Neil David James McDougall · Prevention of Future Deaths report

On the 23rd February 2021 the then-Senior Coroner, Mr Tony Williams, commenced an investigation into the death of Neil David James McDougall, aged 43.

The investigation concluded at the end of the inquest, heard before me, on the 9th August 2022. The conclusion of the inquest was Accidental death, including medical cause of death being 1(a) ████████ toxicity with a finding in box 3 that “Neil David James McDougall was discovered deceased at his home address in the early hours of the 23rd February 2021. He had a long history of mental health problems following active military service. Neil used alcohol as a coping mechanism which both exacerbated but also masked his mental health presentation. Neil had a history of impulsive behaviour, especially when intoxicated as well as a history of stockpiling medications, some of which were sourced outside of legitimate GP prescriptions. It would appear, on the evidence, that on the 22nd Feb 2021 Neil has sadly misjudged the quantities of medication that he was to take, resulted in him succumbing the toxic levels of ████████ that were in his system”.

Neil had joined the military when he was 30 (2007). He remained with the Army until he was medically discharged on the 9th July 2018. He undertook a Tour of Afghanistan.

I hear from Neil’s partner who stated that by 2014 Neil was having recurrent and persistent nightmares and hallucinations about his experiences on a Tour in Afghanistan.
Mr McDougall was first seen by the military psychiatrists at the DCMH (Department of Community Mental Health) on the 09 October 2009. He was again referred to the DCMH in December 2016 until the 25th April 2018 when his care was transferred to TILS in anticipation of being seen once he was discharged from the Army in July 2018.

His recorded diagnosis in March 2017 was of a depressive episode with marked anxiety. He had an inpatient admission between 12th – 20th July 2017 with the diagnosis on discharge being given as depression (ICD-10 F33) and Alcohol dependency – binge (F10.2)

I heard that Neil appeared to go from crisis to crisis with his mental health; there was a recurrent cycle of peaks and troughs. In the December of 2017 he was reporting symptoms more consistent with generalised anxiety and depression. Whilst the Inquest found that Neil’s mental health was either exacerbated by and/or masked by his alcohol misuse, it was clear that there was an underlying mental health situation. Neil appeared to use alcohol as a coping mechanism, but sadly this only made him worse.

Neil was medically discharged by a Full Medical Board on the 12th December 2017 with his last day of service being set as the 9th July 2018. On discharge his mental health care was transferred to the community/NHS.

I was told that one month after discharge, so in August 2018, Neil was formally diagnosed with PTSD by Dr ████████. He had not received this diagnosis whilst he was under military mental health care, although the evidence given by the military Psychiatrist was that Neil did not present in such a way as to meet the criteria/threshold for such a formal diagnosis at that time.

I heard from a civilian Consultant Psychiatrist who saw Neil in August and October 2020. The long-term treatment plan was for Neil to join a men’s Cognitive Analytical Therapy (“CAT”) group which has been successful for numerous ex-military veterans, but he wasn’t anywhere near ready to engage in that level of talking therapy at the time as he was unable to talk about his past experience(s). I was told that he would need to undergo mindfulness and Cognitive Behavioural Therapy first to pave the way for him to join the CAT group in time.

Sadly, Neil did not commence any therapeutic intervention as he was discovered deceased at his home address on the morning of the 23rd February 2021.

(1) I was told that the de-brief for serving personnel after returning from a Tour is undertaken as part of a group. There appeared to be some limitations to this process. I was told that there are no 1-to-1 sessions in which personnel can openly talk about their experiences and trauma, which is something that they may be reluctant to do in an open setting for fear of going against the grain or culture of being physically and mentally resilient. The debrief or recovery process itself appeared to centre more around the consumption of alcohol rather than the encouragement to talk about any distressing or harrowing experiences of active combat and service and I remain concerned that the culture/stigma does not lend itself to those suffering taking the first step and effectively raising their hands and asking for help.

(2) I was told that on leaving the Army all leavers go through a “Re-Settlement” process. This transitional process involves mandatory courses that assist with re-integration back into civilian life and endeavour to provide leavers with ‘life skills’ such as CV writing, interview techniques/preparation etc to assist leavers in gaining employment once outside of the Army.

The mandatory transitioning arrangements only apply to ‘skills’ and I was told that it is entirely possible to ‘walk out of the door’ without any mental health assessment whatsoever, with the Army appearing to rely on the availability of services provided within the community and/or by charitable organisations that the Army can either signpost the leaver to, or they can access for themselves once a civilian.

(3) I believe that action should be taken to ensure that there is an effective and comprehensive assessment of the mental health and/or wellbeing of those leaving the Army. I can see no justification for some elements of re-settlement/re-integration being mandatory whilst others remain purely optional. I believe there should be some assessment and coordination of the discharge process to ensure that those leaving service are assessed, with appropriate intervention(s) identified rather than simply being allowed to leave and rely on help being available somewhere/somehow in the community.

(4) I am concerned by the level of suicides amongst ex-military personnel and I do not believe that Neil was an exceptional case, he is representative of the rising figures and statistics; ex-military (predominantly men) who suffer from poor mental health as a result of active service.