Investigation and inquest
On 3rd February 2014 I commenced an investigation into the death of Corporal Anne-Marie Katherine Element aged 30. The investigation concluded at the end of the inquest on 3rd March 2014. The conclusion of the inquest was as follows:
At some time around 8 pm on Sunday 9th October 2011 the deceased attached one end of a ligature formed from a scarf to the fire escape outside her room at Flat 1, Block 609, Kiwi Barracks, Bulford, Wiltshire. Having attached the other end of the ligature around her neck the deceased hanged herself, subsequently being pronounced dead at Salisbury District Hospital, Salisbury, Wiltshire.
Anne-Marie Element took her own life. The following matters contributed to her death:
(1) The lingering mental effects of an act of alleged rape during the night of 19th/20th November 2009.
(2) Bullying in the work place.
(3) Work related despair
(4) The effects of a break-up of a romantic relationship
Circumstances of the death
Anne-Marie Katherine Element (“Anne-Marie”) died outside her accommodation block at Kiwi Barracks in Wiltshire. She died by her own hand. One of the matters that weighed heavily on her mind at the time of her death was an alleged rape by two fellow soldiers at an army base in Senegal on 19th/20th November 2009. Although the response to the incident by the chain of command was compassionate and well-intentioned, lack of clear guidance meant that the response was haphazard and less than adequate. Subsequently Anne-Marie was made the subject of a Suicide Vulnerability Risk Assessment. The officer responsible for implementation of the SVRA after the assessment had taken place, lacked knowledge and adequate training in respect of the system.
Coroner’s concerns
1. There is an existing code of practice entitled “Services to be provided by the Armed Forces to cover the victims of Crime”. It was released in September 2008. The code of practice covers victims of crime generally and although it also makes provision for vulnerable victims it does not specifically deal with the likely repercussions on the victim of an alleged rape by one soldier on another. It is suggested that the code of practice be reviewed either with a view to possible revision or with a view to establishing a separate code of practice to deal specifically with a victim of a serious sexual assault alleged to have been committed by another soldier.
2. The evidence at the Inquest suggested that those responsible for the implementation of measures to be put in place following a Suicide Vulnerability Risk Assessment had insufficient training in the system with no evidence of regular follow-up training. This is in marked contrast with the prison system where those responsible for managing at risk prisoners have specific targeted training with regular updates. The evidence at the Inquest suggested that instruction on the subject of suicide and vulnerability risk assessment formed little more than a lecture.