Inquest into Death of Kosovo Veteran Alan Forcer

22 November 2022

The inquest into the death of Alan Forcer concluded on  Friday 18 November following three days of evidence heard by Clare Bailey, Senior Coroner for Teesside.

Claire Bailey concluded that Alan, who was a military veteran with PTSD, had hanged himself on 21 May 2020.

During the course of the inquest, the Coroner heard evidence from witnesses from Cleveland Police, Combat Stress and a Psychiatric Nurse from the Veterans Transition, Intervention and Liaison Service (TILS) in relation to Alan’s mental health care at the end of 2019 early 2020.

During the evidence, the following issues were highlighted:

1. That Alan had a diagnosis of service attributable PTSD, which was likely to be complex and had been receiving psychological intervention and treatment by the veterans charity, Combat Stress;
2. That in January 2020 Alan was informed due to a service redesign that intervention could no longer be provided by Combat Stress and a referral was made to the NHS TILS service to assist him with his identified needs that being anger management and complex trauma support;
3. That when TILS agreed to accept the referral no clinical information was transferred from Combat Stress to TILS although a phone call did take place between the two services;
4. During his first assessment Alan completed a number of self reporting diagnostic tools which demonstrated that in the previous weeks leading to the assessment he had severe depression, anxiety and symptoms of PTSD;
5. Evidence was heard from RMN David Shaw from the TILS service that these demonstrated that Alan needed stabilisation before he could start any psychological therapy. RMN Shaw stated that this could be met by local non-veteran specific services rather than the veteran-specific complex treatment service and therefore he signposted Alan to those services, albeit Alan decided he would try to get help from Help For Heroes instead;
6. In a further call on 10 March Alan was discharged despite the fact that he had still not accessed any psychological intervention from any service;
7. Evidence from RMN Shaw demonstrated that although he met most of the criteria to be referred to the veteran-specific complex treatment service, as there were local services available that could provide the treatment that was a bar from being able to refer him to that team. It was accepted that those local services were not veteran-specific, although stated that generally those services would have people working for them with some experience with veterans.

During the inquest, a number of issues came to light about the specific challenges that veterans as a community have in accessing healthcare when they return to civilian life. It was accepted in evidence by RMN Shaw, that there are difficulties for veterans in navigating the civilian NHS but they try to assist in signposting where possible. He also recognised that one difficulty with assessments are that veterans also experience stigma and that they can often minimise their symptoms when talking to mental health professionals.

Commenting after the inquest, Alan’s family said:

“Although a very traumatic experience, we are pleased that an identifiable flaw has been highlighted within the veteran care pathway. Essentially we have identified that there is in fact a stumbling block for future veterans to access what has been presented as a newer, improved veteran mental health service that will be easier for veterans to access.

“It is well known that veterans find it incredibly difficult to engage with those professionals who do not have a deep rooted understanding of the military mind and culture. There is therefore a reluctance for them to “opt in” to these services which is what they are being asked to do.

“What is the point of a veteran-specific mental health service if veterans cannot access it without first failing in their treatment with non-specialist veteran local services?

“We feel quite strongly that they failed to give Alan the tools to cope and now we have to live the rest of our

Alan’s family is being represented by Lily Lewis of our inquests and inquiries team, instructed by Gemma Vine of Ison Harrison Limited.

This update comes from the original media release from Ison Harrison Limited.