The Royal Commission into Defence and Veteran Suicide has been told it takes more than 600 days on average to complete an independent report into a death.

May 23, 2023

Independent reports into dozens of defence suicides took more than 18 months to complete, an inquiry has been told.

The Royal Commission into Defence and Veteran Suicide on Tuesday focused on statistical analysis of 57 death reports between 2016 and 2022.

Counsel assisting Gabriella Rubagotti told the hearing it took the inspector-general of the Australian Defence Force 575 days on average to complete each death by suicide report.

“That refers to permanent members and reservists (and) for permanent members (only) it was even longer, 610 days,” she said.

Group Captain Daniel Drinan, former director of Defence’s Strategic and Sensitive Issues Management unit, said every case was unique and factors such as coronial investigations could delay reports being completed.

“Every range of circumstances needs to be explored based on the requirements and expectations both of the inquiry officer and how the inquiry officer engages with the family,” he said.

Ms Rubagotti asked Capt Drinan if he agreed that 610 days between a death and a report’s release was a “fairly long time”.

“It would be difficult to identify whether this is high or low or should be different because the circumstances are the primary driver,” he replied.

Capt Drinan told the inquiry commissioners the completed reports were handed to the Office of the Chief of the Defence Force and the Strategic and Sensitive Issues Management unit, where the recommendations were identified for implementation.

Asked how long the process took, Capt Drinan said: “There’s no policy (but) there are time frames that we factor into our own internal planning process so that we understand how long overall this may take.”

“That will be heavily dependent on the nature of the recommendations,” he said.

Capt Drinan said some recommendations following a suicide could be implemented before the reports were completed but others involved changing infrastructure and that “takes time”.

“If it is something that can be managed at a unit level within a particular unit then that is different to an enterprise-wide change,” he said.

“Sometimes we see reports that have a mixture of both and that will extend our ability to compete and close the work.”

The commissioners were also told about the limitations of the reports, such as not including the geographic location of the member when they died or their length of service with the ADF.

The reports also paid limited attention to external factors that may have impacted the member before they died, like relationship breakdowns, mental health issues or alcohol abuse.

Royal commission chair Nick Kaldas said it was important for the reports to identify such factors.

“What if all 57 (deaths) were in the one place,” he said, referring to the failure to include the location of the member who had died.

Anneliese Hilder, former deputy director of assurance at ADF headquarters, said the overall analysis of the 57 deaths showed mental health was a dominant factor in 61 per cent of the reports into member suicides.

Two-in-three members were receiving treatment for mental health issues around the time of their deaths and 51 per cent had been assessed for risk of suicide in the previous year.

Of the members who died, 83 per cent also had additional risk factors such as a relationship breakdown or chronic pain, with 32 per cent experiencing mental health concerns or a breakdown at the time of their death.

The hearing continues.