A coroner has warned that more military veterans suffering PTSD may take their own lives unless urgent action is taken to improve their care.
Emma Brown, the coroner for Birmingham and Solihull, has written to NHS services and police highlighting a catalogue of failures in the treatment of Lance Corporal Dave Jukes in the months leading up to his suicide.
Earlier this month, she ruled the 49-year-old veteran from Birmingham, who had served in Iraq, Afghanistan, and Bosnia, took his own life last year after repeated calls for help were largely ignored.
In a strongly worded letter seen by The Sunday Telegraph, she has urged NHS England, Birmingham and Solihull Mental Health Trust and West Midlands Police to learn from mistakes in the soldier’s treatment.
The move has prompted the infantryman’s widow, Jo Jukes, and campaigners fighting for better treatment of veterans to call for a nationwide review of care for those suffering combat PTSD.
Mr Jukes had battled for years with acute depression triggered by his service in war zones with the British Army. Ms Brown listed repeated mistakes and missed opportunities to help the former soldier before he hanged himself last October.
The coroner highlighted how a specialist mental health team dedicated to treating veterans had delayed seeing him resulting in a severe decline in his mental state.
“In my opinion there is a risk that future deaths will occur unless action is taken,” she wrote.
She also warned that if numerous health care agencies and emergency services did not share details about veterans’ mental illnesses there would be “a risk to life from ill-informed decision making”.
Explaining how Mr Jukes should have been seen by a psychiatrist after being detained by West Midlands Police following a violent episode , she wrote: “Not having a robust and effective system to carry out necessary assessments whilst a patient is detained in police custody puts lives at risk.”
She also pointed out how poor record keeping and underfunding resulting in “too few staff” for mental health teams meaning “lives are at risk”.
Welcoming the coroner’s letter, Mrs Jukes said there remained “gaps in the system” which means the complex needs of veterans can still be ignored.
"We lost everything and changing the system will help to make that loss mean something," she said. "I am now calling for an end to the postcode lottery that exists in veterans care.
"I would welcome opportunities to work with the people who can make changes to this broken system because Dave’s story is still happening today across our country."
“This case shows the entire system is very broken and means the lives of veterans who fall between the gaps in the many services and agencies are at risk,” he said.
A West Midlands Police spokeswoman said the force was “satisfied correct police procedure was followed” but acknowledged the coroner’s findings. A Birmingham and Solihull Mental Health NHS Trust said a review was conducted after Mr Jukes’ death and lessons had been learned with more funding given to teams helping veterans.