Inquest into the death of Ian Turner

Contributing factors

• combat-related PTSD
• deployment despite known mental health issues
• disciplinary proceedings and rank reduction
• company transfer removing support networks
• inadequate mental health management and coordination
• failure to escalate severe deteriorating mental health
• accumulated psychological stressors
• alcohol abuse as coping mechanism
• domestic violence and relationship breakdown
• access to multiple medications from different prescribers

Coroner's recommendations

1. Introduce systematic process for mapping deployment history, RtAPS/POPS screening data, and psychiatric diagnoses in member health records
2. Mandatory annual training for all Special Forces members in recognising and destigmatising PTSD symptoms and management, including real-life scenario simulations
3. Establish system for family members to communicate psychological distress in home environment to ADF unit with recording and notification mechanisms
4. Provide opportunities for ADF families to be notified of and involved in treatment programs for combat-related PTSD and psychological conditions
5. Require mental health impact be taken into account in deployment, company change, and study/transitional plan decisions
6. Require automatic offer of psychological screening and support during disciplinary proceedings
7. Provide psychological screening and support whilst deployed to members with previous PTSD diagnosis
8. Employ enlisted psychiatrists with specialist military/veterans' psychiatry training and security clearances appropriate to treating members
9. Ensure enlisted and contracted psychologists have security clearances consistent with ADF members being treated
10. Establish systems and culture of transition from Special Forces with adequate support for transition to non-combat roles or civilian employment
11. Undertake evidence-based review of limits on number of combat deployments before mandatory transition to non-combat roles
12. Review policy framework for deployment decisions of PTSD-diagnosed members with clear guidelines on decision-making, appeal processes, roles and responsibilities of personnel, information access, and risk mitigation strategies
13. Where RtAPS/POPS reveals severe PTSD symptoms and permission to advise Chain of Command not forthcoming, promptly notify Chain of Command by simple alert
14. Implement training programs for command role members on PTSD identification and appropriate management
15. Review management of soldiers with mental health conditions in 2CDO regarding best clinical practice, longitudinal management, and single point of coordination for treatment
16. Review role of padre in identification, treatment and management of soldiers with mental health conditions in 2CDO
17. Implement system to formally track ADF member deployment time via leave entitlements, leave taken, and lapsed leave in deployment decisions
18. Undertake study of effects of repeated deployments on member home and family life
19. Conduct research on correlation between domestic violence and PTSD and impact of vicarious trauma on ADF member intimate partners and children
20. Require RtAPS and POPS assessors to consider previous screening results, receive training on combat trauma identification and response, and conduct assessments in environments allowing full participation
21. Provide education regarding subsyndromal PTSD and conduct independent review of health files with policy development
22. Recognise medical discharge for combat PTSD as red flag for unit and trigger suitable interventions
23. Review ADF policies and practices in managing complex psychiatric cases with clarity on support and referral options
24. Amend Army Standing Instruction regarding support to wounded, injured and ill members to include responsibility for providing proceedings details to members unable to attend, referral processes for escalation, inclusion of Director Garrison Operations in quarterly welfare boards, and service coordination
25. Clearly delineate difference between medical clearance and command waiver in all documentation and policies
26. Undertake research on value of transition period between operations and return to domestic environment