Inquest into the death of Alex Tostevin, focussing on mental health provision within UK special forces, finds that there was a missed opportunity to assess his risk of suicide in the days before his death
An inquest into the death of Corporal Alex Tostevin on the 18th of March 2018 today found Alex’s death was possibly contributed to by a missed opportunity to reassess his risk of suicide in the days before his death.
Over two weeks the inquest heard evidence on the events leading up to the death of Corporal Alex Tostevin who took his own life on the military base where he lived whilst serving in the Special Boat Service (SBS). Alex was 28 at the time of his death and he had served in the Armed Forces for the majority of his adult life and completed several military tours.
Alex grew up in Guernsey with his parents and younger sister. He was described as a happy and popular child, who maintained close relationships with his family. He never displayed any signs of anxiety or other mental health issues as a child or teenager. His decision to leave school at 18 to join the Armed Forces was thought to suit his energetic and action-loving personality.
In 2010, very soon after his passing out ceremony in April 2009, Alex was deployed on Op Herrick 12 in Sangin, his first overseas tour. The tour is widely understood to have been the most brutal and traumatic tour for the British Armed Forces. Whilst in action, Alex was shot in the head by an enemy sniper, narrowly avoiding fatal injury as the bullet ricocheted around the inside of his helmet and exited. He was recognised in dispatches for his bravery and branded a hero, having got up and continued to fight alongside his comrades.
Changes in Alex’s previously warm and outgoing character were slowly observed by his family upon his return. He became irritable and developed a quick temper. He seemed unable to relax, even around his close friends and family. He developed a dislike of fireworks, which he had previously loved, and struggled with crowds.
Alex was redeployed overseas and continued to engage in active combat. Over the years, Alex’s mental health deteriorated and his family became increasingly concerned for his well- being. His behaviour was erratic and he expressed suicidal thoughts, a fact that was known to his colleagues, but the extent of which Alex’s family were not made aware of until after his death.
The coroner found that Alex had made clear that he was practicing suicide in the days before his death and that although he told a member of the welfare team who e-mailed the medical team, this fact was apparently not known by the medical team and chain of command before Alex’s death. The coroner rightly found that this was a very significant missed opportunity to reassess Alex’s risk of suicide and that this possibly contributed to Alex’s death. The coroner also found that chain of command closed down Alex’s attempts to seek help from Rock to Recovery and there was no consideration as to why he was seeking alternative medical help outside the SBS and that this represented a missed opportunity to identify Alex’s views on his treatment and to allow Alex to feel that he was being listened to.
In terms of the safety plan, the coroner found that the consultant with care of Alex failed to tell both Alex’s friend and the nurse assessing Alex that he considered that Alex should remain with his friend over the weekend.
Since Alex’s death the Family have fought for the inquest into his death to be open to public scrutiny, something that the MoD sought to restrict (see Notes to Editors below).
The Coroner announced that he would make the following three recommendations to the Ministry of Defence arising of concerns of a risk to the lives of others as identified in Alex’s inquest:
The risk of underreporting of mental health symptoms by soldiers due to fact that there is duty to report such information to the chain of command where such information may undermine operational effectiveness.
There is a hierarchy in the appreciation of risk in the SBS which may result in a failure to identify risk. Welfare were trained at identifying risk but the views of welfare on risk were considered secondary.
A lack of a composite care plan and risk assessment which is used in other mental health trusts which risks key information and risk factors being missed.
Alison Tostevin, Alex’s mother, said: “Alex was asking for help for a long time and as a family we feel he was failed. He wasn’t satisfied with the help he was receiving and looked elsewhere but was ordered not to attend the appointment he made with Rock2Recovery. He was not given the support he needed or deserved.
“We want to thank those who loved our son Alex and did all they could to help him. We hope that he is remembered as he was in life – a highly skilled, dedicated, and respected soldier, a loyal friend, fun loving, generous, kind and larger than life in every way – the best son, brother, grandson and friend anyone could ever have. We hope more members of the forces will talk about mental health – Alex wouldn’t want anyone else to suffer as he did. We strongly believe that Alex was suffering from undiagnosed PTSD. Alex told all those involved in his care that he was unwell and suffering and we believe the care that he received was inadequate.
“We miss Alex so much. We love Alex and will miss him until the day we die, and not until that day will we stop saying his name.”
Jocelyn Cockburn, Partner at Hodge Jones & Allen, said: “This inquest has been a battle for the family to get to the truth. The MoD has exercised too much control over the proceedings by repeat applications to restrict public scrutiny of mental health care within the Special Boat Service. I am relieved that the Coroner resisted this approach and held an in-depth investigation into what happened to Alex.
“Today’s recommendations should serve as a wake-up call for the MoD that the mental health of UK special forces must be protected. There is a lack of independence between military and chain of command which risks disincentivising openness in personnel seeking mental health care. This puts the lives of service personnel at risk”
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