 July 2010, page 48.
60 Minute Jeffrey to Minister(AF) [MOD], 29 February 2008, ‘Boards of Inquiry and Inquests’.
61 Minute PS/Min(AF) to APS/Secretary of State [MOD], 11 April 2008, ‘Boards of Inquiry and Inquests’.

 

16.3 | Military fatalities and the bereaved
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• use of archive footage by the media which featured the deceased as though they were still alive, causing confusion about what was the truth.

86. The experiences shared with the Inquiry suggest that the creation of the JCCC led to an improvement in the quality of the notification process.

87. There was also considerable variation in families’ experience of the support provided by Visiting Officers (VOs). In some cases, an enduring and positive relationship resulted. In others:

• The VO was changed without warning, in some instances more than once.

• The VO was badly briefed and lacked knowledge of procedures.

• Insensitive language and behaviour caused distress.

• Contact was sporadic.

88. The Inquiry also heard about a number of distressing incidents which, although
they do not form part of a wider pattern, are illustrative of how a lack of care can have
a significant impact. They were:

• Following an air crash in which several Service Personnel died, a number of body parts remained unidentified. Families of those who had died were not told about the existence of those unidentified body parts, and many had already held funerals by the time identification was complete, making a second ceremony necessary.

• One family discovered that photographs of their son’s body had been used, without permission being sought, in a training seminar.

• One family member accepted military advice not to view their son’s body based on the impact of the injuries suffered. But facial reconstruction had taken place and there had already been a viewing for another family member.

89. Anyone serving in the Armed Forces is asked to designate one person as their official next of kin. When a fatality occurs, the CNO contacts the next of kin, and they
are the ongoing point of contact for a VO.

90. Parents who lost children in Op TELIC told the Inquiry that one consequence of this arrangement was a disparity between the information and support provided to the partner of the deceased, usually the person named as next of kin, and to parents.
As one father told the Inquiry, being a bereaved parent can be a very lonely business.

91. The need for greater support to a wider family than just the next of kin was recognised by the Government in July 2008: “We recognise that the loss of a Service person affects the whole of the bereaved family, not just the next of kin or nominated emergency contacts, on whom we

 

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traditionally tend to focus our contact and support. We will review our procedures to
ensure that in future sufficient account is taken of the needs of the wider family.”62

Early concerns about military investigations

92. The MOD had a wide range of internal investigations that could be carried out
following a fatality or other serious incident occurring on operations.63 They included:

• Land Accident Investigation Team (LAIT) investigations. The LAIT could
respond to incidents at very short notice and would normally report within
30 days. It sought to determine the cause of an accident and make timely
recommendations to prevent reoccurrence. It did not apportion blame. A LAIT
report could inform a Board of Inquiry/Service Inquiry, or substitute for it where
the facts of the case were sufficiently clear.

• Service Police investigations. Each Service has its own Service Police force;
for the Army, that is the Royal Military Police (RMP). The Special Investigation
Branch (SIB) of each Service Police force investigates the most serious
cases. The MOD told the Inquiry: “While the need for a prompt investigation is
important, and may be vital, there are no specific deadlines for the completion
of Service Police investigations.”

• Boards of Inquiry (BOIs). The purpose of a BOI was to establish the facts about
an event, to make recommendations to prevent a reoccurrence, and to inform
any decision on whether other action, such as administrative or disciplinary
action, should be initiated.64 BOIs would not generally attribute blame.
Impact of a study on military inquiries and investigations, March 2004

93. On 26 June 2003, Mr Hoon received an update on the SIB investigation into the
death of a member of the Armed Forces.65

94. Mr Hoon’s Private Office responded on 30 June, expressing Mr Hoon’s
concern that the individual’s next of kin had not yet been informed of the result of the
post‑mortem, in particular as the media might release that information.

95. Mr Hoon’s Office also asked for an update on all the BOIs and other investigations
that had been launched into the deaths of Service Personnel killed in Iraq, including
details of the “timescales and inter‑dependencies on the investigations reaching their
conclusions”.

 

Footnotes

62 Ministry of Defence, The Nation’s Commitment; Cross‑Government Support to our Armed Forces, their Families and Veterans, July 2008, Cm 7424, para 2.34.
63 Paper MOD, [undated], ‘Service Inquiries and Investigations’.
64 Paper [SPEG], 19 July 2004, ‘Proposals for a Tri‑Service Inquiry System’.
65 Minute APS/Secretary of State [MOD] to PJHQ Civ Sec, 30 June 2003, ‘Completion of Main Stage of SIB Investigation into the Death of [name redacted] and Other Action’.

 

16.3 | Military fatalities and the bereaved
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96. On 4 July, Mr Ian Gibson, MOD Deputy Director Service Personnel, sent an update on progress on BOIs and investigations to Mr Hoon’s Office.66 The update detailed 43 fatalities resulting from 21 incidents. Only one BOI, into the loss of a Sea King helicopter with six UK Service Personnel on board on 22 March, had so far reported. A date for the inquest had not yet been set.

97. Later that month, Mr Gibson sent Mr Hoon’s Office a paper describing military investigative and BOI processes, which highlighted the different approaches taken by the Services.67 The Royal Navy and RAF would generally launch a BOI as soon as an incident occurred, at the same time as they deployed a criminal investigative team (if they thought that one was required). In contrast, the Army would only launch a BOI after an investigative team had reported. The MOD was considering the scope for harmonising the Services’ approaches to BOIs as part of the Tri‑Service Armed Forces Act.

98. Mr Ingram’s Private Secretary wrote to ACM Bagnall on 15 September:
“Minister (AF) [Mr Ingram] is concerned about the increasing perception amongst next of kin (and as a consequence Parliamentarians) that investigations into the deaths of personnel in Iraq lack focus and are taking too long. Families also have the impression that they are not kept informed of progress, however modest.
These are admittedly perceptions, but most investigations seem slow.”68

99. While Mr Ingram understood the complications arising from the roulement of formations and the operational situation: “Nonetheless, he feels that we need to strengthen our ‘grip’ on these sensitive issues, to ensure that corporate memory is preserved, that investigations are prosecuted as vigorously as possible, and that the flow of information to NOK [next of kin] is actively managed. This may best be done through the DCMO [Defence Crisis Management Organisation].”

100. Mr Ingram’s Private Secretary asked for advice on how that “central management” of the process might be achieved.

101. ACM Bagnall received advice in September and October on how the MOD’s investigative processes might be improved.

102. Major General Richard Shirreff, Chief of Staff LAND, advised ACM Bagnall on 24 September that the key to accelerating RMP/SIB investigations in Iraq was more

 

Footnotes

66 Minute Gibson to APS/Secretary of State [MOD], 4 July 2003, ‘Investigations into Op TELIC UK Service Personnel and UK Civilian Deaths’.
67 Minute Gibson to APS/Secretary of State [MOD], 17 July 2003, ‘Investigations into Op TELIC UK Service Personnel and UK Civilian Deaths: Procedures for Service Deaths’.
68 Minute PS/Min(AF) [MOD] to MA/VCDS, 15 September 2003, ‘TELIC Incidents: Investigations’.

 

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resources, and asked that mobilised Reservists and military police from other Services
should be deployed to assist with Op TELIC investigations.69

103. Lt Gen Palmer advised ACM Bagnall on 17 October that the Army’s policy of
investigating all deaths, while “cautious and prudent”, placed a heavy burden on RMP/
SIB resources.70 There was scope for the Services to consider a common policy on
when it was necessary for Service Police to investigate an incident, and when a BOI
or LAIT investigation would suffice.

104. Lt Gen Palmer also advised that, notwithstanding the Army’s policy, the main
reason for delays to investigations on Op TELIC was the difficult working environment
in Iraq (including the need for force protection for Service Police and a potentially hostile
population). The MOD was now deploying “SIB qualified” Reservists to Iraq, but the
RMP “remain swamped with the volume of investigative work”.

105. In early 2004, ACM Bagnall and Lt Gen Palmer commissioned an internal study
to identify improvements that could be made to the MOD’s investigative processes, and
in particular the scope for harmonising procedures across the three Services.71

106. The study reported in late March 2004. It concluded that the core BOI process
ran “reasonably well” once triggered. The more significant problems related to how
and when BOIs were convened, how they linked to other investigations, and how their
findings were processed.

107. The study highlighted the “considerable delay” to Army BOIs that could be caused
by a LAIT investigation and by the Army’s practice of undertaking a full RMP/SIB
investigation into all sudden deaths: “LAIT TOR [Terms of Reference] define four weeks for issue of report after return from investigation, and HQLAND BOI Standing Orders define another 14 weeks after issue of final LAIT and SIB Reports before the BOI first sits. In other words, the target for the BOI to start is some five months after the incident, if everything goes to plan … five months seems too long for a routine target.”

108. The study also reported that, while existing guidance emphasised that
investigations and inquiries should be opened and concluded as quickly as possible,
“the words and figures do not match, and it has to be said that the Army’s target
timescale of some 10 to 11 months after incident [to the conclusion of the BOI] looks
somewhat excessive, particularly when only two months of that is the BOI itself sitting”.
The majority of that 10‑11 month period was allocated to “waiting for any successive
comments” from advisers and senior officers to complete the BOI report.

 

Footnotes

69 Minute Shirreff to VCDS, 24 September 2003, ‘Op TELIC Incidents – Investigations’.
70 Minute Palmer to VCDS, 17 October 2003, ‘TELIC Incidents: Investigations’.
71 Paper MOD, 25 March 2004 [incorrectly dated on original as 24 February 2004], ‘Inquiries/Investigations into Death or Serious Injury on Operations: Scope for Improvement and Tri‑Service Harmonisation – a Short Study for VCDS/DCDS(Pers)’.

 

16.3 | Military fatalities and the bereaved
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109. The study made 15 recommendations, including:

• Commands should establish a senior focal point with responsibility for pro‑actively monitoring all investigations and BOIs.

• There should be a presumption across all three Services that a BOI President should be appointed promptly.

• A BOI President should be required to exercise grip and co‑ordination over all Service investigative bodies, and liaise with non‑Service bodies. Presidents should be released from other duties.

• There should be a “renewed emphasis … upon early commencement and conclusion of all phases and maximum concurrent activity”. The standard target timescales for all phases of the investigative and inquiry processes should be reviewed and tightened. The time allowed for advisers and senior officers to comment should be limited to six weeks.

• All communication with families should be routed through a “single established and known contact”, who could explain the context of any correspondence and “head‑off any infelicitous or insensitive drafting”.

• A “knowledgeable and consistent” officer should regularly brief families on the detail and progress of the entire investigation and BOI process.

110. The study also reported that there was a significant increase in public expectations that there should be a BOI into every incident, and that its conclusions should be disclosed. That imposed a “heavy workload” on all three Services but especially the Army.

111. Lt Gen Palmer wrote to Mr Ingram on 6 April, advising that all the recommendations in the study had been agreed by the Services; the “main recommendations” would be implemented immediately.72 The “main advance” from the existing process was that the presumption that a BOI should be convened promptly, with a BOI President appointed within 48 hours of the incident, would now be extended to the Army (it was already standard practice in the Royal Navy and RAF). 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”.

112. Lt Gen Palmer set out how communication with the next of kin would be improved. All communications would be routed through a single “personal contact point”. The next of kin would be “briefed clearly, comprehensively and regularly” on the investigation and BOI process. Information that would not compromise the BOI could be released to the next of kin before the final report issued; a clear disclosure policy consistent with

 

Footnotes

72 Minute Palmer to Ingram, 6 April 2004, ‘Inquiries into Unnatural Death and Serious Injury on Operations: Improvements in Process and Briefing’.

 

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the Data Protection Act (DPA), Freedom of Information Act (FOI Act) and other relevant
legislation would be developed.

113. Lt Gen Palmer also advised that a report on the progress of all Inquiries and
investigations would be sent to Ministers every two months.

114. Mr Hoon met some of the families bereaved during Op TELIC on 28 April.73
They expressed concern about the Services’ investigative processes in general and in
particular the quality and frequency of communication from the MOD, and said that they
lacked confidence in the BOI and investigative processes. Their concerns triggered a
review of Service Police investigations, which is described later in this Section.

115. Mr Hoon received the first progress report on investigations and BOIs on 14 June.74

116. Mr Hoon’s Assistant Private Secretary responded to the progress report on
18 June, stating that the MOD now had, for the first time, visibility of the extent and
progress of all current investigations.75 The Assistant Private Secretary reported that
Mr Hoon had: “… noted that the submission has confirmed a number of weaknesses, in particular the length of time it has taken to complete many of the investigations and the
apparent lack of communication with some of the families on the more protracted
investigations. The Secretary of State [Mr Hoon] will expect to see improvement
in these and the other areas as the Board of Inquiry study recommendations are
implemented. He will also wish to see early results in the work commissioned by
VCDS into the procedural aspects of SIB investigations. It is important that these
workstrands are linked: how many BOIs are delayed because of SIB work? He
will also wish to see progress in the next report on bringing the more protracted
investigations to a speedy close.”

117. Mr Hoon’s Assistant Private Secretary concluded that Mr Hoon would “wish to be
assured that making progress on the various investigations and the Boards of Inquiry
continues to receive appropriate senior management attention”.

118. Lt Gen Palmer told the Inquiry: “… the Secretary of State [Mr Hoon] himself was personally briefed every two months by me as to exactly which Board of Inquiry was delayed, or rather the findings were delayed, why they were delayed, what the reasons for the delay was. Could we do anything to speed up the process, and how are the families reacting to this?”76

 

Footnotes

73 Minute DCDS(Pers) to APS/SofS [MOD], 30 June 2004, ‘Boards of Inquiry – Improvements in Process’.
74 Minute DCDS(Pers) to APS/SofS [MOD], 30 June 2004, ‘Boards of Inquiry – Improvements in Process’.
75 Minute APS/Hoon to DCDS(Pers), 18 June 2004, ‘Inquiries into Unnatural Death and Serious Injury on Operations: First Routine Report’.
76 Public hearing, 21 July 2010, page 56.

 

16.3 | Military fatalities and the bereaved
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119. On 24 June, Lt Gen Palmer reported to ACM Bagnall that the “initial tranche” of improvements identified by the BOI study (comprising 13 of the 15 recommendations) was now in place.77 Each Service had appointed a “Senior Co‑ordinator”, to act as a focal point for monitoring investigations and BOIs. Lt Gen Palmer gave ACM Bagnall
the “specific reassurance” that he had requested, that:

• Each Service had agreed to appoint a BOI President within 48 hours, unless judged unnecessary by a higher authority.

• Each Service had undertaken to provide regular briefings to next of kin on process and progress. All communication with the next of kin would be routed through a single contact (normally the Visiting Officer) who would “act as a sift” to filter out any insensitive or inconsistent drafting.

120. Lt Gen Palmer also reported that he had carefully considered a suggestion from Mr Hoon that the BOI process should include “an individual who is independent of both MOD and the bereaved family … who would give a view of whether or not the BOI had completed its job successfully, before the report was published”, but had concluded that:
“… the purpose for which BOIs are established and the perceived presentational need to prove to external parties that they carry out their work successfully cannot sensibly be reconciled.”

121. Lt Gen Palmer advised that including an independent element would delay the BOI process, “yet bring no guarantee of adding value, credibility or acceptability of a Board’s findings”. Families’ concerns could largely be met by the “administrative arrangements – including better communications – already put in place”.

122. Ministers returned to the question of whether there should be an independent member on a BOI in 2007.

123. On 30 June, Lt Gen Palmer sent Mr Hoon a progress report on work to improve the BOI process.78 Lt Gen Palmer wrote that it was “clear that we are failing to meet some families’ expectations in respect of the quality and quantity of information we are providing to them”. The key to improving the flow of information to families would be the new Senior Co‑ordinators, who would ensure that BOIs proceeded quickly and that families were briefed on progress.

124. Lt Gen Palmer reflected on the role and impact of the Senior Co‑ordinator in his evidence to the Inquiry: “… he was responsible for the progress of Boards of Inquiry. If there were delays, why there were delays and what should be done about it, and keeping, importantly, the families informed through the visiting officers as to what was going on.

 

Footnotes

77 Minute DCDS(Pers) to VCDS, 24 June 2004, ‘Inquiries into Unnatural Death and Serious Injury: Improvements in Process and Briefing’.
78 Minute DCDS(Pers) to APS/SoS [MOD], 30 June 2004, ‘Boards of Inquiry – Improvements in Process’.

 

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“We put that in place relatively quickly.
“Now that did not immediately speed up the Boards of Inquiry, because some
of them were quite complicated.
“We have already alluded to a shortage of military police investigators … but the
emphasis – because I think this is what the grievance was – was lack of information.
The families felt they were excluded from the process.
“I personally believe, once we put … in place … a regular briefing for families about
where their particular Board of Inquiry had got to, they were less exercised …”79

125. Lt Gen Palmer also advised that all the “quick wins” identified in the BOI study
were now in place; work continued to establish a robust disclosure policy and devise a
mechanism to allow local commanders to initiate an immediate investigation in urgent
and exceptional cases.

126. The target timeline for a BOI was tightened in June 2004, to allow 14 weeks from
the incident to the formal release of the completed BOI report to the next of kin.80 That
timeline comprised eight weeks for the production of the BOI report and six weeks for
advisers and senior officers to comment and complete it.

127. The BOI process was also amended at that time to include the production of
additional progress reports for the next of kin.

128. The steps taken by the MOD to improve communication with and support for next
of kin and bereaved families, including the review of bereavement procedures and the
review of training for personnel involved in bereavement support, are described later in
this Section.

 

Review of Service Police investigations, October 2004

129. During a meeting with Mr Hoon on 28 April 2004, a number of bereaved families
expressed a lack of confidence in the Services’ investigative processes.81

130. In response to those concerns, ACM Bagnall commissioned a review of the
timeliness and effectiveness of Service Police investigations.82

131. The review, which reported in October, concluded that:

• There were no major issues that were not already being considered.

• There was no evidence that the quality of Service Police investigations was
inadequate.

 

Footnotes

79 Public hearing, 21 July 2010, pages 55‑56.
80 Minute DCDS(Pers) to PS/SoS [MOD], 17 July 2006, ‘BOI Timelines – a Proposal for Extension’.
81 Minute DCDS(Pers) to APS/SofS [MOD], 30 June 2004, ‘Boards of Inquiry – Improvements in Process’.
82 Report Loudon, 12 October 2004, ‘Review of Service Police Investigations on Operations’.

 

16.3 | Military fatalities and the bereaved
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• Service Police in Basra were “operating at full stretch and had a considerable backlog”. A key constraint was that relatively few Service Police investigators were qualified to Level 3 (able to carry out the investigations into the most serious offences). More investigative personnel should be trained to the Level 3 standard, and deployed.

• Service Police in Basra needed more equipment and administrative support.83

132. On the timeliness of investigations, the review stated: “There can be both avoidable and unavoidable delays, but complex investigations and the post‑investigative processes do take time and speed must not be at the expense of quality. That said, some trimming may be possible in respect of the timescales for some steps in the process.”

133. The review recommended that the timescales for the individual steps of the post‑investigative process should be revalidated.

134. The review also identified the practical difficulties in undertaking investigations in
a non‑permissive environment such as Iraq, including:

• A number of Service Police personnel had been tasked to train the Iraqi Police Service.

• Service Police needed force protection, which was not always available.

• Access to the crime scene and to witnesses could be difficult, and could cause further tension.

135. Lt Gen Irwin told the Inquiry: “… as the operation [in Iraq] developed, it began to be something that came to my attention and, therefore, could be regarded as a possible problem, that the Royal Military Police were not there in sufficient numbers to do everything that was required of them in a completely timely fashion.
“Now, of course, when you are trying to investigate incidents when there is shooting going on, there is always going to be a delay that would not occur in the normal circumstance, but nevertheless I began to get a feeling that maybe there were not enough military police in Iraq and maybe also that, extrapolating from that, there were not enough military policemen … in the British Army.
“So I spent – I would not say every day, but quite regularly I used to speak to the Provost Marshal (Army) and ask him the direct question, looking at him in the eye, ‘Have we got an issue here? Are your people bearing up to the strain? Are they going over too often with too short tour intervals? Do you want me to try to find some other way of reinforcing you, like doing something which the bureaucracy sometimes

 

Footnotes

83 Report Loudon, 12 October 2004, ‘Review of Service Police Investigations on Operations’.

 

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calls ‘novel and contentious’, which was to get civilian police to sort of come along
and help?’
“The answer was always, ‘We are a bit stretched, but we are fine’. My people and
I just took that at, not exactly face value, but kept our eyes on it and at no stage
did we ever have to do anything that was ‘novel and contentious’.”84

The deaths of six RMP Personnel at Majarr al Kabir

On 24 June 2003, six RMP Personnel – Sergeant Simon Hamilton‑Jewell, Corporal
Russell Aston, Corporal Paul Long, Corporal Simon Miller, Lance Corporal Benjamin
Hyde, and Lance Corporal Thomas Keys – were killed at Majarr al Kabir in Iraq.
Mr Hoon informed the House of Commons on 17 November 2004 that a BOI into that
incident had now completed its work.85 Because of the “wider parliamentary and public
interest”, the MOD had taken the unusual step of providing a summary of the BOI’s
findings to Parliament and to the media. The families of those who died would be briefed
by the President of the BOI, and would subsequently meet Mr Hoon to discuss the BOI’s
findings and any concerns they might have.
Continued criminal investigation prevented the BOI from considering the events that were
the direct cause of the six deaths, but Mr Hoon informed the House: “The Board found that the incident at Al Majarr Al Kabir was a surprise attack, which could not reasonably have been predicted. The Board also found that a number of factors may potentially have had a bearing on the deaths of the six soldiers, including issues relating to ammunition, communications and command relationships within the battle group to which the Royal Military Police platoon was attached. The Board was not, however, able to state that any of these factors, either in isolation or in combination directly determined the six soldiers’ fate.”
Mr Hoon went on to acknowledge: “I am aware that some of the families have been critical of the Army’s response to the deaths of the six soldiers. I hope they recognise the Board’s work for the thorough and detailed review that it is. I hope, too, that they now have a much better understanding of the events leading up to the death of their loved ones and the wider context in which the events occurred, and can take some comfort from this.”
The RMP suffered 12 fatalities during the course of Op TELIC, including the six fatalities
at Majarr al Kabir.86

136. An April 2005 review of the MOD’s future requirements for Service Policing
recorded that “The recommendations of the [2004] review have largely been
implemented”.87

 

Footnotes

84 Public hearing, 21 July 2010, pages 19‑20.
85 House of Commons, Official Report, 17 November 2004, columns 90‑91WS.
86 GOV.UK, 12 December 2012, British Fatalities: Operations in Iraq.
87 Minute Rooks to VCDS, 29 April 2005, ‘Review of the Department’s Requirements for Service Policing’.

 

16.3 | Military fatalities and the bereaved
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137. The 2005 review stated that, in relation to investigations on operations, “delay
is still an issue”. Delays were generally due to “overstretch and practical inhibitors”,
such as the need for force protection, rather than any specific failings on the part of
the Service Police.

138. The review also stated that the “primary RMP output” in Iraq was now providing support for the reform of Iraq’s security forces.

139. The review recorded that work on the future structure of the Army had resulted
in an uplift of nearly 10 percent in the baseline figure for RMP manpower.
Changes to MOD processes

140. AM Pocock wrote to Mr Des Browne, the Defence Secretary, on 17 August 2006 proposing that the timeline for conducting BOIs should be increased from 14 to 27 weeks.88 The MOD was operating at “maximum efficiency, within resources” but, for the Army in particular, experience since the current timeline was introduced in June 2004 had shown that it was “not achievable”. No Army BOI had met the current 14‑week timeline. The Royal Navy and RAF did not have a problem with the current timeline but “saw merit” in extending it.

141. AM Pocock summarised the problems in meeting the current timelines:

• It was not possible to produce a Convening Order and Terms of Reference (TORs) for a BOI within 48 hours (as the current timeline required). TORs were often dependent on Service Police or LAIT reports, which could take “several months” to produce.

• It was not possible to “staff” a BOI report (secure comments from advisers and senior officers) within six weeks.

142. AM Pocock advised that underlying those problems was a resource issue.
The Army was currently required to convene up to 20 BOIs a month (compared with one or two for the Royal Navy and RAF). It took time to identify and nominate suitable experienced and available Presidents, to confirm the Terms of Reference, and for officers to consider a BOI report.

143. AM Pocock closed his advice: “Delays in completing BOIs have been linked in the media to delays in Coroners’ inquests. Some families … have also been critical of the time it takes to complete BOIs. It is, however, unlikely that extending the BOI timeline will attract significant media coverage.”

144. In an annex to his minute, AM Pocock analysed the reasons for delays in completing BOIs. It concluded that progress had been made since 2004 but that,

 

Footnote

88 Minute DCDS(Pers) to PS/SofS [MOD], 17 August 2006, ‘BOI Timelines – A Proposal for Extension’.

 

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against a background of an increasing number of incidents, “the rate of closure has now
remained more or less constant since January 2005”.

Creation of the Army Inquest Cell

145. In February 2007, in response to Ministerial concerns over the MOD’s support
for the inquests into the deaths of Sergeant Steven Roberts and Lance Corporal of
Horse Matthew “Matty” Hull, the Army established a small Army Inquest Cell with a
remit to, “through more effective handling of documents and stakeholders … provide a
better co‑ordinated service to the Department [MOD], the coroner, and to the bereaved
families”.89 Mr Ingram was advised that the Army’s existing arrangements had been
unable to manage the volume of work associated with inquests.

146. An MOD official advised Mr Ingram in March that good progress was being made
in clearing the “backlog” of Army BOIs.90 The Army Inquest Cell had “now assumed the
role of managing of the Inquest process”, allowing the Army Inquiries and Aftercare
Support Cell (AIASC) to revert to its primary role of supporting bereaved families.

147. In June, Mr Ingram informed the House of Commons that the Army was planning
to appoint permanent Presidents for BOIs, in order to deliver a more consistent
approach and avoid delays.91

148. In January 2008, Mr Giles Ahern, MOD Deputy Director Personnel with
responsibility for the Army Inquest Cell, advised General Sir Richard Dannatt, Chief of
the General Staff, that the team had made “significant progress” in reducing the time
taken to hold an inquest.92

149. Mr Ahern advised that, despite this progress, Ministers remained “very concerned”
about the MOD’s performance. The Army Inquest Cell was focusing on:

• The provision of information to families. In the past, families had received little
formal information before the inquest about how their relative had died. AIASC
now provided a “Record of Events” based on SIB findings, but that might only
reach the family just before the inquest. The Cell was developing an “Initial
Account” containing “some basic information”, which could be passed to families
about one month after a death.

• Timely completion of SIB and BOI reports. In a number of cases, completion
of SIB and BOI reports was “judged to have taken longer than necessary”.
The Cell was trying to “expedite” completion and sign‑off of reports by the
chain of command.

 

Footnotes

89 Minute Pitt‑Brooke to PS/Minister(AF) [MOD], 26 February 2007, ‘Support to Inquests – Project AJAX’; Minute Ahern to MA1/CGS, 15 January 2008, ‘Project AJAX – An Update on the Army Inquest Cell’.
90 Minute Pitt‑Brooke to PS/Minister(AF) [MOD], 30 March 2007, ‘Support to Inquests – Project AJAX’.
91 House of Commons, Official Report, 7 June 2007, column 28WS.
92 Minute Ahern to MA1/CGS, 15 January 2008, ‘Project AJAX – An Update on the Army Inquest Cell’.

 

16.3 | Military fatalities and the bereaved
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• Ensuring that witnesses were properly prepared for inquests, by briefing them on their purpose and format.

• Handling of classified material. Recent lapses had resulted in the unauthorised release of classified US material; this had undermined Ministers’ confidence in the MOD’s management of inquests. A review was under way on whether the Services’ support for inquests should be centralised, possibly using the model provided by the Cell.

Reducing the number of redactions in BOI reports released to families
150. The MOD released redacted versions of BOI reports to the next of kin and coroners. The version released to the next of kin was redacted to remove personal information relating to third parties, and security and operationally sensitive information. The version released to the coroner was redacted to remove certain security and operationally sensitive information only, with a request that the report was not introduced into court.93

151. The inclusion of the names of third parties in the version of the BOI released to the coroner allowed the coroner to identity potential witnesses for the inquest.

152. In November 2006, Ms Selena Lynch, Deputy Assistant Coroner for Oxfordshire, directed the MOD to provide a “full set of papers” to a bereaved family’s legal team and indicated that she might consider a legal challenge if the MOD did not comply.94

153. Mr Chris Baker, MOD Director General Service Personnel, advised Mr Ingram on 22 January 2007: “It is evident that the manner in which some of the BOI reports have been redacted, by blocking out the names and text … renders them unintelligible. Families and their respective Counsel claim that because they are unable to follow the narrative of the BOI it is difficult to consider whether to request the coroner to invite additional witnesses.”

154. Mr Baker stated that the MOD’s position was that the redaction of the names of third parties was necessary “to comply with both our responsibilities in accordance with the Data Protection Act 1998, and in common law, as an employer to protect the identity of current and former employees”.

155. Mr Baker concluded that to meet the concerns of families and the coroner, the MOD would replace the names of third parties with unique identifiers (such as Person AA and Officer BB), which would enable families to follow the narrative of the BOI report more easily while still protecting individual identities.

 

Footnotes

93 Paper [MOD], 17 December 2004, ‘BOI Reports – Disclosure Policy’.
94 Minute Baker to PS/Minister(AF) [MOD], 22 January 2007, ‘Board of Inquiry Reports – Disclosure for the Purposes of an Inquest’.

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156. The MOD issued revised instructions for the disclosure of BOI reports in May.95
The instructions advised that following the full implementation of the FOI Act on
1 January 2005, the current policy (of limited release of BOI reports outside the MOD)
was no longer sustainable; the underlying principle of the FOI Act was that information
should be available to members of the public on request unless it had an absolute
exemption or there was an overriding public interest in withholding it.

157. The way in which BOIs were conducted would not change, but the reports should
now be prepared in two parts:

• Part 1, which would be generally known as the “BOI Report”, should include the
convening order, terms of reference, findings, recommendations, and comments
from senior officers. It should be carefully structured to ensure that it contained
no exempt material or, if that was not possible, suitably redacted.

• Part 2 would include all other supporting documentation including witness
statements and police and investigative reports.

158. There would also be a separate master “Schedule of Proceedings”, listing
everything that constituted the full BOI Report.

159. Part 1 of the full BOI Report would be proactively published by the MOD under
their Publication Scheme. Requests for further information would be considered under
the FOI Act in the normal way. Applicants could be provided with the Schedule of
Proceedings to help them refine their request.

160. Next of kin should, in the first instance, be given only Part 1 of a BOI Report.
Requests for information from Part 2 would be treated in the same way as other FOI
requests (although it would normally be inappropriate to redact non‑sensitive personal
information about the family member). The instructions stated:
“Although this may be seen as restricting what is given to next of kin, it should
be borne in mind that Part 1 … will be a synthesis of all the relevant information
presented to the Board. Although the next of kin should always be treated in a
sympathetic and helpful manner, the provisions of the FOI Act and DPA98 and
other relevant legislation and common law must be observed.”

161. Coroners would “continue to be provided with the full unredacted copy of the report
(Parts 1 and 2)”, on the understanding that the report contained only information owned
by the UK and was not quoted from or admitted into evidence without further reference
to the MOD.

162. The instructions directed that where names were redacted, they should be
replaced by a unique identifier.

 

Footnotes

95 Defence Instructions and Notices, May 2007, ‘Disclosure of Board of Inquiry Reports, 2007DIN02‑15’.

 

16.3 | Military fatalities and the bereaved
107

163. In early November, Ms Lynch issued her ruling on the death of Fusilier Gordon Gentle.96 She concluded that it was probable that the roadside bomb that killed him would not have detonated if a disabling device had been fitted to the vehicle in which
he was travelling.

164. The press reported that Ms Lynch had described the MOD’s policies for the disclosure of evidence to the inquest as “illogical and based on errors of law”,97 and that she had stated that the inquest had been delayed by the MOD’s failure to provide documents and their policy of redacting names from the documents that were provided.98

165. Sir Bill Jeffrey advised Mr Ainsworth in February 2008, in the context of a paper on how to improve the BOI system, that while the MOD continued to face criticism over the redaction of BOI reports, “we have gone as far as practicable within the law”.99

166. An MOD/Ministry of Justice (MOJ) information booklet for bereaved families on the BOI and inquest processes, which was issued in 2008, stated that “where names are removed, each will be replaced with a term like Person A, Person B to help you follow the sequence of events in the report”.100

167. A number of the BOI reports seen by the Inquiry have followed this practice.
Creation of the Defence Inquests Unit

168. In early February 2007, the MOD sought and received an adjournment to the inquest into the death of Lance Corporal of Horse Matthew “Matty” Hull, who had been killed in a friendly‑fire incident with US forces in 2003, to allow them more time to secure US agreement to the use in court of a US cockpit recording of the incident.101

169. The adjournment came as the UK was negotiating with the US Government on
US participation in inquests into the deaths of UK Service Personnel. Those negotiations are described later in this Section.

170. Mr Baker wrote to MOD officials on 19 February advising that, in the light of the inquest into the death of L Cpl Hull, MOD Ministers might wish to have a “further urgent examination” of the BOI process, possibly including “a fundamental review as to whether [BOIs] can be considered fit for purpose given the wider uses to which they are increasingly put”.102 Mr Baker asked recipients to provide “positive points … in support of the BOI system as it currently stands” and information on planned improvements.

 

Footnotes

96 BBC News, 7 November 2007, Army supply ‘chaos’ proved fatal.
97 BBC News, 7 November 2007, Army supply ‘chaos’ proved fatal.
98 Daily Telegraph, 7 November 2007, Army failings led to death of Gordon Gentle.
99 Minute Jeffrey to Minister(AF) [MOD], 29 February 2008, ‘Boards of Inquiry and Inquests’.
100 Ministry of Defence & Ministry of Justice, Boards of Inquiry and Coroners’ Inquests: information for bereaved families, 2008.
101 Minute Ferguson to APS/Min(AF) [MOD], 2 February 2007, ‘Oxfordshire Inquests: Release of US Classified Information’.
102 Minute Baker to DG Sec LF, 19 February 2007, ‘Boards of Inquiry’.

 

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171. Mr Ingram subsequently met Mr Baker and other MOD officials to discuss work
already in hand to improve the BOI process.103 Mr Ingram’s Private Secretary recorded
that Mr Ingram: “… postulated that there might be a need to consider a more radical approach; that rather than working to make the current system work better, we might need to consider adopting a different system.”

172. Mr Baker said that he had already discussed the possibility of a more radical
approach with the Services, and concluded that “there was no realistic alternative to
the BOI process”. The MOD needed a thorough process of examination in order to
learn lessons, and needed to be able to ensure that it could be undertaken quickly and
address all the relevant issues. Mr Baker advised that the arguments for continuing with
the BOI process would be set out in a submission.

173. An MOD official working in Mr Baker’s Directorate sent Mr Ingram’s Private Office
advice on the “rationale for continuing with the BOI process” on 2 March.104

174. The official identified three alternative mechanisms for establishing the facts
surrounding an incident – Learning Accounts, Service Police investigations, and inquests
– and concluded that none of them met the MOD’s requirements.

175. The official concluded that the current BOI system played a “valuable role” in
“establishing the full details of the circumstances surrounding an incident and in learning
the lessons to prevent a recurrence”. Particular advantages were:

• BOIs enabled the MOD to fulfil its duty of care and health and safety obligations
towards its employees.

• Investigations into sensitive matters could be carried out “within the Service
environment and by the relevant subject matter experts”.

• As BOIs did not seek to apportion blame, and evidence given to a BOI could not
be used in a Service court, witnesses might be more candid than in another type
of investigation.

• BOIs were “tried and tested and worked well”.
The official also described the work under way to improve the BOI process.

176. The BOI report into the loss of Nimrod XV230 in September 2006 (in Afghanistan)
was published on 4 December 2007. Mr Browne told the House of Commons on the
same day: “By its nature, the Board was not in a position to go into the history of those
arrangements [for assessing the airworthiness of Nimrod aircraft] or to assess
where responsibility lies for failures … Flying will never be risk‑free. But I do believe

 

Footnotes

103 Minute Johnson to DG SP Pol, 22 February 2007, ‘Boards of Inquiry’.
104 MOD [junior official] to PS/Minister(AF) [MOD], 2 March 2007, ‘Boards of Inquiry (BOIs)’.

 

16.3 | Military fatalities and the bereaved
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that the families of those who died are due more of an explanation of the history than the Board of Inquiry could be expected to provide. I have therefore decided to put in place a review of the arrangements for assuring the airworthiness and safe operation of the Nimrod aircraft over its service life; to assess where responsibility lies for any failures; to assess more broadly the process for compiling safety cases, taking account of best practice in the civilian and military world; and to make recommendations.”105

177. Mr Browne discussed the BOI into the loss of Nimrod XV230 with MOD Ministerial colleagues the following day.106 He said that the MOD would shortly announce the name of the Queen’s Counsel who would lead the independent review. It would be important for the families to be able to feed their questions into that process.

178. During the meeting, MOD Ministers concluded that the Nimrod BOI was “a further example of the [BOI] process not necessarily being suited to the requirements of the MOD, the individuals and families involved and, crucially, public expectation”. Mr Browne suggested that there might be merit in a new process comprising: “… a short, focused Learning Account style review … conducted in a matter of a few months followed, as required, by a further review to look beyond the immediate circumstances and which was empowered to engage with individuals and the families affected by the incident, had an independent element and could draw from the advice of those who were well‑practiced in preparing for evidence‑based reviews”.

179. Mr Browne’s Private Secretary asked Mr Bill Jeffrey, the MOD’s Permanent Under Secretary,107 to provide “advice on the scope and options for improving the BOI process” by the end of January.

180. Mr Browne’s Private Office wrote to Mr Ainsworth’s Private Office later that week, reporting Mr Browne’s concern that recent good progress in clearing the backlog of inquests would not be sustained as the military investigation/BOI process was moving too slowly.108 Particular concerns included:

• The significant number of cases (13) over six months that were still awaiting completion of a BOI or RMP investigation, or even a decision on whether a BOI was required. In one case, a decision on whether to hold a BOI was still awaited nearly one year after the incident.

• The number of cases where the Swindon and Wiltshire Coroner was awaiting SIB reports.

 

Footnotes

105 House of Commons, Official Report, 4 December 2007, column 687.
106 Minute Forber to PS/Minister(AF) [MOD], 5 December 2007, ‘Defence Ministerial Meetings’.
107 Mr Jeffrey was knighted in the 2008 New Year’s Honours.
108 Minute APS/Secretary of State [MOD] to PS/Minister(AF) [MOD], 7 December 2007, ‘BOI and Inquest Backlog’.

 

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181. Mr Browne asked Mr Ainsworth to look into the backlog of incomplete BOIs and
“investigate what further action should be taken to speed up this process, including
whether additional staff resource is needed in theatre”.

182. On 28 February, Mr Ainsworth and Ms Bridget Prentice (Parliamentary
Under‑Secretary of State for the Ministry of Justice), met Mr Andrew Walker
(Assistant Deputy Coroner for Oxfordshire) and Mr David Masters (Coroner for
Wiltshire & Swindon), at Mr Ainsworth’s request, to discuss what could be done
to accelerate the inquest process.109

183. Ms Prentice’s Assistant Private Secretary recorded that Mr Walker had welcomed
the new Army Inquest Cell, which had had “a profound effect” on the conduct of inquests
into the deaths of Army Personnel. Working with the Cell, he had trialed a number of
proposals to improve and streamline the inquest process.

184. Mr Walker described how that new partnership had worked in a recent inquest:
“Despite the fact that there was extremely sensitive intelligence involved, the inquest
was completed within 12 months from the date of the incident. The key difference
was that he [Mr Walker] had been in contact with the Board of Inquiry (BOI) team
from the beginning of their investigation and was kept informed throughout, enabling
him sufficient time to build up the technical knowledge required to adequately
conduct the inquest. Crucially, this early involvement avoided the complicated ‘cold’
handover from the BOI to the inquest.”

185. Both coroners felt that the new arrangement enabled them to update families more
effectively on progress and to respond to their needs.

186. Both coroners contrasted that positive experience, with their experiences with
the Royal Navy and RAF. In one case, they said that they had had to wait four months
“for a signature on a piece of paper”. In four cases, it was alleged to have taken over
a year to reach a decision on whether or not to hold a BOI. The coroners felt that the
establishment of a tri‑Service Inquest Cell based on the Army model would be a “very
positive step”.

187. The MOD team confirmed that the idea of a tri‑Service Inquest Cell was being
considered, and highlighted the greater complexity often associated with Royal Navy
and RAF BOIs.

188. Mr Ainsworth told the Inquiry that he had considered the end‑to‑end process of
investigating fatalities and had taken the unusual step of meeting both Mr Walker and
Mr Masters to discuss ways in which the MOD could help.110 He recalled some anxiety
that a meeting might be seen as interfering with the coroners’ independence, but he

 

Footnotes

109 Minute Spence to Rothapel, 28 February 2008, ‘Bridget Prentice MP Meeting with Bob Ainsworth MP and the Coroners for Oxford and Swindon & Wiltshire on 21 February’.
110 Public hearing, 6 July 2010, page 30.

 

16.3 | Military fatalities and the bereaved
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believed that it was possible both to respect that independence and to seek
to understand “how the system is working for them from their point of view”.
189. Sir Bill Jeffrey responded to the requests for advice on how the BOI process
could be improved and how the existing process could be accelerated in a minute
to Mr Ainsworth at the end of February 2008.111

190. Sir Bill advised that, in response to Mr Browne’s question, it would be possible to hold a relatively short fact‑finding exercise followed by a “fuller inquiry into the whole course of events”. While the Nimrod XV230 BOI included a careful investigation of the incident itself, its remit did not extend into the history and safety record of the Nimrod; that question was now being examined by Mr Charles Haddon‑Cave. Where there was “a need to capture the broader departmental perspective, and where there is high public interest in the case”, the remit of the BOI could be broadened or a “further reaching independent inquiry”, running concurrently with the BOI, could be held.

191. Sir Bill also advised that:

• A new direction should be issued to the chain of command, that families should always be briefed as soon as practicable after an incident and kept regularly informed thereafter.

• A new joint Secretariat should be established, building on the Army’s Inquest Cell, to co‑ordinate all three Services’ management of inquests, the relationship with coroners and joint reports to Ministers.

192. The Army had appointed Permanent Presidents to lead high‑profile Army BOIs;
the Royal Navy and Royal Air Force were taking steps to establish “pools of expertise” from which Presidents could be selected.

193. There were currently 100 open inquests. That was “below last summer’s peak of 132, but still well above the backlog of 80 inquests that was judged to be unacceptable in Spring 2006”. The use of pre‑inquest hearings, while a valuable contribution to the inquest process, could introduce delays into the process. Coroners often waited for access to the MOD’s reports, including BOI reports, before undertaking an inquest. Sir Bill commented: “We must show coroners that we treat our investigations as matters of urgency so that we might expect them to do the same.”

194. On 9 April, Mr Ainsworth met senior officials and military officers to discuss Sir Bill’s advice.112 Mr Ainsworth stated that he and Mr Browne remained of the view that there needed to be a “step change in the way in which the BOI and inquest process was handled, end‑to‑end”. He had already discussed the advice with Sir Bill, and agreed that

 

Footnotes

111 Minute Jeffrey to Minister(AF) [MOD], 29 February 2008, ‘Boards of Inquiry and Inquests’.
112 Minute PS/Min(AF) [MOD] to APS/Secretary of State [MOD], 11 April 2008, ‘Boards of inquiry and Inquests’.

 

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it formed “a good basis for further discussion”. The key proposal was the establishment
of a “single inquest cell”.

195. The meeting agreed that a single inquest cell should be established as a matter
of urgency. Key responsibilities would be to:

• professionally manage the MOD’s relationship with coroners;

• chase progress on BOIs in order to “drive down” the time between incident and
inquest; it would need sufficient “authority and clout” to do that;

• identify weaknesses in policy and ensure they were addressed, and ensure that
existing policy and best practice was adhered to; the lead for developing policy
would often sit outside the cell; and

• ensure the right training and guidance was provided to VOs.
196. The cell would not carry out BOIs (which would continue to be the responsibility for
the Services).

197. Mr Ainsworth’s Private Secretary recorded that, although the other proposals made
by Sir Bill had not been discussed in any detail at the meeting, Mr Ainsworth would like
them “taken forward in the context of the establishment of the new cell”.

198. The Defence Inquests Unit (DIU) was created in May 2008 to act as the focal point
for all coroners’ inquests into the deaths of Service and MOD civilian personnel.113

199. The Army Inquest Cell was disbanded on the creation of the DIU, and its posts
moved into the DIU.114

200. Mr Ainsworth told the Inquiry that the role of the DIU was not just to ensure that the
MOD was providing the support that coroners required:
“… my motives were more than just helping the bereaved, they were about the MOD
getting better at learning some of the lessons that flowed from inquests … some
of our systems were, from time to time, exposed pretty badly by coroners’ inquests
and, you know, they were a mine of information … if you were prepared to really
embrace the findings …”115

201. Mr Mike Venables, Head of the DIU from 2009 to 2012, described the DIU’s role
as supporting bereaved families by making sure that coroners had everything they
needed.116 This included:

• providing all relevant reports and information, and explaining that material where
necessary;

 

Footnotes

113 Defence Instructions and Notices 2008DIN05‑052, December 2008, ‘The Defence Inquests Unit’.
114 Minute D/VCDS to Min(AF) [MOD], 24 April 2008, ‘Inquests Cell: Terms of Reference’.
115 Public hearing, 6 July 2010, pages 30‑31.
116 GOV.UK, 23 February 2012, Defence Inquests Unit: helping to find the answers.

 

16.3 | Military fatalities and the bereaved
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• helping to identify and locate military witnesses;

• organising familiarisation events on military equipment for coroners; and

• providing support to witnesses.

202. Mr Venables also indicated that the creation of the DIU served to change the MOD’s policy on legal representation at inquests. The MOD had tended to be legally represented at inquests: “But we took the view that some families see that as intimidating. It looked as though the big bad Ministry had turned up, so now, even if the families choose to have a barrister, we tend not to, we … send a case officer.”

Introduction of Service Inquiries

203. Section 343 of the Armed Forces Act 2006 (AFA 2006), which came into force on 1 October 2008, provided for the establishment of a single form of statutory inquiry – the Service Inquiry (SI) – for all the Services.117

204. The Royal Navy, Army and RAF had previously held inquiries under the Prerogative, Army Act 1955 and Air Force Act 1955 respectively.

205. The MOD told the Inquiry that the AFA 2006 represented the first complete overhaul of the Service justice system in 50 years, harmonising practices and procedures across the Services to provide a single system of Service law.

206. The MOD also told the Inquiry that SIs had the same purpose as BOIs (subject to its terms of reference, to establish the facts of a particular matter and make recommendations to prevent recurrence).

Efforts to reduce the backlog of inquests, 2005 to 2007

Support for the Oxfordshire Coroner

207. From March 2003 to 1 April 2007, military fatalities on Op TELIC were repatriated to RAF Brize Norton in Oxfordshire.

208. In early 2005, Mr Gardiner applied to the Oxfordshire County Council, then to the Home Office, and finally to the MOD for additional funding to enable him to carry out his duties.118

209. In May 2005, the MOD convened a series of meetings with officials from the Home Office and the Department for Constitutional Affairs (DCA)119 to consider how to resolve

 

Footnotes

117 Paper MOD, 2011, ‘Service Inquiries and Investigations’.
118 Paper MOD, May 2006, ‘Coronial Issues’.
119 The DCA took over responsibility for coronial policy from the Home Office in May 2005.

 

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the immediate problem and “explore alternative arrangements to ensure that the issue
does not reoccur”.

210. On 24 May, the Home Office provided £80,000 to allow Mr Gardiner’s office
to recruit an additional Coroner’s Officer to help manage inquests into the deaths of
Service Personnel in Iraq.120

211. Mr Don Touhig, Parliamentary Under Secretary of State for Defence, told
the House of Commons in early June 2005 that the decision to provide support to
Mr Gardiner’s office predated recent press reports on delays in holding inquests into
the deaths of Service Personnel.121

212. A June 2007 DCA briefing assessed that that support had “little effect” on the
backlog.122 The main constraint was the time that Mr Gardiner himself was able to
devote to considering case papers in preparation for inquests.

213. On 6 February 2006, Ms Harriet Harman, Minister of State for the DCA, informed
the House of Commons that she intended to bring forward legislation to reform the
coroner service:
“Under the current coroner service, families frequently get overlooked during the
inquest process … The system is fragmented, with no national leadership, and it
is not accountable … Standards are not uniformly good; everything rests too much
on the personal qualities and abilities of individuals within the system. The legal
framework is downright archaic. For most coroners, this is not even their principal
occupation; it is a secondary one, added on to their main work as solicitors in
private practice …
“The coroner service must serve the public interest and meet bereaved families’
concerns in a way that, frankly, it currently does not …”123

214. In May 2006, in response to renewed Parliamentary concern over delays in holding
inquests into the deaths of Service Personnel, Ms Harman was charged with “dealing
with the problem”.124

215. On 22 May, Ms Harman wrote to Mr Browne suggesting that they meet to discuss
how to clear the backlog of inquests in Oxfordshire.125 It was important that all coroners
conducted inquests in good time; she was particularly concerned that the families of
Service Personnel should not face a long wait before an inquest was concluded.

 

Footnotes

120 Paper MOD, May 2006, ‘Coronial Issues’.
121 House of Commons, Official Report, 6 June 2005, column 982.
122 DCA [junior official] to Harman, 12 June 2007, ‘Request from Wiltshire and Swindon Coroner for Additional Resources to Deal with Military Fatalities Repatriated via RAF Lyneham’.
123 House of Commons, Official Report, 6 February 2006, column 607.
124 DCA [junior official] to Harman, 17 May 2006, ‘Oxfordshire Coroner and Inquests into Iraq Fatalities’.
125 Letter Harman to Browne, 22 May 2006, ‘Oxfordshire Coroner and Iraq Deaths Inquests’.

 

16.3 | Military fatalities and the bereaved
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216. Ms Harman wrote:

• The DCA had been endeavouring to get a full picture of the extent of the delays, working with MOD officials and Mr Gardiner’s Office, and had compiled a grid showing the number of inquests yet to be undertaken. That analysis indicated that there were 39 military deaths and 5 civilian deaths relating to Iraq in the “inquest queue”, excluding cases where Mr Gardiner was waiting for evidential material from the MOD.

• The first military deaths in that queue related to the loss of a Sea King helicopter on 22 March 2003.126 The first deaths on which Mr Gardiner had not yet received material from the MOD related to the loss of a CH46 helicopter on 21 March 2003.

• Mr Gardiner estimated that to clear the backlog, he would need an additional Assistant Deputy Coroner and continued funding for the additional Coroner’s Officer, at a cost of £125,000 a year for two years. DCA officials had not yet assessed whether that estimate was realistic. The DCA was “poorly placed” to provide that funding. If those resources could not be found, the current position that most inquests were held in Oxfordshire (rather than in the home area of the deceased) would need to be reconsidered.

217. Ms Harman, Mr Browne and Mr Ingram met on 24 May.127 Ms Harman advised that further work by DCA officials suggested that £250,000 would be required over six months in order to list or complete all cases by the end of the year.

218. A record of the meeting by Mr Browne’s Assistant Private Secretary, which was circulated only within the MOD, reported that Mr Browne had agreed that if there was a “practical plan” to reduce the backlog and there was no possibility of securing funding from the Reserve, then he was “prepared in principle to put in £125,000 for the first year”.

219. An informal record of the meeting by a DCA official reported that Mr Browne had agreed to provide £125,000, and to hold a further £125,000 “in reserve” which could be made available depending on progress.128

220. In a Written Ministerial Statement to the House of Commons on 5 June, Ms Harman and Mr Browne set out the support that the Government would provide
to the Oxfordshire Coroner’s office to enable it to deal with “outstanding inquests”:

• three Assistant Deputy Coroners (Sir Richard Curtis, Ms Selena Lynch and Mr Andrew Walker);

 

Footnotes

126 The (Royal Navy) BOI into the loss of a Sea King helicopter on 22 March 2003 had reported on 1 May 2003 (it was the first BOI relating to Op TELIC to report); the BOI report had been made available to families on 9 June 2003.
127 Minute APS/SoS [MOD] to SPPol SC‑D, 24 May 2006, ‘Iraq Inquest Backlog – Oxford Coroner – Meeting with Harriet Harman MP’.
128 Email Woolfenden to Sadler, 24 May 2006, ‘Iraq Deaths’.

 

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• two additional Coroner’s Officers;

• an additional member of support staff; and

• recording equipment which would enable two extra courts to operate
simultaneously.129

221. There were currently 59 inquests into the deaths of Service Personnel killed in Iraq
and 11 inquests into the deaths of civilians to be concluded. Mr Gardiner expected, with
this additional support, to be able to conclude inquests into the deaths of 30 Service
Personnel where the MOD had completed their own inquiries and case papers had been
prepared, and conclude inquests into the deaths of three civilians where he had been
provided with reports and other information, by the end of the year.

222. Ms Harman and Mr Browne undertook to report quarterly to Parliament on
progress in clearing the backlog of outstanding inquests.

223. As the Statement was being drafted, Ms Harman expressed her strong view
that it should be sent to the families of deceased Service Personnel before it was laid
in Parliament.130

224. DCA officials advised that they were “not convinced” by that proposal, and
that it was in any case impractical as the MOD was “not prepared” to supply family
contact details.131

225. Ms Harman and Mr Browne agreed on 1 June that the Statement should be sent
to families before it was laid in Parliament.132

226. Two of the three Assistant Deputy Coroners were appointed in early June, the third
in early August.133

227. The effectiveness of the additional support provided to the Oxfordshire Coroner’s
office in clearing the outstanding inquests is considered below.

228. In July, as the capacity of the Oxfordshire Coroner’s office was being increased,
the MOD extended the target timelines for the completion of BOIs; that decision is
described earlier in this Section.

229. By the end of July, it had become clear that the MOD and DCA did not have
a shared understanding of how much, and at what point, the MOD would contribute
to the cost of the additional support provided to the Oxfordshire Coroner’s office.

 

Footnotes

129 House of Commons, Official Report, 5 June 2006, column 4WS.
130 Email Tierney to Woolfenden, Patterson & Bainbridge, 1 June 2006, ‘Writing to the Families’.
131 Minute Bainbridge to Harman, 31 May 2006, ‘Oxon Coroner’.
132 Email Tierney to Anderson, 1 June 2006, ‘Note of Telephone Call between Harriet Harman and Des Browne – Iraq/Coroner’.
133 Minute DCA [junior official] to Harman, 6 October 2006, ‘Oxfordshire Coroner: Written Ministerial Statement on Progress with Iraq Related Inquest Backlog’.

 

16.3 | Military fatalities and the bereaved
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The discussions between the DCA, the MOD, and the Treasury from July 2006 to February 2007 on that issue are described below.

230. The DCA bore the costs that were being incurred by the Oxfordshire Coroner’s office while those discussions continued.134

DISCUSSIONS ON FUNDING

231. On 22 May 2006, Mr Alex Allan, Permanent Secretary at the DCA, and Mr Ian Andrews, 2nd Permanent Under Secretary at the MOD, discussed how the additional funding required by the Oxfordshire Coroner might be found.135 Mr Allan’s Assistant Private Secretary reported that Mr Allan had stated that neither the local authority nor the DCA could provide that additional funding. Mr Andrews said that the Treasury met the MOD’s “operational costs”, and indicated that the funding for the Oxfordshire Coroner should be included within that arrangement.136 That would be for the MOD to explore with the Treasury.

232. On 20 July, Ms Harman sent Mr Browne an update on progress on clearing the backlog of inquests, and concluded that she “hoped that we can clarify the amount
of money you will pay”.137

233. On the same day, Ms Harman wrote to Lord Falconer of Thoroton, the Secretary of State for Constitutional Affairs and Lord Chancellor, asking if he would speak to Mr Browne to ensure that Mr Browne’s decision to provide £250,000 would be communicated to MOD finance officials.138

234. Mr Browne replied to Ms Harman on 14 August stating that, as he had previously indicated, given that the inquests were a result of operational commitments, his preference would be for the additional funding to be sought through a call against the Reserve.139 He stood ready to support a request to the Treasury. If funding could not be secured from the Reserve, he was “in principle willing to provide a contribution of £125,000 for the first year towards the financial costs of the additional resources, subject to Accounting Officer and Treasury approval”.

235. Lord Falconer wrote to Mr Browne later that month, stating that £125,000 was insufficient to cover the costs involved and that, while DCA officials would look at the suggestion of making a bid on the Reserve, “given that the backlog is driven by the

 

Footnotes

134 Letter Harman to Browne, 28 December 2006, ‘Proposals Arising from Meeting with Relatives of Service Personnel on their Experience of the Inquest System’.
135 Email DCA [junior official] to DCA [junior official], 22 May 2006, ‘Coroners – Inquest Delays/MOD’.
136 The established arrangements whereby the MOD claimed the Net Additional Costs of Military Operations (NACMO) from the Treasury are described in Section 13.
137 Letter Harman to Browne, 20 July 2006, ‘Iraq Inquests Backlog’.
138 Minute Harman to Falconer, 20 July 2006, ‘Funding for Extra Resources for the Oxfordshire Coroner’.
139 Letter Browne to Harman, 14 August 2006, ‘Iraq Inquest Backlog’.

 

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MOD’s policy to repatriate Iraq fatalities to RAF Brize Norton in Oxfordshire” it would
not be appropriate for the DCA to make that bid.140

236. Mr Browne replied on 10 September, stating that while there was a strong case
for funding the additional costs from the Reserve, the Treasury would expect the bid
to come from the Department responsible for coronial policy.141

237. Lord Falconer replied on 6 October, advising that while the DCA held policy
responsibility for coroners, operational responsibility rested with the relevant local
authority.142 In this case, it would normally be for Oxfordshire County Council to meet
the costs of the inquests. He continued:
“The Cabinet Office Ministerial Code of Conduct (paragraph 6.10) clearly sets out
the principle that Departments responsible for initiating policy are required to take
into account the effect their proposals have on other departments. It is MOD policy
to repatriate bodies to RAF Brize Norton rather than Lyneham, Fairford or elsewhere
and it is a direct result of this decision that the backlog of cases has occurred. If
fatalities were shared amongst a number of coroners this problem would have
been avoided.
“It is for this reason that I consider that it is your Department’s responsibility to
shoulder the costs arising from the Iraq inquest backlog … If you are unable to fund
the additional resources from your existing budget then it is for your Department,
not mine, to approach the Treasury for a Reserve claim.”

238. Officials from the MOD, the DCA and the Department for Communities and Local
Government (DCLG) met on 8 November to discuss funding options.143

239. A DCA official reported to DCA colleagues only that all three departments had
difficulties in providing funding from within their existing budgets. The MOD had argued,
for the first time, that it would be inappropriate for the MOD to be seen to be funding
the inquest process when it had a clear interest in the cases involved. The meeting
had agreed that DCA officials should approach the Treasury informally to see whether
funding from the Reserve could be made available and, if not, whether they could
suggest an alternative solution.

240. A DCA official advised Ms Harman on 13 December that the Treasury had “not
replied positively” to that approach.144 The DCA had subsequently written to the MOD,
asking it to confirm that it would provide the necessary funding.

 

Footnotes

140 Letter Falconer to Browne, 31 August 2006, ‘Funding for Additional Resources for the
Oxfordshire Coroner’.
141 Letter Browne to Falconer, 10 September 2006, [untitled].
142 Letter Falconer to Browne, 6 October 2006, ‘Funding for Additional Resources for the
Oxfordshire Coroner’.
143 Email DCA [junior official] to Tierney, 10 November 2006, ‘Oxfordshire Coroners: Progress Report’.
144 Minute DCA [junior official] to Harman, 13 December 2006, ‘Oxfordshire Coroner: Written Ministerial Statement on Progress with Iraq Related Inquest Backlog’.

 

16.3 | Military fatalities and the bereaved
119

241. On 7 January 2007, Mr Lee McCauley, MOD Assistant Director of Defence Resources and Plans, wrote to a Treasury official to advise him that the MOD had “reluctantly concluded” that all additional costs related to the Oxfordshire Coroner should be “funded this year through Defence”.145 There were several arguments against doing so, but Ministers wanted the issue to be resolved. Treasury approval would be required, as the MOD did not have authority to meet costs that fell to other parts of Government.

242. Mr McCauley proposed that the MOD treat the costs as part of the Net Additional Cost of Military Operations (NACMO), and claim them from the Treasury
in the normal way. If that was not possible, the MOD would need to find the funds within its core settlement.

243. On 13 February 2007, Mr Browne wrote to Ms Harman:
“My officials have explored at length with the Treasury the possibility of making a claim against the Reserve. The Treasury have refused on the principle that such costs should lie where they fall and this is not a legitimate charge to Defence for the additional costs of operations. In light of this, I cannot accept an argument that the backlog stems solely from MOD policy: there are sound practical reasons for repatriation of bodies to RAF Brize Norton but there are also, as the current initiative146 shows, ways in which the burden may be shared with other coroners.”147

244. Mr Browne concluded by confirming that he held to his earlier offer to contribute £125,000 towards the additional costs of the Oxfordshire Coroner during 2006/07.
That contribution should not be seen as setting a precedent for MOD funding to address “future inquest backlogs, should they arise”.

245. Ms Harman replied on 27 March, expressing her disappointment with that contribution but confirming that she would accept it.148 She would expect the MOD
to contribute if further backlogs emerged.

PROGRESS IN CLEARING THE BACKLOG OF INQUESTS

246. Ministers provided quarterly reports to the House of Commons on progress in clearing the backlog of inquests in Oxfordshire. The table below summarises these reports.

247. The first report, in June 2006, covered only outstanding inquests into deaths relating to Iraq.149 Subsequent reports included outstanding inquests relating to previous conflicts and military exercises overseas, for which the Oxfordshire Coroner was responsible.

 

Footnotes

145 Letter McCauley to Treasury [junior official], 11 January 2007, ‘Oxfordshire Coroner: Funding’.
146 To allocate inquests directly to ‘home‑town’ coroners, bypassing the Oxfordshire Coroner.
147 Letter Browne to Harman, 13 February 2007, ‘Proposals Arising from Meeting with Relatives of Service Personnel on their Experience of the Inquest System’.
148 Letter Harman to Browne, 27 March 2007, ‘Proposals Arising from Meeting with Relatives of Service Personnel on their Experience of the Inquest System’.
149 House of Commons, Official Report, 5 June 2006, column 4WS.

 

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248. Ms Harman informed the House of Commons on 12 October that Mr Gardiner
would not be able to meet the target set in her June 2006 update for the completion
of pre‑June 2006 inquests (the end of 2006).150

Table 2

249. The June 2007 report stated that of the 72 inquests which had been completed
by the Oxfordshire Coroner’s Office since June 2006, Mr Gardiner had conducted five,
Sir Richard Curtis six, Ms Selena Lynch 28, Mr Andrew Walker 32, and Ms Jennifer
Leeming, the Greater Manchester West Coroner, one.157

250. The additional resources provided by the Government in June 2006 enabled the
Oxfordshire Coroner’s office to clear the backlog of outstanding inquests (into deaths
occurring before June 2006) by October 2007.

251. The two outstanding inquests reported in the October 2007 report related to the
deaths of Fusilier Gordon Gentle on 28 June 2004 and Lieutenant Richard Palmer on
15 April 2006. The inquest into Fusilier Gentle’s death was due to open on 29 October
2007. The coroner had decided to await the completion of the BOI into Lt Palmer’s death
before opening an inquest; that inquest would therefore not be held until 2008.

 

Footnotes

150 House of Commons, Official Report, 12 October 2006, column 28WS.
151 House of Commons, Official Report, 5 June 2006, column 4WS.
152 House of Commons, Official Report, 12 October 2006, column 26WS. Nine inquests had been completed since the June 2006 WMS, but Mr Gardiner had advised the Government of nine additional outstanding cases relating to deaths from previous conflicts and overseas military exercises.
153 House of Commons, Official Report, 18 December 2006, column 112WS.
154 House of Commons, Official Report, 29 March 2007, column 120WS. The Statement corrected the number given in the 18 December 2006 Statement for Inquests held since October 2006, from 18 to 19.
155 House of Commons, Official Report, 20 June 2007, column 97WS.
156 House of Commons, Official Report, 30 October 2007, column 35WS.
157 House of Commons, Official Report, 20 June 2007, column 97WS.

 

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121

Efforts to transfer more inquests to local coroners

252. In early September 2006, after discussions with DCA officials, Mr Gardiner alerted coroners that the additional resources he had received from the Government were not intended to be “long term” and were only to reduce the current backlog of cases.158 He was, therefore, likely to “increasingly be making transfer requests under Section 14(i) of the Coroners Act 1988”.

253. A DCA official advised Ms Harman on 6 October that Mr Gardiner’s office was now receiving a significant number of fatalities from Afghanistan, as well as from Iraq.159 The additional resources announced on 5 June only covered inquests that were outstanding at that date. The DCA had “serious doubts” that Mr Gardiner’s office could handle the new (post‑June 2006) cases, once the pre‑June backlog was cleared and staffing levels returned to normal.

254. The official commented that it was not helpful that the MOD continued to repatriate bodies to RAF Brize Norton: DCA and MOD officials were meeting shortly to discuss that issue.

255. MOD and DCA officials met on 18 October to reconsider the policy of repatriating the bodies of deceased Service Personnel via RAF Brize Norton.160 Points made in the discussion included:

• Mr Gardiner was “considering transferring cases to other jurisdictions, but in limited circumstances”. That was in line with established policy. Mr Gardiner would not be transferring cases where there were multiple deaths in a single incident, and all transfers required the agreement of the receiving coroner.

• Arrangements for inquests relating to incidents in 2003 and 2004 were “well in hand”, but there were still “serious delays” to later inquests and the number of bodies repatriated to RAF Brize Norton was increasing.
• One unavoidable factor behind those delays was the need to wait for a BOI
to conclude before beginning an inquest.

• It was crucial to keep families informed of progress.

• MOD officials felt that Mr Gardiner and his officers provided effective support
to families through the inquest process.

• DCA officials considered that Mr Gardiner’s office would be unable to cope with the workload once the additional resources provided by the Government were removed.

 

Footnotes

158 Letter Gardiner to Harman, 21 November 2006, ‘Foreign Service Fatalities’.
159 Minute DCA [junior official] to Harman, 6 October 2006, ‘Oxfordshire Coroner: Written Ministerial Statement on Progress with Iraq Related Inquest Backlog’.
160 Record, 18 October 2006, ‘Oxfordshire Coroner: Note of a meeting at 10am on 18 October 2006 in room 8.04 Steel House’.

 

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256. The meeting considered a number of options, and agreed that:

• The MOD should continue to use RAF Brize Norton.

• MOD policy should be amended, so that when a death occurred (and before the
body was repatriated), the appropriate local coroner would be alerted that the
body of the deceased would be coming into their district.

• The body would be taken to the local coroner immediately after the repatriation
ceremony. Such a policy “would avoid the need to involve the Oxfordshire
Coroner at all”.

257. Ms Harman wrote to Mr Gardiner on 17 November, following up on discussions
between Mr Gardiner and DCA officials, to seek his views on that approach.161

258. Mr Gardiner replied on 21 November, recalling that the Coroner’s Act required
him to hold an inquest if he was informed that a body was within his jurisdiction and the
death appeared violent or unnatural, and advised:
“In practice it is inevitable that I will be informed, either directly or through my
Officers, of any bodies in my jurisdiction. Indeed … I would be failing in my duties
if I had not over the years established appropriate lines of communication.”162

259. Mr Gardiner also advised that he had had informal discussions with a number of
coroners, and most of them had indicated that they would accept transfers from him
under Section 14 of the Coroners Act. Since he had alerted coroners to the likelihood
that he would be transferring more cases (in early September), he had transferred
three cases.

260. On 4 December, Ms Harman met relatives of Service Personnel killed in Iraq to
discuss their experience of the investigation and inquest process and the coroners’
service.163 The meeting, which was facilitated by an external organisation called Opinion
Leader, was attended by 17 relatives from 12 families.

261. A record of the meeting by a DCA official highlighted relatives’ concern over the
distance they had to travel to inquests (there was a “particular difficulty” with Scottish
fatalities as there was no discretion to hold a Fatal Accident Inquiry in Scotland where
the death occurred overseas), and the perceived failure of the MOD to provide them
with all documentation before the inquest.164 The official commented that the Oxfordshire Coroner had been encouraged to transfer cases to other coroners. The DCA was also exploring ways to transfer a body directly to a local coroner.

 

 

Footnotes

161 Letter Harman to Gardiner, 17 November 2006, ‘Iraq and Afghanistan Fatalities: Handling Future Inquests’.
162 Letter Gardiner to Harman, 21 November 2006, ‘Foreign Service Fatalities’.
163 Report Opinion Leader, January 2007, ‘DCA Meeting with Families of Military Personnel who Lost their Lives in Iraq’.
164 Email DCA [junior official] to Burden, 8 December 2006, ‘Short Paper on Actions from Iraq Inquest Meeting with Families’ attaching Paper, [undated], ‘Actions from Iraq Inquest Meeting with Families’.

 

16.3 | Military fatalities and the bereaved
123

262. Discussions on whether a Fatal Accident Inquiry could be held for all Scottish fatalities are addressed later in this Section.

263. On 13 December, a DCA official advised Ms Harman that the Oxfordshire Coroner’s office continued to receive a significant number of fatalities from Iraq and Afghanistan (15 and 33 respectively, since June).165 The DCA continued to have serious doubts about whether it could cope with that workload. The Coroner’s office had “raised the possibility” of extending the additional staff until all inquests (pre‑ and post‑June 2006) had been cleared, but the DCA had advised them that that would be a matter for Oxfordshire County Council.

264. Ms Harman told the House of Commons on 18 December that, following the 4 December meeting, the DCA was “working on providing families with better information about the inquest system, how we can help families to have access to all material relevant to the inquest, and holding inquests closer to where the relatives live”.166

265. Ms Harman wrote to Mr Browne on the same day, highlighting five areas identified at the 4 December meeting where changes might improve a family’s experience:

• Holding the inquest closer to the family’s home, rather than in Oxford. The DCA was encouraging Mr Gardiner to transfer cases to other coroners as a way of reducing his backlog. Another possibility would be to repatriate the bodies of deceased Service Personnel directly to the family’s local coroner without any involvement by the Oxfordshire Coroner.167

• Creating an information pack for families of deceased Service Personnel which described what to expect from an inquest and where to go for further support. Ms Harman suggested that DCA and MOD officials should discuss the contents of the pack.168

• Establishing a “victims’ advocate service” for families, similar to the Coroner’s Court Support Service but tailored to address the particular problems of families of those killed abroad and in conflict. The service could build on the support already provided by Visiting Officers.

• Ensuring earlier and more complete advance disclosure of documents and key facts to families.

• Ending the practice of charging families for access to documents, including inquest transcripts.

 

Footnotes

165 Minute DCA [junior official] to Harman, 13 December 2006, ‘Oxfordshire Coroner: Written Ministerial Statement on Progress with Iraq Related Inquest Backlog’.
166 House of Commons, Official Report, 18 December 2006, column 116WS.
167 Letter Harman to Browne, 18 December 2006, ‘Proposals Arising from Meeting with Relatives of Service Personnel on their Experience of the Inquest System’.
168 The resulting booklet, MOD & MOJ Boards of Inquiry and Coroners’ Inquests: Information for Bereaved Families (2008), was published in early 2008.

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266. The Opinion Leader record of the 4 December meeting, which issued in January
2007, reported that the Coroner’s service had not sufficiently met the needs of most
families.169 It identified six main issues:

• the time between incident and inquest (more than three years in some cases);

• insufficient notification of an inquest, leaving little opportunity to prepare;

• not having access to key information;

• specific problems with the running of the inquest (including key witnesses not
being present, factual errors, and not having the opportunity to ask questions);

• a lack of sensitivity in the treatment of families; and

• cost and logistical issues (including being asked to pay for documents and the
difficulty faced by some families in paying for legal representation).

267. The report advised that families had also raised concerns relating to their treatment
by the media and the Army’s investigative processes.

268. On 22 January 2007, Mr David Cameron, the MP for Witney, in whose constituency
RAF Brize Norton was located, wrote to Lord Falconer stating that it was “patently unfair”
that Oxfordshire County Council should have to provide funding to clear post‑June 2006
inquests.170 The Council estimated that the Coroner’s office would require an additional
£100,000.

269. On 13 February, Mr Browne replied to Ms Harman’s letter of 18 December:
“… I understand that your officials have confirmed with the Oxfordshire Coroner
that provided the body is not formally reported to him he would be content for the
repatriated body to be transferred directly from Brize Norton after the ceremonial
to the area of the ‘home’ coroner.”171

270. Mr Browne commented that this was a welcome development, provided that
flexibility was retained; there would be occasions when the Oxfordshire Coroner, with the
pathology services available to him, would be able to release a body to the family more
quickly than a local coroner.

271. On 27 March, a DCA official advised Ms Harman that the DCA’s line that
Oxfordshire County Council should provide funding was “becoming harder to
maintain”.172 It was important that Mr Walker was retained to deal with the post‑June
2006 backlog. The DCA would look to the MOD to provide funding, but it was certain to resist.

 

Footnotes

169 Report Opinion Leader, January 2007, ‘DCA Meeting with Families of Military Personnel who Lost their Lives in Iraq’.
170 Letter Cameron to Falconer, 22 January 2007, ‘Coroner Service in Oxfordshire’.
171 Letter Browne to Harman, 13 February 2007, ‘Proposals Arising from Meeting with Relatives of Service Personnel on their Experience of the Inquest System’.
172 Minute DCA [junior official] to Harman, 27 March 2007, ‘Oxfordshire Coroner: Written Ministerial Statement on Progress with Iraq Related Inquest Backlog’.

16.3 | Military fatalities and the bereaved
125

272. Ms Harman informed the House of Commons on 29 March that the Government had made further resources available to the Oxfordshire Coroner office’s to enable Mr Walker to remain as Assistant Deputy Coroner and to enable one Coroner’s Officer
to be retained, to handle the new (post‑June 2006) backlog of inquests.173

273. Ms Harman advised Mr Browne at the end of March that, since the Oxfordshire Coroner was now routinely transferring inquests to the appropriate local coroner, there had been no need to repatriate bodies directly to a local coroner without any involvement by the Oxfordshire Coroner.174 Ms Harman understood that the practice of transferring single death inquests would be followed by the Swindon and Wiltshire Coroner (when fatalities began to be repatriated through RAF Lyneham from 1 April).
Support for the Swindon and Wiltshire Coroner

274. From 1 April 2007, due to essential repair work at RAF Brize Norton, ceremonial repatriations took place through RAF Lyneham in Wiltshire.

275. In May, the DCA took on certain responsibilities from the Home Office and was renamed the Ministry of Justice (MOJ). Ms Harman retained Ministerial responsibility
for coronial policy.

276. Mr David Masters, the Coroner for Wiltshire & Swindon, wrote to the Ministry of Justice on 21 May, requesting additional resources for his office to enable it to deal with the bodies of Service Personnel killed in Iraq and Afghanistan.175

277. An MOJ official advised Ms Harman that she should resist providing additional funding, but offer Mr Masters a meeting with MOJ and MOD officials to discuss his workload and possible options. There was a risk that without additional funding a backlog could develop (as it had in Oxfordshire), but there was also a case for challenging the argument that Mr Masters could not cope without it.

278. Ms Harman replied to Mr Masters on those lines.176

279. Subsequently, against a background of Parliamentary concern over the possibility that the backlog of inquests was increasing, she agreed with Mr Jack Straw, Secretary
of State for Justice and Lord Chancellor, that he should meet Mr Masters.

280. Mr Straw and Ms Prentice met Mr Masters on 23 July.177 Mr Masters said that he had transferred 17 cases relating to single deaths to other coroners, but retained

 

Footnotes

173 House of Commons, Official Report, 29 March 2007, column 124WS.
174 Letter Harman to Browne, 27 March 2007, ‘Proposals Arising from Meeting with Relatives of Service Personnel on their Experience of the Inquest System’.
175 Minute MOJ [junior official] to Harman, 12 June 2007, ‘Request from Wiltshire and Swindon Coroner for Additional Resources to Deal with Military Fatalities Repatriated via RAF Lyneham’.
176 House of Commons, Official Report, 12 July 2007, column 1623.
177 Minute PS/Prentice [MOJ] to MOJ [junior official], 23 July 2007, ‘Meeting with Wiltshire Coroner – 23 July 2007’.

 

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126

jurisdiction in 16 cases relating to multiple deaths or where the deceased was from
Scotland. He needed additional staffing and resources to deal with the additional
workload. Mr Straw and Ms Prentice both said that they were “sympathetic” to
that request.

281. Mr Straw and Mr Browne agreed later that month that the MOJ and the MOD
should share the cost of supporting Mr Masters’ office,178 and in October that their
Departments should share the cost equally.179 The cost for 2007/08 was likely to be
£230,000, and £350,000 a year thereafter.

282. In October, an MOJ official advised Ms Prentice that there was no backlog of
military inquests in Wiltshire and Swindon.180

283. The Coroners and Justice Bill, which was introduced into Parliament in January
2009, included a number of measures to ensure that any future backlogs of inquests
could be addressed more easily. The Bill is described later in this Section.
Efforts to improve the inquest process, 2006 to 2009

US participation in inquests

284. Ms Harman wrote to Mr David Johnson, the Deputy Chief of Mission at the US
Embassy in London, on 20 July 2006 about “the need for US co‑operation which was
contributing to delays in inquests” into the deaths of British Service Personnel in Iraq.181

285. The inquest into the death of Mr Terry Lloyd, an Independent Television News
(ITN) journalist who died in a friendly fire incident with US forces on 22 March 2003,
was conducted by Mr Andrew Walker, the Assistant Deputy Coroner for Oxfordshire,
in October 2006. Mr Walker found that Mr Lloyd had been unlawfully killed.

286. In early August, as part of the preparations for that inquest, MOD and FCO officials
met US Embassy staff on behalf of Mr Walker, to try to secure US authority to use a US
Marine Corps report into one part of the incident and additional material covering the
precise circumstances of Mr Lloyd’s death.182

287. The Pentagon advised MOD officials in late September that a redacted version
of the Marine Corps report could be used and that no additional material was available.
288. Mr Walker then asked for US Service Personnel to attend the inquest. When
that request was refused, he ruled that the information provided by the US was

 

Footnotes

178 Letter Straw to Browne, 26 July 2007, ‘Wiltshire and Swindon Coroner: Additional Funding’.
179 Minute MOJ [junior official] to Prentice, 18 October 2007, ‘Overseas Military Inquests: October Written Ministerial Statement’.
180 Minute MOJ [junior official] to Prentice, 18 October 2007, ‘Overseas Military Inquests: October Written Ministerial Statement’.
181 Letter Harman to Johnson, 6 November 2006, ‘Oxfordshire Iraq related Inquests’.
182 Briefing MOD, [undated], ‘Meeting with David Johnson, Deputy Chief of Mission US Embassy London (16 November 2006)’.

 

16.3 | Military fatalities and the bereaved
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“inadmissible”, as he would not have the opportunity to question those who had provided witness statements.

289. Ms Harman wrote to Mr Johnson again on 6 November, to advise him that difficulties in securing US co‑operation remained.183 It appeared that US Service Personnel did not regard themselves as being required to attend inquests, despite being requested to do so. Mr Walker had told her that the inquest into the death of Mr Lloyd would have benefited considerably from the presence of US witnesses who could be questioned by him and the next of kin. Reading out the witnesses’ statements (with the names of the witnesses redacted) “was no substitute”.

290. Ms Harman reassured Mr Johnson that an inquest was not a criminal trial, and there was no reason for US Service Personnel not to attend. She suggested that they should meet to discuss the issue.

291. Ms Harman met Mr Johnson on 20 November.184

292. In advance of the meeting, Ms Harman asked for advice on a number of issues including how the UK would respond to a request for UK Service Personnel to attend
a US inquest (or equivalent).185

293. The MOD advised that there was:
“… no formal process … to facilitate such attendance. Attendance would have to be assessed on a case‑by‑case basis and the MOD would have to carefully consider the rights of the individual under different legal/constitutional systems”.186

294. At the meeting, Mr Johnson said that the US had provided redacted copies of US reports into incidents for a number of inquests; he was disappointed that Mr Walker had “rejected” that material.187 Ms Harman suggested that the key issue was the ability of the coroner and families to question the material. Mr Johnson asked whether individuals who had been closely involved with the investigation of an incident could attend the inquest, instead of individuals who had been involved in it. Ms Harman agreed that that option should be explored, but said that it was for the coroner to decide who should give evidence.

295. Mr Johnson asked if UK Service Personnel were obliged to attend US or other inquests and inquiries; Ms Harman said that she had discussed that point with Mr Hoon,

 

Footnotes

183 Letter Harman to Johnson, 6 November 2006, ‘Oxfordshire Iraq related Inquests’.
184 Email Tierney to English, 21 November 2006, ‘Note of Meeting between Harriet Harman and David Johnson’.
185 Email Tierney to English, 14 November 2006, ‘Meeting with US Embassy Deputy Chief of Mission’.
186 Briefing MOD, [undated], ‘Meeting with David Johnson, Deputy Chief of Mission US Embassy London (16 November 2006)’.
187 Email Tierney to English, 21 November 2006, ‘Note of Meeting between Harriet Harman and David Johnson’.

 

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who thought that “they should”. Mr Johnson also raised concerns about creating a
precedent for similar processes in other countries.

296. An FCO official who attended the meeting reported that the US appeared to have
two concerns:

• the material that they might be required to provide; and

• the risk that attendance at inquests by US Service Personnel might expose
those individuals to civil action in the UK.188

297. In the following weeks, DCA and FCO officials provided advice to the US
Embassy on the inquest process189 and the extent of extra‑territorial jurisdiction under
English law.190

298. The FCO’s advice on extra‑territorial jurisdiction was that:

• English criminal law was essentially territorial. There was no jurisdiction in
English law to prosecute a foreign national for homicide committed overseas.

• If there was no extra‑territorial jurisdiction, there was no question of any charges
being issued against US Service Personnel.

• There were a group of “international” offences for which the UK had taken
universal jurisdiction, including most relevantly “grave breaches” of the Geneva
Conventions committed anywhere by persons of any nationality. It was, however,
“hard to imagine circumstances in which a ‘friendly fire’ incident would amount
to a grave breach” of the Convention.

299. Ms Harman met Mr Johnson again on 6 December.191 Ms Harman suggested that
the meeting should focus on the inquest into the death of L Cpl Hull.

300. Ms Harman said that she had spoken to Mr Walker, the coroner responsible for
that inquest. He would like US witnesses to the incident to attend the inquest; however,
he could accept “as a minimum”:

• an unredacted copy of the US report on the incident: the US and UK reports
differed, and the US report had “large sections, even whole pages” redacted;
and

• a US representative to speak to and explain the contents of the report.

301. An MOD official added that “in a reverse situation the UK would consider what
we could offer in terms of best evidence”.

 

Footnotes

188 Email FCO [junior official] to MOD [junior official], 20 November 2006, ‘Iraq Coroners Inquests’.
189 Email DCA [junior official] to US Embassy [junior official], 30 November 2006, ‘Questions from the US Embassy about Inquests’.
190 Email Adams to US Embassy [junior official], 1 December 2006, ‘Questions from US Embassy about inquests’.
191 Minute Burden to Harman, 11 December 2006, ‘Update Meeting between Harriet Harman and David Johnson on US Attendance at UK Inquests into Deaths in Iraq’.

 

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302. Mr Johnson advised that the US Government had concluded that it would not be possible for US witnesses to an incident to participate in the inquest. It was now considering whether it could provide someone who could speak authoritatively to a US report.

303. On 1 February 2007, Mr Walker stated that he wished to play in open court a video‑recording taken by one of the A‑10 aircraft showing the attack on L Cpl Hull’s convoy.192 That recording had been provided to the MOD by the US for use in the BOI into the incident, and had subsequently been shown to the coroner by the MOD on the mistaken premise that it was UK‑owned material.

304. The following day, the MOD sought and received an adjournment to the inquest
to allow time to consult the US on disclosure of the recording.

305. These events attracted a great deal of media attention, focusing on:

• claims that the family of L Cpl Hull had previously been informed by the MOD that no video‑recording of the incident existed;

• the MOD’s decision to seek an adjournment, thus delaying the inquest; and

• the US Government’s position that US witnesses to an incident should not participate in any subsequent UK inquest.

306. On 4 February, The Observer newspaper quoted Ms Harman’s view: “My letters haven’t proved successful, phone calls haven’t proved successful, requests from the coroners haven’t. It’s just not fair on the relatives to sit in on an inquest and to know that they can’t ask questions. They’re entitled to know the truth from our allies.”193

307. The recording was leaked to the press on 6 February.194

308. Later that day, the US told the Government that the recording could be viewed
by the coroner, an MOD representative and L Cpl Hull’s family only.195

309. On 19 February, prompted by concerns arising from the MOD’s support for the inquest into L Cpl Hull’s death, Mr Ingram sought advice on whether the MOD should adopt a fundamentally different BOI process. This is described earlier in this Section.

 

Footnotes
192 Minute Ferguson to APS/Min(AF), 2 February 2007, ‘Oxfordshire Inquests: Release of US Classified Information’.
193 The Observer, 4 February 2007, Why won’t the US tell us how Matty died?
194 The Guardian, 6 February 2007, US allows ‘friendly fire’ tape in court.
195 Minute DCA [junior official] to Tierney, 21 February 2007, ‘Note of meeting with David Johnson (Deputy Chief of Mission, US Embassy)’.

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310. Ms Harman met Mr Johnson for a third time on 21 February.196 A DCA official
recalled Mr Walker’s requests for an unredacted copy of the US report on the attack on
L Cpl Hull’s convoy and for a US representative to speak to the report. Ms Harman said:
“… although it is difficult for the US to do what the coroner is asking, it is worse for
the US not to … providing no document and no representative at the inquest would
be unacceptable.”

311. Mr Johnson advised that the US Government was still considering these requests;
discussions between the US and UK military would take place later that week.

312. Mr Bill Jeffrey and Mr Gordon England, the US Deputy Defense Secretary,
discussed the issue two days later.197 Mr England advised that, while the US aimed to be
as co‑operative as possible:

• They could not provide an unredacted version of the US report to Mr Walker,
could not agree that he should contact the A‑10 pilots directly, and could not
provide an official to answer questions on the training of A‑10 pilots.

• They could not agree to the in principle release of classified US information
to coroners in future cases.

• They could not agree to provide “third‑party US officials” to attend inquests.

313. Mr Jeffrey asked Mr England to reconsider the provision of third‑party US officials;
Mr England agreed that he would.

314. On 16 March, Mr Walker ruled that L Cpl Hull was unlawfully killed.198 The press
reported that Mr Walker was critical of the failure of the US authorities to co‑operate with
the inquest.

Legal representation at inquests

315. The Government’s position at the beginning of Op TELIC was that legal aid
was not normally necessary at inquests as the inquest procedure was designed to
be inquisitorial and non‑adversarial.199 Legal aid could be provided in exceptional
circumstances by the Lord Chancellor, provided that the Legal Services Commission
(LSC) recommended it. Such exceptional circumstances might relate to a wider public
interest in the applicant being legally represented, or to a need for the applicant to be
legally represented to enable the coroner to carry out an effective investigation.

 

Footnotes

196 Minute DCA [junior official] to Tierney, 21 February 2007, ‘Note of meeting with David Johnson (Deputy Chief of Mission, US Embassy)’.
197 Minute PS/PUS [MOD] to Policy Director, 23 February 2007, ‘Coroners’ Inquests – PUS Phonecall with Gordon England: 23 February 2007’.
198 Daily Telegraph, 17 March 2007, Killing of British soldier by US pilot criminal.
199 Standard Note, 28 January 2010, Legal aid for representation at Inquests.

 

16.3 | Military fatalities and the bereaved
131

316. Legal Help might be available (subject to a means test) to provide legal advice
and assistance before an inquest.

317. The Deepcut Review into the circumstances surrounding the deaths of four soldiers at the Princess Royal Barracks, Deepcut between 1995 and 2002, led by Mr Nicholas Blake, reported in March 2006.200 He concluded that the participation of the family of the deceased in an inquest was desirable, and that their participation was assisted by “having experienced legal professionals to advise them whether there are reasons for concern, and how they can be properly addressed”. He also concluded that, in some circumstances, it was “invidious for the Army to be legally represented at such an inquest at public expense whilst the family is not”.

318. Mr Blake recommended: “As part of the military covenant with the soldier, the MOD should ensure that the family of a deceased soldier have access to legal advice and, where appropriate, legal representation prior to, and during, the inquest or FAI [Fatal Accidents Inquiry].”

319. The Government’s formal response to the Deepcut Review was issued in June, and stated: “An inquest is an inquisitorial, non‑adversarial fact finding process of limited scope which does not make findings of civil or criminal liability. It is the general presumption that legal representation is not necessary, and it is quite appropriate for those deemed interested persons by the Coroner to ask questions of witnesses at an inquest without legal assistance. Government provision of legal aid … is not therefore normally available … However, under the Access to Justice Act 1999 allocation may be made to the Legal Services Commission for exceptional funding.”201

320. Ms Harman met relatives of Service Personnel killed in Iraq on 4 December, to discuss their experience of the investigation and inquest process.202 The formal record
of the meeting reported that families “would like to be informed of their right to have legal representation [at an inquest], and that the Government should provide funding for legal representation where families could not afford it”.

321. Ms Harman wrote to Mr Browne later that month summarising the conclusions
of the meeting; her letter did not address the issue of legal representation.203

 

Footnotes

200 Nicholas Blake QC, A Review of the circumstances surrounding the deaths of four soldiers at Princess Royal Barracks, Deepcut, between 1995 and 2002, HC795, 29 March 2006, paragraph 12.110 and recommendation 31.
201 Ministry of Defence, The Government’s Response to the Deepcut Review, Cm 6851, June 2006.
202 Report Opinion Leader, January 2007, ‘DCA meeting with families of military personnel who lost their lives in Iraq’.
203 Letter Harman to Browne, 18 December 2006, ‘Proposals arising from meeting with relatives of service personnel on their experience of the inquest system’.

 

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132

322. On 13 December, during Prime Minister’s Questions, Mr Roger Gale asked
Mr Blair: “When inquests are held into the deaths of Service Personnel whose bodies are
returned to the UK, the Government are represented by the Treasury Solicitor, who
has access to effectively unlimited taxpayers’ funds for QCs, witnesses and support
investigations. In contrast, families of the bereaved attending the same inquest have
to pay out of their own pockets. Is it right that the dice should be loaded against the
bereaved?”204

323. Mr Blair replied that Ms Harman was looking at the arrangements for inquests,
adding that “it is of course important to make sure that bereaved families are given every
possible facility”.205

324. Mr Gale continued to press the Government to provide funding routinely for legal
representation for bereaved families at inquests into the deaths of Service Personnel.

325. On 17 January 2007, a DCA official advised Ms Vera Baird, Parliamentary Under
Secretary of State for the DCA, that Ms Harman had received representations on the
issue during a consultation meeting on the draft Coroners Bill and at her 4 December
meeting with the families of Service Personnel who had died in Iraq.206 Ms Harman
was concerned that there was a “real or perceived inequality” when a public authority
was legally represented at an inquest but the family of the deceased was not. She
had therefore asked officials to explore options for providing (non‑legal aid) funding for
families at inquests where public authorities had legal representatives. That work was
still at a very early stage.

326. A DCA official detailed Ms Harman’s position and that work on 22 February:
“Harriet [Ms Harman] was clear that it is of fundamental importance that there should
be equality of arms between the families and MOD and something needs to be done
to achieve this urgently … Her view is that if it is not possible for families to be given
legal support over and above the legal aid provisions then she would propose that
equality of arms is met by there being no MOD lawyers present at the inquests in
which they have an interest.”207

327. Work was under way to:

• develop a consultation paper to seek views on how representation for families
could be paid for outside of the legal aid system, in cases when a public

 

Footnotes

204 House of Commons, Official Report, 13 December 2006, column 872.
205 House of Commons, Official Report, 13 December 2006, column 872.
206 Minute DCA [junior official] to Baird, 17 January 2007, ‘Advice and draft reply to Roger Gale MO – funding for representation at Inquests’.
207 Minute DCA [junior official] to Falconer, 22 February 2007, ‘Legal Funding of Military Inquests: Correspondence from Roger Gale MP’.

 

16.3 | Military fatalities and the bereaved
133

authority was represented; the favoured option was a surcharge on those authorities; and

• conduct a study to establish fair and effective ways of ensuring that families routinely had official material disclosed to them before an inquest; that should improve the opportunity for families to participate in inquests on equal terms.

328. On 27 February, the All Party Parliamentary Group on Army Deaths held a seminar focusing on the issue of legal representation for families, which Ms Harman attended.208

329. On 9 March, a DCA official advised Ms Harman that:

• the MOD had had legal representation at eight of the 45 inquests (into 63 deaths in Iraq and Afghanistan) that had been completed;

• at five of those eight inquests, the family had also had legal representation; and

• at three other inquests the family had had legal representation and the MOD had not.209

330. The official advised that the DCA had been able to confirm only two cases where families had received legal aid for an inquest relating to Iraq (at a total cost of some £38,000).

331. The official recalled the Government’s response to the Deepcut Review and commented: “If the MOD maintain the line that inquests are not adversarial … so that families do not need to be represented, this begs the question as to why MOD needs to
be represented.”

332. Ms Harman wrote to Mr Browne on 14 March: “I am becoming increasingly concerned about the lack of legal representation for families at inquests where the military are represented.210…
“One solution to the problem might be for neither the military nor the family to be legally represented. Alternatively, funding should be provided to families for representation in those cases where the MOD is represented. I would look to your Department to fund this…
“I would welcome an early meeting to discuss this.”

333. Ms Harman concluded with the handwritten comment: “I know you share my concern on this.”

 

Footnotes

208 Email Robins to Burton, 27 February 2007, ‘Seminar on Army deaths’.
209 Minute DCA [junior official] to Falconer, 9 March 2007, ‘Legal Representation in Military Inquests’.
210 Letter Harman to Browne, 14 March 2007, ‘Legal Representation at Inquests’.

 

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134

334. Ms Harman and Mr Ingram met on 18 April to discuss legal representation at
military inquests.211 Ms Harman said that there were two distinct areas to consider:

• “logistical and moral” support and advice for families; and

• legal advice and representation.

335. Mr Ingram and Ms Harman both stated that their departments did not have the
resources to fund legal representation. They agreed that: “… the increased support for families from the MOD and the increased support for coroners as well as the work on greater disclosure of information would go a long way to providing families with the support they want at inquests.”

336. They also agreed to set out that increased support in a Written Ministerial
Statement.

337. Mr Ingram undertook to ensure that families had an MOD representative with them
at the inquest “to provide explanations and support”.

338. Mr Ingram made a Written Ministerial Statement on 7 June on improved support
to bereaved families.212 The Statement did not cover legal representation for bereaved
families at inquests.

339. The Royal British Legion’s “Honour the Covenant” campaign, which was launched
in September 2007, highlighted the distress caused to families by delays to and the lack
of legal representation during inquests, and called for legal advice, representation and
advocacy to be provided to all families at public expense.213

340. Ms Joan Humble, chair of the All Party Parliamentary Group on Army Deaths,
wrote to Ms Prentice on 14 December seeking advice on how the Group could best
engage with Government discussions on the reform of the inquest system and in
particular the issue of legal representation for the families of deceased Service
Personnel.214 Ms Humble stated: “To grieving families it seems a travesty of justice that MOD and Service Personnel should appear in court represented at public expense while they may have been advised they don’t require representation or [are] forced to put their life savings on the line.”

341. Ms Prentice replied on 19 February 2008, recalling the position that legal aid was
not usually available for representation at an inquest because it was a “fact‑finding

 

Footnotes

211 Minute Tierney to DCA [junior official], 19 April 2007, ‘Note of meeting between Harriet Harman and Adam Ingram on legal representation at military Inquests’.
212 House of Commons, Official Report, 7 June 2007, column 26WS.
213 The Royal British Legion, September 2007, Honour the Covenant.
214 Letter Humble to Prentice, 14 December 2007, [untitled].

 

16.3 | Military fatalities and the bereaved
135

process” and not a trial.215 Legal representation could be provided in exceptional circumstances, and the MOJ had not refused any exceptional funding applications
(from the Legal Services Commission) concerning deaths in Iraq or Afghanistan.

342. Ms Prentice continued: “I would also say that when I met representatives of the War Widows Association recently, they did not feel that legal representation at inquests was necessary, if the families were taken through the inquest process slowly and gently by the coroner.”

343. On 13 March 2008, in response to a further question from Mr Gale, Ms Harman (Leader of the House of Commons) said: “I agree with the hon. Gentleman that if bereaved relatives with no legal representation turn up on the steps of a coroner’s court and find that the Ministry of Defence and the Army have a great battery of solicitors and QCs, they cannot help but feel that the position is unfair. The MOD is very concerned about the issue, which will be considered during debate on the Coroners Bill. We need to give bereaved relatives at inquests a real sense of fairness and support.”216
The Coroners and Justice Act, 2009

344. A January 2009 briefing on the Coroners and Justice Bill advised that it would contain a number of measures to ensure that any future backlogs of inquests could be addressed more easily:

• It would create a new national head of the coronial system, the Chief Coroner, who would be able to reallocate work between coroners and request the Lord Chief Justice to appoint judges to act as coroners in complex cases.
The wishes of the bereaved family would be taken into account in determining the location of the inquest.

• Coroners would have new powers to obtain information to help their investigations. “Rigid restrictions” on where inquests and post‑mortems could be held would be relaxed and the power to transfer cases to prevent delays would be enhanced.217

345. The Bill would also give the Lord Chancellor powers to issue statutory guidance on how the coroners’ system should operate, in particular with respect to bereaved families.

346. The Coroners and Justice Bill was introduced to Parliament on 14 January 2009.218 It did not contain any reference to public funding for legal representation at inquests.

 

Footnotes

215 Letter Prentice to Humble, 19 February 2008, ‘All Party Group on Army Deaths’.
216 House of Commons, Official Report, 13 March 2008, column 421.
217 Briefing, 28 January 2009, ‘Coroners and Justice Bill: Military inquests briefing 28 January 2009’.
218 Coroners and Justice Act 2009 c.25 Explanatory Notes, paragraph 820.

 

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136

347. On 21 October 2009, during a debate on the Bill in the House of Lords,
Lord Thomas of Gresford moved an amendment which would have the effect of bringing
inquests into deaths in State custody or while on active military service within the scope
of legal aid.219

348. Lord Bach, Parliamentary Under Secretary of State for the MOJ, agreed to
consider that amendment, adding: “Obviously I cannot give any guarantees that I will be able to bring forward a suitable amendment … but I shall certainly do my best.”220

349. An MOJ official provided advice to Lord Bach on 23 October on the form and cost
of such an amendment.221 The official identified a number of risks, including:

• The MOD was trying to reduce how often it chose to be legally represented at
inquests “to tackle the perception that they have the advantage over families”.
If bringing military inquests into the scope of the legal aid scheme meant
that most families had legal representation, then the MOD would also want
representation. The MOD had chosen to be represented at “only” 45 percent
of inquests in 2008.

• Bringing military inquests into the scope of the legal aid scheme meant that
decisions on whether to provide legal aid would be made by the Legal Services
Commission (LSC) without reference to Ministers. That might lead to military
inquests being refused legal aid, particularly where the LSC did not waive the
financial eligibility limits. The official recalled that all 17 of the applications for
exceptional funding in relation to military inquests which had so far been made
by the LSC had been granted by the MOJ.

350. When the Bill reached its Third Reading in the House of Lords on 5 November,
the Government tabled an amendment which made specific provision for legal
representation at an inquest into the death of British Service Personnel on active service
to be publicly funded.222 A means test applied.

351. The Bill became the Coroners and Justice Act in November 2009, with the
amendment included as Section 51. That Section was not brought into force
immediately.

352. Section 51 was repealed by the Legal Aid, Sentencing and Punishment of
Offenders Act 2012.223 The MOJ’s consultation paper for that Act, which was published

 

Footnotes

219 House of Lords, Official Report, 21 October 2009, column 746.
220 House of Lords, Official Report, 21 October 2009, column 749.
221 Minute MOJ [junior official] to Bach, 23 October 2009, ‘Legal Aid – Coroners and Justice Bill – Extending Legal Aid to Death in Custody and Military Personnel Inquests’.
222 Coroners and Justice Act 2009 c.25 Section 51 and Explanatory Notes, paragraphs 326 and 820.
223 Standard Note, 10 March 2014, ‘Legal aid for representation at Inquests’.

 

16.3 | Military fatalities and the bereaved
137

in November 2010, proposed that as inquests were non‑adversarial in nature, legal aid could not be justified.

353. Following the 2010 UK general election, the incoming Government first announced that the Office of the Chief Coroner would be abolished, because of the costs involved, and then proposed to leave the Office on the statute book but to transfer some (but not all) of the functions to other posts and institutions.224

354. In November 2011, following criticism in Parliament and from concerned organisations, the Government announced that it would establish the Office of the Chief Coroner.

355. The first post‑holder, His Honour Judge Peter Thornton, took up the post in September 2012.225

Fatal Accident Inquiries in Scotland

356. The Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 provided for the Lord Advocate to instruct a procurator fiscal to investigate a death if it appeared to the Lord Advocate that an investigation would be in the public interest. This contrasted with the position in England and Wales, where coroners had a statutory duty, under the 1988 Coroners Act, to investigate deaths which were reported to them when the body was lying in their district and there was reason to believe that the death was violent or unnatural, or was a sudden death of unknown cause, or in some other circumstances.226 That duty applied “whether the cause of death arose in his district or not”.

357. On 2 April 2003, two weeks after the start of military operations against Iraq, a Home Office official wrote to Mr Nicholas Gardiner, the Oxfordshire Coroner, proposing guidelines for transferring cases to other coroners: “An aspect of this we had not yet addressed is the handling of fatalities where they are to be transferred to Scotland or Northern Ireland. I have had a brief word with my Northern Ireland and Scottish counterparts. In neither territory would there normally be inquests or other inquiries into deaths abroad. It would therefore seem inevitable for you to accept jurisdiction for inquests in such cases …”227

358. Mr Gardiner agreed with that assessment.228

359. There are no indications that the issue was considered again until 2006.

 

 

Footnotes
224 House of Commons Library Standard Note, 24 November 2011, ‘The Office of the Chief Coroner’.
225 Report of the Chief Coroner to the Lord Chancellor, 2014, First Annual Report: 2013‑2014.
226 Coroners Act 1988. The Act was replaced by the Coroners and Justice Act 2009.
227 Letter Home Office [junior official] to Gardiner, 2 April 2003, ‘Section 14 and War Deaths’.
228 Letter Gardiner to Home Office [junior official], 4 April 2003, ‘Section 14 etc’.

 

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360. The Deepcut Review into the circumstances surrounding the deaths of four
soldiers at the Princess Royal Barracks, Deepcut reported in March 2006.229 The Review
recommended: “There should always be an inquest, or, in Scotland, a Fatal Accidents
Inquiry, into a sudden death of a solider, wherever the death has occurred.”

361. The Government’s formal response to the Review, which issued in June, stated that
discussions were continuing between the MOD and the DCA, with a view to responding
to the recommendation in the context of the Coroners Bill.230 Responsibility for legislation on inquiries into deaths in Scotland was delegated to the Scottish administration; any proposals would therefore need to be discussed with the Scottish Executive.

362. On 4 December, Ms Harman met relatives of Service Personnel killed in Iraq, to
discuss their experience of the investigation and inquest process.231 The record of the
meeting reported that there was consensus that inquests should be held “more locally,
including in Scotland”.

363. Ms Harman wrote to Mr Browne later that month summarising the conclusions
of the meeting, including: “There is a particular issue about Scottish fatalities which are repatriated to England  and Wales … unless there is an inquest in England there will be no inquiry at all in Scotland. It was suggested [at the meeting] that until such time as the Scottish Executive’s position changes, a coroner in the north of England might be able to
take on inquests for Scottish families, and my officials are looking into this possibility.
I am also going to discuss with the Scottish Executive the issue of extending the
scope of the Fatal Accident Inquiry to cover Service deaths abroad.”232

364. In April 2007, Ms Harman met Mr Ingram to discuss legal representation for
families at inquests.233 Mr Ingram asked whether there was scope to transfer the inquest
into the loss of Nimrod XV230 to Scotland. Ms Harman said that she had discussed the
issue with the Scottish Lord Advocate and relevant Scottish Executive Minister, who
had both confirmed that there was no scope in Scotland for an inquest or Fatal Accident
Inquiry (FAI) into the incident.

365. Nimrod XV230 had crashed in Afghanistan on 2 September 2006, with the loss of
14 crew.234 The aircraft was based at RAF Kinloss in Scotland.

 

 

Footnotes
229 Nicholas Blake QC, A Review of the circumstances surrounding the deaths of four soldiers at Princess Royal Barracks, Deepcut, between 1995 and 2002, HC795, 29 March 2006.
230 Ministry of Defence, The Government’s Response to the Deepcut Review, Cm 6851, June 2006.
231 Report Opinion Leader, January 2007, ‘DCA meeting with families of military personnel who lost their lives in Iraq’.
232 Letter Harman to Browne, 18 December 2006, ‘Proposals arising from meeting with relatives of service personnel on their experience of the inquest system’.
233 Minute Tierney to DCA [junior official], 19 April 2007, ‘Note of meeting between Harriet Harman and Adam Ingram on legal representation at military inquests’.
234 GOV.UK, 3 September 2006, Fourteen personnel in Afghanistan Nimrod crash named.

 

16.3 | Military fatalities and the bereaved
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366. During Defence Questions in the House of Commons on 14 May 2007, Mr Angus Robertson asked: “Will the Ministry of Defence work with the incoming Scottish Executive to ensure that inquiries [into the deaths of Service Personnel] can take place under Scots law? After all, that would help to reduce the backlog and to ease the inconvenience to
the families.”235

367. Mr Ingram replied: “The answer to that is yes … My understanding is that there would need to be a change to primary legislation. We need to look into that, but if there is a will to change in Scotland, let us hear the propositions.”236

368. Mr Ingram subsequently discussed with MOD officials how he could respond
to Mr Robertson’s call.237

369. On 2 June, Mr Ingram wrote to Mr Kenny MacAskill, Cabinet Secretary for Justice at the Scottish Executive, to open a discussion on the issue: “Ensuring that they [inquests] are conducted in a family‑friendly manner remains a priority for us and, where practical, we are allocating them to ‘home’ coroners in England and Wales. We share your concern that it has not been possible to hold them in Scotland.
“The fact that we have, so far, repatriated the bodies of Scottish Service Personnel to England ensures that there can be an inquest, albeit under the Coroner’s Court arrangements for England and Wales.
“We would favour moving towards a position where, if appropriate, Inquiries into
the deaths of Service Personnel can take place in Scotland. We would be happy
to work with you to achieve this. However, we believe it will require a change of law in Scotland …”238

370. Ms Prentice wrote to Mr MacAskill on 25 October, asking if there had been any developments since Mr Ingram’s letter.239 In the absence of an appropriate process in Scotland, the bodies of Scottish Service Personnel were repatriated to England “to ensure that there can be an inquest”. This meant that families had to travel considerable distances from their homes in Scotland to attend inquests.

 

 

Footnotes
235 House of Commons, Official Report, 14 May 2007, column 382.
236 House of Commons, Official Report, 14 May 2007, column 382.
237 Minute Baker to PS/Minister(AF) [MOD], 22 May 2007, ‘Fatal Accident Inquiries for Service Deaths Overseas’.
238 Letter Ingram to MacAskill, 2 June 2007, [untitled].
239 Letter Prentice to MacAskill, 25 October 2007, ‘Inquests of Scottish Service Personnel’.

 

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371. Officials from the MOD, MOJ and Scottish Executive met on 14 December to
consider the possibility of transferring responsibility for inquiries into the deaths of
“Scottish‑based” Service Personnel who were killed overseas from the coroners’ service
to the Crown Office and Procurator Fiscal Service (COPFS),240 “with a view to FAIs being
held rather than coroners’ inquests”.241 The meeting concluded that:

• The way forward might be an order under Section 30 of the Scotland Act
1998.242 That possibility would be explored by the Scottish Government Legal
Directorate and the Office of the Solicitor to the Advocate General (OSAG).

• There did not appear to be any “fundamental obstacles” to the proposed
transfer.

• The discretionary nature of the FAI system would need to be addressed.

372. On 27 March 2008, in response to a letter from Mr MacAskill, Mr Browne wrote:
“Addressing these issues is … a matter for Scottish Ministers. The answer is for
you to make a commitment to amend Scots law in a way that can guarantee that
Scottish‑based Service families can be assured of mandatory inquiries into overseas
operational deaths. If that were to happen then it would be entirely appropriate to
repatriate deceased Service Personnel to Scottish bases once the law has been
changed. You will understand, however, that I cannot contemplate changes without
your commitment to mandatory investigations.”243

373. Mr Browne’s letter was copied to all Members of the Scottish Parliament, in order
to inform the debate on the planned review of FAIs which would be held in the Scottish
Parliament later that day.

374. The issue of enabling inquiries to be held in Scotland into the deaths of Service
Personnel normally domiciled in Scotland featured heavily in the debate.244

375. Closing the debate, Mr MacAskill stated that an amendment to the Scotland Act
1998 would be necessary before Scotland could act: “If Des Browne agrees to the making of a section 30 order, we can begin to make progress; without a section 30 order, it would be ultra vires for us to proceed – the Parliament simply could not take such action.”

 

 

Footnotes
240 The Crown Office and Procurator Fiscal Service is Scotland’s prosecution service.
241 Report, [undated], ‘Note of meeting to discuss possibility of Fatal Accident Inquiries into deaths of Scottish‑based Service personnel in St Andrews House, 14 December 2007’.
242 Orders made under Section 30(2) of the Scotland Act 1998 allow for modifications to be made to Schedule 5 to the Scotland Act, which lists those matters that are reserved to the UK Parliament, and as such defines the competence of the Scottish Parliament. The order-making power allows the Scottish Parliament’s legislative competence to be altered by removing or updating existing reservations, or by adding new ones.
243 Letter Browne to MacAskill, 27 March 2008, [untitled].
244 Scottish Parliament, Official Report, 27 March 2008.

 

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376. The following day, an MOJ official advised Ms Prentice that the 14 December 2007 meeting of officials, and subsequent exchanges, had identified “no simple solution”.245 There were plans for officials to meet again.

377. On 4 November, Mr Bob Ainsworth, successor to Mr Ingram as Minister of State for the Armed Forces, informed the House of Commons that: “No reply [to Mr Browne’s letter of 27 March] has yet been received from the Scottish Executive.”246

378. That exchange prompted Mr Ainsworth to ask MOD officials how momentum could be regained on the FAI issue.247

379. An official advised Mr Ainsworth on 11 November that the Scottish Executive had given “considerable thought” to how inquiries could be held in Scotland without changing the devolution settlement, but Scottish Ministers did not appear to have come to a conclusion. The official was not sure that work was now being actively pursued. It was not satisfactory to let the issue drift.

380. Mr Ainsworth wrote to Ms Prentice the following day, proposing that Ministers and officials should meet to consider the way forward.248 A copy of the letter was sent to Ms Ann McKechin, Parliamentary Under Secretary of State at the Scotland Office.

381. Mr MacAskill replied to Mr Browne’s letter of 27 March on 19 November.249

382. After a further exchange in January 2009, Mr Ainsworth wrote to Mr MacAskill on 29 January stating that “we do indeed have the basis for a way ahead”.250 That was to use the Coroners and Justice Bill to amend the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, so that the Chief Coroner (a new post that would be created by the Coroners and Justice Bill) could request the Lord Advocate to hold an FAI into
a particular death.251

383. Section 12 of the Coroners and Justice Act provided for the Secretary of State or the Chief Coroner to notify the Lord Advocate that a death should be investigated under the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976.252

 

 

Footnotes
245 Minute MOJ [junior official] to Prentice, 28 March 2008, ‘Coroners Service in Oxfordshire’.
246 House of Commons, Official Report, 4 November 2008, column 294W.
247 Minute MOD [junior official] to PS/Minister(AF) [MOD], 11 November 2008, ‘Fatal Accident Inquiries in Scotland’.
248 Letter Ainsworth to Prentice, 12 November 2008, ‘Inquiries into the Deaths of Scottish‑based Service Personnel’.
249 House of Commons, Official Report, 3 February 2009, column 1111W.
250 Letter Ainsworth to MacAskill, 29 January 2009, [untitled].
251 Minute Scotland Office [junior official] to Parliamentary Under Secretary of State [Scotland Office], 28 January 2009, ‘Fatal Accident Inquiries and overseas Service deaths’.
252 Coroners and Justice Act 2009, Section 12(4) and (5).

 

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384. The Act also amended the Fatal Accidents and Sudden Deaths Inquiry (Scotland)
Act 1976, to provide for the Lord Advocate to investigate when such a notification had
been received.253

Honouring the dead
Repatriation ceremonies

385. The MOD’s policy on the repatriation of the dead was set out in a paper produced
by Lt Gen Palmer on 14 March 2003: “Repatriation to UK of the dead is to take place wherever possible and as soon as practicable.”254

386. Before Op TELIC, repatriations were conducted with very little or no formal
ceremony.255

387. The MOD put in place a unique arrangement for the repatriation of Service
Personnel who died during Op TELIC, known as Operation KEIR. The repatriation
ceremony under Op KEIR was designed to “demonstrate the highest level of respect”,
and included attendance by members of the Royal Family (or their representatives) and
Ministers, military pall‑bearers and a military band.

388. In his autobiography, General Sir Mike Jackson described attending a repatriation
ceremony in his capacity as Chief of the General Staff: “We gathered before the aircraft landed, and were seated on the edge of the apron outside the terminal building to watch the C‑17 aircraft land and taxi into position, coming to a rest with the nose of the aircraft facing diagonally away from the mourners. Then the ramp was lowered. A bearer party of six soldiers in parade dress advanced and marched up the ramp to take the first coffin. As they came into view down the ramp carrying the coffin, a band began playing and everyone stood. We all saluted as the bearers marched past in slow time, carrying the coffin to the waiting hearse. This simple, but profoundly moving, ceremony was repeated for each coffin on board the aircraft.”256

389. Lt Gen Mans told the Inquiry that a repatriation ceremony could “help the bereaved
family to start closure on the whole process of losing a loved one”.257

 

 

Footnotes
253 Coroners and Justice Act 2009, Section 50.
254 Paper Palmer, 14 March 2003, ‘UK Forces: Repatriation of the Dead’.
255 Minute DDSP Pol O&M to PSO/CDS, 17 March 2004, ‘Policy for Repatriation of Deceased Personnel from Overseas’.
256 Jackson M. Soldier: The autobiography of General Sir Mike Jackson, Bantam Press, 2007.
257 Public hearing, 19 July 2010, page 63.

 

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390. In February 2004, Mr Ingram agreed that, following the end of major combat operations in Iraq, the MOD should “rationalise” the repatriation process.258 The MOD would adopt three levels of repatriation:

• for non‑battle deaths, where repatriation would mirror the pre‑Op TELIC model;

• for Service Personnel killed in action or who had died of their wounds, where repatriation would include a “degree of ceremony” including military pall‑bearers; and

• for exceptional circumstances where it was appropriate to demonstrate the highest level of respect, where Op KEIR would be used. It would be for Mr Hoon to determine whether to invoke Op KEIR, taking into account factors including the circumstances surrounding the incident.

391. Lt Gen Palmer told the Inquiry that the issue of who should attend a repatriation ceremony quickly became “a big issue”: “Everybody wanted to be there, to show support.
“I think what we realised early on was that this was going to be ongoing. Unfortunately, casualties were going to keep coming. We could not have everybody rushing to [RAF] Brize Norton, as it was then, [RAF] Lyneham, as it is now, every time there was a casualty. So we developed, I think, an extremely good policy, which I think has worked very well, about how repatriations are done.”259

392. Lt Gen Palmer added that, in planning and conducting repatriation ceremonies:
“… with Ministers and everybody in the MOD the absolute key thing was to try to be as responsive and sensitive to the families as we possibly could at this enormously difficult moment for them.”

393. In September 2007, a fourth level of repatriation was added, covering repatriations in the event of a mass fatality incident (defined as between 15 and 35 fatalities).260

394. In April 2009, the MOD amended its policy so that all deaths on operations (including non‑battle deaths) received a formal repatriation ceremony, in the light of the difficulty in drawing a distinction between an individual killed by direct enemy fire and one killed in an accident in direct support of operations, and given public and familial expectations that individuals who died on operations should be honoured.261

 

 

Footnotes
258 Minute DDSP Pol O&M to PSO/CDS, 17 March 2004, ‘Policy for Repatriation of Deceased Personnel from Overseas’.
259 Public hearing, 21 July 2010, page 40.
260 Minute Fancourt to various, 17 September 2007, ‘Policy for Repatriation of Deceased Personnel from Overseas’.
261 Minute DCDS(Pers) to APS/SoS [MOD], 22 April 2009, ‘Policy for Repatriation from Operations’.

 

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ROYAL WOOTTON BASSETT

395. From April 2007, due to essential repair work at RAF Brize Norton, ceremonial
repatriations took place through RAF Lyneham in Wiltshire.

396. Corteges departing RAF Lyneham passed through Wootton Bassett. The Royal
British Legion reported in June 2011 how the town had responded: “The first [repatriation] was acknowledged by a few members of the public which
included members of the Royal British Legion …
“Over the past four years the number of people has increased and where we were
once paying tribute on a more personal basis we have now come to represent the
country.
“The repatriation tributes were never and are still not organised – things just happen,
such as the Church Bell which started when a bell‑ringing practise was taking place
just before the repatriation was due, and as a mark of respect the one bell was tolled
on that occasion….
“When the cortege is about to leave Lyneham, the police alert us here in Wootton
Bassett. The Standard Bearers form an orderly line, spacing themselves at equal
distances down the opposite side of the road to the War memorial … When the
cortege reaches the edge of town the bell‑ringer is notified and the Church Bell
starts to toll and the town falls silent. Shopkeepers close their premises and join
the crowds and there is not a sound to be heard.”262

397. A military parade was held in Wootton Bassett in October 2008 to thank
the town.263

398. In March 2011, Prime Minister David Cameron announced that The Queen had
agreed “to confer the title ‘Royal’ upon the town, as an enduring symbol of the nation’s
admiration and gratitude”.264

Letters of condolence

399. In July 2002, following a meeting with the parents of a deceased Serviceman,
Mr Hoon asked the MOD to consider whether he or the Prime Minister should routinely
write to the next of kin of Service Personnel killed on operations.265

 

 

Footnotes
262 The Royal British Legion website, June 2011.
263 Daily Express, 13 October 2008, Military pays tribute to respectful residents of Wootton Bassett.
264 GOV.UK, 16 March 2011, Prime Minister announces ‘Royal’ Wootton Bassett.
265 Minute McLoughlin to APS/SofS [MOD], 17 September 2002, ‘Letters to next of kin (NOK)’.

 

16.3 | Military fatalities and the bereaved
145

400. Ms Elizabeth McLoughlin, the Director General of Service Personnel Policy, responded in September, having consulted the Chiefs of Staff.266 Existing practice was that, apart from letters written by those serving with the individual who had been killed,
a senior officer would write one letter of condolence “on behalf of both the Sovereign and the Service”. While the Services appreciated the wish to provide additional comfort to the families of personnel killed on operations, they were concerned that:

• It would be very difficult for any letter, unless written locally by the unit commander, to be other than “bland and impersonal”. Experience had shown that it was not helpful for families to receive a large number of official condolence letters based on generic information.

• The Services (and the Chief of Defence Staff in particular) did not want to distinguish, for this purpose, between individuals killed on operations and those who died “as a result of the normal rigours of Service life”. They did not believe that the circumstances of a death made the next of kin any more or less deserving of sympathy.

• There was also a question of whether the next of kin of Reservists and MOD civilians should be included.

• In the event of mass casualties, writing to the next of kin might be difficult.

401. Ms McLoughlin concluded that the existing practice should continue, although the Prime Minister or the Secretary of State might in addition send a personal note in “exceptional cases where it is felt that families would benefit”. That would need to be assessed on a case‑by‑case basis.

402. In late March 2003, No.10 asked the MOD for advice on how Mr Blair should honour UK Service Personnel killed on Op TELIC, and especially whether he should write letters of condolence to the families of Service Personnel killed on operations and whether there should be a ceremony or function to commemorate deceased Service Personnel.267

403. Mr Hoon’s Private Office responded to Mr Blair’s Assistant Private Secretary on 27 March, advising that:

• the current policy (whereby a senior officer wrote a single letter of condolence) remained sound; and

• it would be appropriate for a ceremony to be held after the conflict had concluded.268

 

 

Footnotes
266 Minute McLoughlin to APS/SofS [MOD], 17 September 2002, ‘Letters to next of kin (NOK)’.
267 Minute Gibson to APS/Secretary of State, 27 March 2003, ‘Request from No.10: Letters for the Families of the Bereaved and Memorial Ceremony’.
268 Letter Williams to Cannon, 27 March 2003, ‘Recognition of Armed Forces Personnel who died on Operations’.

 

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404. On 7 April, Mr Blair wrote to a bereaved spouse who had lost her husband
on Op TELIC, to respond to her concerns about the way she was being treated by
the MOD.269

405. On 9 May, in response to a further request for advice from No.10 on whether
Mr Blair should write letters of condolence to the families of Service Personnel killed
on operations, Mr Hoon’s Private Office repeated the advice that the current policy
(whereby a senior officer wrote a single letter of condolence) remained sound.270
Mr Hoon’s Private Office added that the MOD was reviewing its policy on writing letters
of condolence “in the light of the specific circumstances of the operation in Iraq”, but was
unlikely to change it.

406. Mr Hoon’s Private Office advised No.10 on 16 May that the review had concluded
that the MOD’s policy should not change: “… you [No.10] asked if our experience during operations in Iraq had caused us to alter our position … It has not … The Prime Minister wrote in exceptional circumstances and in response to correspondence.”271

407. The MOD looked again at the policy at the end of June, following a meeting
between Mr Blair and General Sir Michael Walker, Chief of the Defence Staff, during
which Mr Blair expressed a personal desire to write.272

408. Lt Gen Palmer advised Mr Hoon on 30 June that, while the Chiefs of Staff
considered that the policy remained sound, given Mr Blair’s desire to write and the fact
that he was already corresponding with some families, their preferred option was that
Mr Blair should write only to the next of kin of “those who die on Op TELIC”.

409. Mr Hoon’s Private Office wrote to No.10 later that day, to confirm that it “could be
appropriate” for Mr Blair to write to the next of kin of those killed on Op TELIC (including
civilians and those killed in circumstances other than in direct action with the enemy).273

410. On 1 August, Mr Matthew Rycroft, Mr Blair’s Private Secretary for Foreign Affairs,
advised Mr Blair that the MOD had, again, reviewed its policy and that Mr Hoon would
now write to the next of kin of individuals who had died “while in an operational area”.274
Mr Rycroft recommended that Mr Blair should now write only to the next of kin of
individuals who had been killed in action.

 

 

Footnotes
269 Letter Blair to [name redacted], 7 April 2003, [untitled].
270 Letter Williams to Cannon, 9 May 2003, ‘Recognition of Armed Forces Personnel who Died on Operations’.
271 Letter Williams to Cannon, 16 May 2003, ‘Recognition of Armed Forces Personnel who Died on Operations’.
272 Minute DCDS(Pers) to PS/SoS [MOD], 30 June 2003, ‘Letters of condolence from Prime Minister to Bereaved Families of Service Personnel’.
273 Letter Williams to Cannon, 30 June 2003, ‘Letters of Condolence from the Prime Minister to Bereaved Families of Service Personnel’.
274 Minute Rycroft to Blair, 1 August 2003, ‘Letters of Condolence to Bereaved Families of Service Personnel’.

 

16.3 | Military fatalities and the bereaved
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411. The policy was reflected in the first Joint Casualty and Compassionate Policy and Procedures (JSP 751), which was published in March 2005.275

Commemoration in Parliament

412. It has become established practice for the Prime Minister and Leader of the Opposition to pay tribute to fallen Service Personnel at the start of Prime Minister’s Questions (PMQs). The Inquiry has considered the origins and evolution of this public commemoration.

413. The first time a Prime Minister offered condolences for the deaths of Service Personnel in Iraq at PMQs was 2 April 2003. On that day, Mr Blair said he was “sure that the whole House will want to pass on its sympathies to the families of British Servicemen who have tragically been killed in the service of their country in the past week. Again, we pay tribute to their courage and dignity and we pass on our condolences and sympathy to their families and their friends.”276

414. The practice was repeated a week later, when Mr Blair offered condolences to the families of all those who had lost their lives in the intervening seven days.277

415. On 25 June, he paid tribute to (but did not name) the Royal Military Police (RMP) officers who had lost their lives and been injured at Majarr al Kabir the previous day.278

416. On 10 September, as Parliament returned from the summer recess, Mr Blair paid tribute to the British Servicemen who had lost their lives during the recess.279

417. On 5 November, Mr Blair paid tribute to Corporal Ian Plank of the Royal Marines who had lost his life the previous week.280 That was the first time a Service person had been mentioned by name. It is not clear why the decision was taken to name Corporal Plank.

418. Over the next two years, Mr Blair regularly paid tribute at the beginning of PMQs
to British Servicemen who had lost their lives, but only from April 2006 did the practice
of naming individuals and their regiments become usual.

419. In June 2007, during his last PMQs, Mr Blair described those tributes as “the saddest of duties”.281

420. The practice was continued by Mr Gordon Brown from July 2007.

 

 

Footnotes
275 Paper MOD, 11 July 2005, ‘JSP 751: Joint Casualty and Compassionate Policy’.
276 House of Commons, Official Report, 2 April 2003, column 908.
277 House of Commons, Official Report, 9 April 2003, column 260.
278 House of Commons, Official Report, 25 June 2003, column 1039.
279 House of Commons, Official Report, 10 September 2003, column 319.
280 House of Commons, Official Report, 5 November 2003, column 788.
281 House of Commons, Official Report, 27 June 2007, column 323.

 

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Memorial services

421. In late March 2003, No.10 asked the MOD for advice on how Mr Blair should
honour UK Service Personnel killed on Op TELIC, including whether there should be
a ceremony or function to commemorate deceased Service Personnel.282

422. The MOD responded to No.10 on 27 March, advising that it would be appropriate
for a ceremony to be held after the conflict concluded.283 The MOD intended that the
ceremony “would give the Prime Minister and the Government the opportunity to honour
the efforts of the Services, and their dead”.284

423. Mr Hoon informed Parliament on 17 July that there would be a “national service
of remembrance and thanksgiving for the campaign in Iraq”.285

424. The service took place on 10 October 2003 at St Paul’s Cathedral.286 The service
was attended by the families of the 51 British Service Personnel who had, at that time,
lost their lives in the campaign. They were joined by members of the Royal Family
including Her Majesty The Queen and His Royal Highness The Duke of Edinburgh,
Government Ministers including Mr Blair, and senior military officers.

425. Baroness Symons, joint FCO/Department of Trade and Industry Minister of State
for International Trade and Investment, wrote to Mr Hoon shortly after the service.287
She had spent her time speaking to bereaved families, and reported from those
conversations that:

• There was a generally positive reaction to how they had been informed of their
loss (although two families had heard through the media), and to the subsequent
support from the VO.

• A number of families felt that they had been “ignored” in the design and conduct
of the service.

• All families appreciated the presence of The Queen and the Royal Family at
the service.

426. Mr Hoon’s Private Office wrote to Mr Rycroft on 14 November advising that
feedback from families had been “overwhelmingly positive”.288 There had been a great

 

 

Footnotes
282 Minute Gibson to APS/Secretary of State [MOD], 27 March 2003, ‘Request from No.10: letters for the families of the bereaved and memorial ceremony’.
283 Letter Williams to Cannon, 27 March 2003, ‘Recognition of Armed Forces personnel who died on operations’.
284 Minute MOD [junior official] to APS/Secretary of State [MOD], 27 March 2003, ‘Request from No.10: Letters for the families of the bereaved and memorial’.
285 House of Commons, Official Report, 17 July 2003, column 72WS.
286 BBC News, 10 October 2003, Service honours Iraq war dead.
287 Letter Symons to Hoon, 13 October 2003, ‘Service for Iraq: Friday October 10, 2003’.
288 Letter Davies to Rycroft, 14 November 2003, ‘Iraq: service of remembrance and reception 10 October – feedback’.

 

16.3 | Military fatalities and the bereaved
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deal of praise for the “obvious effort made by the Royal Family and senior members
of the Government and Armed Forces to speak with as many families as possible”.

Armed Forces Memorial

427. Mr Hoon advised the House of Commons in November 2000: “I have given careful consideration to a number of ways in which the recognition of members of the Armed Forces who give their lives in the service of their country might be enhanced. In the light of discussion, I have concluded that the most appropriate would be the erection in central London of a memorial bearing the names of all those killed on duty and by terrorist attack since the end of the Second World War. In accordance with the long established custom for the erection of memorials, I would expect funds to be raised by public subscription. Further consultation will now take place with ex‑Service organisations and other interested bodies.”289

428. Mr Hoon advised the House of Commons in March 2002 that, following that consultation and research into suitable sites, the Armed Forces Memorial (AFM) would be sited at the National Memorial Arboretum in Staffordshire.290

429. On 30 June 2006, following an assessment by officials that there was a significant risk that fundraising for the Memorial would not reach the total required, Mr Des Browne, the Defence Secretary, directed Mr Jeffrey that the MOD should underwrite the Memorial project “in the sum of £3.3m which represents the balance the AFM Trustees require to fully fund the project”.291

430. In October 2007, the Armed Forces Memorial was formally dedicated in the presence of Her Majesty The Queen at the National Memorial Arboretum in Staffordshire.292

431. Ministers were advised in early 2008 that the total cost of the Memorial was expected to be £7.3m.293 The AFM Trustees had raised £6.7m, including £1.5m from the sale of Trafalgar Coins (announced by Mr Gordon Brown, the Chancellor of the Exchequer, in February 2006), £2.417m from the Millennium Commission (agreed in November 2006), with the balance from public subscriptions. There was no realistic prospect of significant further public contributions. Trustees had therefore asked the MOD to provide £500,000 to complete the project.

 

 

Footnotes
289 House of Commons, Official Report, 10 November 2000, column 413W.
290 House of Commons, Official Report, 20 March 2002, column 311W.
291 Minute Jeffrey to Secretary of State [MOD], 29 June 2006, ‘Armed Forces Memorial’; Minute Secretary of State [MOD] to PUS [MOD], 30 June 2006, ‘Armed Forces Memorial’.
292 Armed Forces Memorial website.
293 Email MOD [junior official] to Hardern, 15 May 2008, ‘SPB interest in AFM’.

 

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432. AM Pocock told the Inquiry that the process of securing funding for the Memorial
illustrated the difficulty of translating intent into action: “Although the political intent was perfectly clear, we were also told there was going to be no public money for it. We were hoping to get some money from the Lottery. We did eventually, after some strong support from newspapers caused the Lottery to change the rules….
“We had the designs, it was in The Queen’s diary to come and open it. We actually
had to let the contract but we didn’t have the money, and it wasn’t from lack of effort
… I remember going round embassies with a begging bowl and all sorts of things,
but the money just wasn’t forthcoming.
“The difficulty we had in getting the guarantee from the department [the MOD] was
immense. We eventually did. We were able to build it.”294

433. Both AM Pocock and VAdm Wilkinson felt that the Memorial provided a strong
focus for remembrance. VAdm Wilkinson told the Inquiry: “The focus for recognition and remembrance that it [the Memorial] has provided and the source of comfort to a number of bereaved families, it really is quite remarkable, perhaps, that, as a nation, we didn’t have one before 2007.”295

434. The Memorial also provides a home for the Basra Memorial Wall. The wall was
originally built in 2006 outside the headquarters of Multi‑National Division (South East) in Basra by members of 37 Armoured Engineer Squadron to commemorate those who died
in or as a result of action in Iraq.296

435. PJHQ advised Mr Browne’s Office in June 2007 that its “current intent” was to
move the Basra Memorial Wall (which comprised a collection of memorial plaques from
the various bases that UK forces had occupied) to the National Memorial Arboretum
when UK forces left Basra.297

436. The Memorial Wall was brought to the UK in April 2009, and was re‑dedicated
in March 2010.298

 

 

Footnotes
294 Public hearing, 19 July 2010, pages 59‑60.
295 Public hearing, 19 July 2010, page 61.
296 British Army website, 11 March 2010, Basra Memorial Wall rededicated in moving service at its new home.
297 Minute Green to APS/Secretary of State [MOD], 29 June 2007, ‘Request from Families of Dead Service Personnel to Visit Basra’.
298 BBC News, 11 March 2010, Service to rededicate Basra Memorial Wall.

 

16.3 | Military fatalities and the bereaved
151

The Elizabeth Cross

437. On 10 June 2008, Mr Browne announced the inauguration of a new award.299

438. The award itself had been proposed by the Chiefs of Staff, who concluded that the time was right to recognise the “families of those personnel who die on operations, or as a result of terrorist action whilst on duty”. Mr Browne confirmed that the recommendation had been welcomed by Ministers and approved by Her Majesty The Queen. Paying tribute to the bravery and courage shown by the families of all serving personnel, he hoped that the new award would “provide a more visible form of recognition from the nation for those who pay the ultimate sacrifice in the name of their country”.

439. VAdm Wilkinson told the Inquiry that there was “unanimity” among the Chiefs of Staff “that it was appropriate to recognise the sacrifice that bereaved families had made”.300 The proposal reflected consultation with serving personnel and with bereaved families, as well as consideration of what other nations do to recognise the sacrifice that Service families make.

440. Mr Ainsworth, Mr Browne’s successor as Defence Secretary, set out further
detail about the award and the circumstances in which it would be given in July 2009.301 He confirmed that The Queen had agreed that the award should be known as the Elizabeth Cross, the first new honour to take the name of a serving monarch since the creation of the George Cross in 1940.

441. It would commemorate the lives of those who had died on operations or as a result of terrorism from 1948 onwards (or from 1945 in the case of service in Palestine), in order to fit with the end of the period in which deaths are officially attributed to service in World War II. He reminded Parliament that “this is not a posthumous medal for the fallen but national recognition for the family for their loss”. The award would consist of the Elizabeth Cross itself – awarded to the named next of kin – and a Memorial Scroll, copies of which could be presented to certain additional members of the deceased’s close family. Both the Cross and the Scroll would be awarded on application, as contact details for the several thousand eligible families were unlikely to be up to date.

442. The first presentation of the Elizabeth Cross, made by The Queen, took place in Catterick Garrison, North Yorkshire, on 12 September 2009.302 Those receiving the awards included five families of soldiers killed in Iraq.

443. The Inquiry’s conclusions and lessons on the preparations made for repatriating the bodies of those who lost their lives serving on Operation TELIC, how their deaths were investigated, and the support provided for bereaved families are set out in Section 16.4.

 

 

Footnotes
299 House of Commons, Official Report, 10 June 2008, column 10WS.
300 Public hearing, 19 July 2010, pages 58‑59.
301 House of Commons, Official Report, 1 July 2009, columns 18‑21WS.
302 BBC News, 12 September 2009, Queen honours regiment’s fallen.

About AJ Layon

AJ Layon was, for 28 years, at the University of Florida College of Medicine, in the Division of Critical Care Medicine, in Gainesville, FL. For the past approximately 10 years, until September 2011, he was Professor and Chief of Critical Care Medicine at UF; In September of 2011 he became System Director of Critical Care Medicine in PA. While his interests are primarily related to health care, health care reform, and ethical issues, as a citizen of our United States and our world, he will occasionally opine on issues of our "time and destiny". You are welcome to respond to him at ajlayon@gmail.com.
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