Subcommittee on Personnel
Senate Armed Services Committee Hearings
12 September 1996
Submitted by Charles A. Casto
Mr. Chairman and Honorable Committee Members-I am very pleased to be able to present information and concerns to you in support of efforts to improve the Military Death Investigation process for those deemed "suicide".
Although the introduction of Public Law 103-160, section 1185 enacted in the National Defense Authorization Act for fiscal year 1994 set a positive framework for administratively identifying inadequacies and shortcomings in the death investigation process, much remains to be done to improve the methods and practices used.
In review of the 1994 Congressional report and current Jan. 96 DoD IG report provided Ms. Hill (Eleanor Hill, Inspector General, Department of Defense) - a recurring theme of cases discussed seems to involve preexistent or extenuating circumstances that occurred BEFORE THE DEATH INCIDENT, a poor handling by MCIOs who do not initiate action to conflicting information, and overall treatment of families. Without a lead role being clearly identified, the overall results are unacceptable to families of these fallen service members whose repeated efforts and outcries for assistance have resulted in this Subcommittee Hearing.
Conflict between family expectations and results is compounded when inconsistencies are issued in final reports. After waiting extended time frames, to allow for a comprehensive review involving (presumably) intensive assessment, review & validation of material and aspects, an expectation of excellence is not met. The "COGNIZANT and/or RESPONSIBLE" Investigation office should (and must) perform a role of integration before any significant process improvement can be achieved. YOU SEE BEFORE YOU THE RESULTS OF THIS NOT HAPPENING; each family here can provide specific discussion in this area for their loved one.
I categorically state that in recent final reports received: Conflict/errors are not resolved; a rationale is not provided; and multiple reports produced are (at best) loosely coordinated. In general, we do not believe this result is the intent of existing legislation and policy.
We recognize the "uniqueness" of each investigation and case - yet within the Department of Defense and activities supporting this process - there is not an overall focal point with clearly identified responsibility to integrate different sources of material and results into a "FINAL REPORT’ provided the family. Instead, each major entity (Service, MCIO, Medical Examiner, etc.) prepares individual reports for release purposes - EACH OF WHICH IS CONSIDERED CONCLUSIVE and must be separately requested through FOIA and/or the Privacy Act.! There is a very real "turf" syndrome noted from review of different reports which tends to create a "hands off" or rote acceptance of material not prepared by the reportee. In short, if I’m not responsible, accept it, incorporate it, and move on. This practice reflects profoundly upon the DOD’s integrity and whether occasional occurrences or (as we believe) a systemic issue, this has created a bad apple odor that "TAINTS" the entire organization and creates a general perception of incompetence. Inadequate results are unconscionable.
There are 4 broad concerns related to "SELF INFLICTED" I wish to express which are representative of families gathered here today.
1. ISSUE:
The structure of investigations whereby elements are segregated under separate investigative authority precludes objective & comprehensive presentation of all contributing factors to the investigation. Without formal structure and overall focus, investigative results provided families tend to reflect poorly upon values, integrity, and senior command structure of activities involved. Internal review activity is not effective in evaluating & reporting while simultaneously avoiding "culpability" issues. Internal service administrative reviews are "containment" oriented in that substantive issues are minimized. MCIO investigations do not provide a rationale and creates a clear perception of predisposition. Process disconnects are present from incident through closure for involved activities... Attached to this testimony is an overall process flowchart considered to be representative.
RECOMMENDATION:
Improve the process through proactive planning to assure that requirements flow down from top policy to the lowest operational directives. In conjunction with this, vague, superfluous, and conflicting guidance can be corrected or eliminated. View this process as it really is - HIGHLY INTERACTIVE - involving Services, MCIOs, Medical Examiner’s, AFIP, etc.- with the key elements of coordination and communications identified as a "MUST". For a process of this nature, communication and resolution of open and fragmented issues is critical to assure adequate overall results.
Only after making the process capable can evaluation of actual performance be done - each case reviewed by the DOD Inspector General’s office reflects issues of practice which should not have happened.
This could be effectively done through a multiservice process team (Services, MCIOs, Medical community personnel; perhaps chaired by the DODIG office) to review all prescribed methods & practices and subsequently validate actual actions taken from recent cases handled!
2. ISSUE:
Release of information and material- Following family notification of a death and being provided a copy of the initial casualty report, no information is routinely provided or made available except as specifically requested and/or identified through FOIA.
RECOMMENDATION:
As a minimum, provide a copy of the death certificate and body handling paperwork and information prepared to the funeral home conducting services and burial arrangements. At present, only a bill of lading/shipment receipt is provided.
Additionally, the integrity of the victim’s remains and handling are of concern. This area should be evaluated and immediate action taken to keep desecration of remains from happening.
3. ISSUE:
Overall integrated and focused reports of death investigations deemed self inflicted is not happening. While practices may be largely IAW procedures & prescribed methods, we seem to have lost sight of the process objective in all of the footwork performed. By definition, process inputs are transformed to produce a desired output. Within this cycle a feedback loop for adjustment is critical for controlling the process - this is apparently missing in these cases.
RECOMMENDATION:
Establish a single arbitration type review activity (chaired by the DODIG?) comprised of members of the medical community (specifically including forensic & pathology areas), military services, MCIOs, Veterans administration, etc. (all users of reports/information) to provide a unified, focused summary that addresses the needs of all parties.
The term arbitration is used because of apparent reluctance and unwillingness of different groups to provide a complete investigative report.
4. ISSUE:
There is only temporary administrative recourse available via Public Law 103-160, Section 1185 for familial concerns and issues.
RECOMMENDATION:
Provide an avenue of recourse, either as part of or separate from the Military Justice System, wherein material issues and specific concerns can be formally addressed in a public "forum or environment" by concerned family members.
I request that in your subcommittee review efforts, these broad recommendations be considered since, if implemented, a large portion of concerns could be alleviated. I further stress the need for timely action. Families are put on an emotional roller coaster that should not happen. Each family here can tell you the highs/lows of this cycle which forever impacts and changes them as they are drawn into an unfriendly "containment" oriented system.
In closing, if this is a process, then treat it as one. It can be greatly improved.
I believe that all parties involved are sincerely interested in improvement and committed toward action to resolve items presented here today. In the spirit within which this hearing is held today, breaking the silence on these deaths of military personnel which has long been ignore, we all offer our assistance and input.
THANK you for the opportunity to be here today. Charles Casto....