Recurring concern

Unreliable access to and navigation of veteran support services

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First reported 5 Jun 2023•Latest report 31 Jan 2025

Definition

What this concern includes

Includes failures in veteran-support arrangements that leave veterans or responsible professionals without clear, accessible routes to appropriate mental-health, addiction, welfare or regimental-support services, including unclear service availability, reliance on unsupported self-referral, inadequate assistance with access and failure to explain how relevant veteran-support organisations relate to one another.

Not included

Excludes generic mental-health or addiction service shortages and waiting times where the veteran-support access or navigation condition is not identified.
Excludes deficiencies in the clinical quality of treatment after a veteran has successfully accessed the appropriate service.
Excludes generic staff training, communication or information deficiencies without an explicit veteran-support access, referral or navigation context.
Excludes failures limited to obtaining military medical records where no broader veteran-support access or navigation problem is asserted.
Excludes unrelated armed-forces welfare, employment, benefits or accommodation concerns unless they directly impair access to the same veteran-support service landscape.

Reports: 3
Individual concerns: 5
Date range: 2023–2025
Stated actions: 14

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Ministry of Defence3

Nottinghamshire Healthcare NHS Foundation Trust1

Office of the Chief Coroner1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

31 Jan2025
West Sussex, Brighton and Hove
Concerns raised1
1. Lack of veteran awareness of regimental welfare staff and their role in the veteran support landscape
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Ensure continued efforts to increase awareness of regimental welfare associations among current and former personnel.
  Stated by Ministry of DefenceStated in progress
AI-generated summary

Aeran Luke Sebastian Taylor · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Aeran Luke Sebastian Taylor, a former Army serviceman diagnosed with PTSD, died at his home in Crawley on 27 October 2023. The inquest found that multiple substances combined to a fatal toxic effect, likely resulting from an accidental overdose. Concerns included the lack of mental-health assessment at discharge, limited awareness of veteran welfare support, and insufficient long-term rehabilitation and substance-abuse recovery services for veterans with PTSD.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of veteran awareness of regimental welfare staff and their role in the veteran support landscape
Wider context from the report
“I heard evidence of a lack of awareness of regimental welfare staff and the role such organisations can play in supporting veterans. Again, those now serving may be more aware but there appears to be a community of veterans at risk who remain unaware, including as to how such organisations fit and work within the overall veteran support landscape. ”
Source location
Aeran Luke Sebastian Taylor · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Ensure continued efforts to increase awareness of regimental welfare associations among current and former personnel.

Verbatim wording from the response
“Raising awareness of the support available will include the promotion of regimental welfare associations, whom I agree have an important role to play. While membership is voluntary, each Regimental or Corps Headquarters in the Army has an Association or equivalent for its serving personnel and veterans. In Mr Taylor’s regiment, the RRF, everyone who has served is entitled to be a member and receive support from the Regimental Charity, The Fusiliers Aid Society (FAS), who I understand did provide Mr Taylor with support. I know that the RRF ensure that all Fusiliers are briefed on joining and discharge on the support available to them. However, I accept that does not mean support and awareness is universal, but I would highlight that Regimental and Corps Headquarters are working to increase awareness of their Associations to current and former personnel. I will ensure that this continues.”

Source location
Response from Ministry of Defence
Page 2 · response
Published 3 February 2025
Open published response
15 Oct2024
Liverpool and the Wirral
Concerns raised1
1. Insufficient resources causing delays in veterans' access to support and treatment
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Paul Anthony CHASE · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Paul Anthony Chase, also known as Paul Anthony Malone, was found deceased hanging in Woolton Woods, Liverpool, on 13 March 2024; the post-mortem examination found the cause of death to be hanging. He had a history of post-traumatic stress disorder and cocaine use, and the inquest concluded that he died by suicide. The report raised concerns about limited mental health, alcoholism and addiction support for veterans, including waits of up to 18 months for some services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient resources causing delays in veterans' access to support and treatment
Wider context from the report
“The lack of mental health/alcoholism/addiction support, treatment and therapy provided to veterans whilst they are: 1. Serving within the armed forces. 2. Undergoing intensive combat training whilstserving within the armed forces. 3. When they are released from the armed forces. The availability of resources appears to be extremely limited with some ex-veterans having to wait 18 months before a place is available. ”
Source location
Paul Anthony CHASE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
5 Jun2023
Derby and Derbyshire
Concerns raised3
1. Lack of understanding of services available for Veterans
2. Lack of understanding by Trust mental health practitioners of appropriate referral services for Veterans
3. Failure to assist Veterans in accessing appropriate services
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 13
1. Action
  Reflect veteran suicide-prevention learning at the annual Trust suicide-prevention conference, with veteran-service information available.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
2. Action
  Disseminate the Veterans and Suicide Prevention Champions Network presentation Trustwide through communications and the intranet.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
3. Action
  Distribute veteran-service leaflets, posters and QR-linked intranet information to mental-health practitioners and Trust services.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
1. Action
  Display veteran-service posters at all inpatient sites.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
2. Action
  Distribute veteran-service posters to all community team bases and conduct follow-up checks.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
3. Action
  Disseminate veteran-service learning through Trust bulletins, governance communications and team meetings.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
4. Action
  Present veteran-service information to the Adult Mental Health Quality and Risk Group.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
5. Action
  Review and plan wider dissemination of veteran information, with emphasis on area-specific training.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
6. Action
  Scope mandatory veteran-status recording, service hyperlinks and referral-support prompts in RiO.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
7. Action
  Share the Veteran folder across Mental Health Services after suitability review.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
8. Action
  Include self-referral support and veteran referral requirements in the updated LMHT Standard Operating Procedure and distribute it to staff.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
9. Action
  Support veterans who need self-referral by completing referrals collaboratively with them or on their behalf.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
10. Action
  Audit practice for supporting self-referral and making veteran referrals on patients’ behalf over three months.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
AI-generated summary

Jonathan “Jonny” Philip Cole [JC] · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jonny Cole was found hanging at Old Stone Bridge, Butterley Park, on 9 August 2018, after having acted with the intention to end his life. He had PTSD, anxiety and suicidal ideation and was under the care of his local mental health trust. The report raised concerns about inadequate identification and management of his suicide risk, gaps in trauma treatment and veteran services, shortcomings in Ministry of Defence mental-health provision and compensation processes, and the robustness of the Trust’s investigation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of understanding of services available for Veterans
Wider context from the report
“5. I have a concern that there is: a) a lack of understanding as to the appropriate services to make referrals to for Veterans by Trust mental health practitioners; b) a lack of understanding as to services available for Veterans; c) too much emphasis on Veterans being solely responsible for self-referral, with no assistance to assist in accessing appropriate services; d) A lack of understanding (or effort) as to how to request and obtain military DCMH medical records. ”
Source location
Jonathan “Jonny” Philip Cole [JC] · Prevention of Future Deaths report
Page 9 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of understanding by Trust mental health practitioners of appropriate referral services for Veterans
Wider context from the report
“5. I have a concern that there is: a) a lack of understanding as to the appropriate services to make referrals to for Veterans by Trust mental health practitioners; b) a lack of understanding as to services available for Veterans; c) too much emphasis on Veterans being solely responsible for self-referral, with no assistance to assist in accessing appropriate services; d) A lack of understanding (or effort) as to how to request and obtain military DCMH medical records. ”
Source location
Jonathan “Jonny” Philip Cole [JC] · Prevention of Future Deaths report
Page 9 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to assist Veterans in accessing appropriate services
Wider context from the report
“5. I have a concern that there is: a) a lack of understanding as to the appropriate services to make referrals to for Veterans by Trust mental health practitioners; b) a lack of understanding as to services available for Veterans; c) too much emphasis on Veterans being solely responsible for self-referral, with no assistance to assist in accessing appropriate services; d) A lack of understanding (or effort) as to how to request and obtain military DCMH medical records. ”
Source location
Jonathan “Jonny” Philip Cole [JC] · Prevention of Future Deaths report
Page 9 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Reflect veteran suicide-prevention learning at the annual Trust suicide-prevention conference, with veteran-service information available.

Verbatim wording from the response
“2. The Trust holds an annual Suicide Prevention conference where this learning will be reflected. Our colleagues in OpCourage and Trust Armed Forces Community Network will also be in attendance and hosting an information stall.”

Source location
Response from Nottinghamshire Healthcare
Page 2 · response
Published 12 June 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Disseminate the Veterans and Suicide Prevention Champions Network presentation Trustwide through communications and the intranet.

Verbatim wording from the response
“3. The topic for July’s Trustwide Suicide Prevention Champions Network meeting was Veterans and Suicide Prevention with the Operation Lead for OpCourage Midlands attending as the guest speaker to present and share information about the Armed Forces Covenant and OpCourage with colleagues. This meeting was recorded and is being shared Trustwide through various Communications, including being made available on the Trust’s intranet.”

Source location
Response from Nottinghamshire Healthcare
Page 2 · response
Published 12 June 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Distribute veteran-service leaflets, posters and QR-linked intranet information to mental-health practitioners and Trust services.

Verbatim wording from the response
“The Trust has taken action to gain knowledge of appropriate Veteran services which are available, and we are able to make referrals to. As a result of this, we have looked to update our mental health practitioners with regards to this information. All this information has been collated from Nottinghamshire Healthcare culture and staff engagement facilitators, who are part of the Veterans’ Network. Leaflets and posters have been provided and are being distributed throughout the Mental Health Care Group and shared with the wider Trust for review and distribution. As part of the information provided is a card that has a QR code on it, practitioners can scan this code and it takes them to the Veteran information pages on the Nottinghamshire Healthcare Trust intranet site ‘Connect.’”

Source location
Response from Nottinghamshire Healthcare
Page 2 · response
Published 12 June 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Display veteran-service posters at all inpatient sites.

Verbatim wording from the response
“Concern that there is a lack of understanding as to the services available for Veterans.”

Source location
Response from Nottinghamshire Healthcare
Page 2 · response
Published 12 June 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Distribute veteran-service posters to all community team bases and conduct follow-up checks.

Verbatim wording from the response
“Concern that there is a lack of understanding as to the services available for Veterans.”

Source location
Response from Nottinghamshire Healthcare
Page 2 · response
Published 12 June 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Disseminate veteran-service learning through Trust bulletins, governance communications and team meetings.

Verbatim wording from the response
“Concern that there is a lack of understanding as to the services available for Veterans.”

Source location
Response from Nottinghamshire Healthcare
Page 2 · response
Published 12 June 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Present veteran-service information to the Adult Mental Health Quality and Risk Group.

Verbatim wording from the response
“Op Courage and Army and You. The Nottinghamshire Healthcare culture and staff engagement facilitators are presenting to the members of the Adult Mental Health Quality and Risk Group, which is attended by senior operational managers, service managers team leaders and trainers on 07 September 2023.”

Source location
Response from Nottinghamshire Healthcare
Page 3 · response
Published 12 June 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review and plan wider dissemination of veteran information, with emphasis on area-specific training.

Verbatim wording from the response
“This information has been shared with the Trust for wider learning and Care Group relevant business managers and governance leads are review plans to disseminate this information with the emphasis being focused for the specific areas to include training.”

Source location
Response from Nottinghamshire Healthcare
Page 3 · response
Published 12 June 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Scope mandatory veteran-status recording, service hyperlinks and referral-support prompts in RiO.

Verbatim wording from the response
“The Patient Medical records (RiO) now request that a section to be completed which seeks to ask if they are a veteran. We are in the process of scoping if this can be a mandated question and to also add a hyperlink which will guide the practitioner to the services available. We also plan to add a prompt about ensuring that the patient is supported with the referral if required. This functionality will be audited in 6 months’ time to review accessibility and whether this can be used more widely.”

Source location
Response from Nottinghamshire Healthcare
Page 3 · response
Published 12 June 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Share the Veteran folder across Mental Health Services after suitability review.

Verbatim wording from the response
“A Veteran folder (Appendix 4) has been developed to help and support referrals for Veterans, this has been shared throughout the Adult Mental Health services And is currently being reviewed by our Mental Health Services for Older Peoples leads and Specialist Services leads to check suitability for patient group and will be shared across Mental Health Services by 18 August 2023.”

Source location
Response from Nottinghamshire Healthcare
Page 4 · response
Published 12 June 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Include self-referral support and veteran referral requirements in the updated LMHT Standard Operating Procedure and distribute it to staff.

Verbatim wording from the response
“In addition, guidance has been written for staff to demonstrate professional curiosity in relation to a service users’ motivation or ability to complete self-referrals. This identifies those who need support to self-refer and clinicians will complete this with the individual or for them if appropriate. This guidance will be included in the updated version of the Local Mental Health Team (LMHT) Standard Operating Procedure (SOP), which will be provided for reference once completed by the end of August 2023. This SOP will incorporate the need to refer Veterans to OpCourage rather than rely on self-referral due to the known difficulty our Veterans have in seeking support. All LMHT staff will be provided with a copy via email and this section will be highlighted in the business meetings.”

Source location
Response from Nottinghamshire Healthcare
Page 4 · response
Published 12 June 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Support veterans who need self-referral by completing referrals collaboratively with them or on their behalf.

Verbatim wording from the response
“The Trust has reflected upon the self-referral pathway for Veteran related services that require a self-referral and recognise that this can present with difficulties in accessing further appropriate services. For example, the impact having to tell a personal and sensitive story repeatedly can be distressing and result in a barrier to such services being accessed.”

Source location
Response from Nottinghamshire Healthcare
Page 3 · response
Published 12 June 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Audit practice for supporting self-referral and making veteran referrals on patients’ behalf over three months.

Verbatim wording from the response
“The Trust will need to have assurance that this practice is embedded, therefore an audit will take place over a period of three-month period to identify that staff are exploring if a service user requires support to access self-referral services and for the specific needs of Veterans these referrals are being made on their behalf.”

Source location
Response from Nottinghamshire Healthcare
Page 4 · response
Published 12 June 2023
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of veteran awareness of regimental welfare staff and their role in the veteran support landscape

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Insufficient resources causing delays in veterans' access to support and treatment

Concerns raised3

Lack of understanding of services available for Veterans

Lack of understanding by Trust mental health practitioners of appropriate referral services for Veterans

Failure to assist Veterans in accessing appropriate services

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.13

Actions described in response 1

Actions described in response 13