A coroner has ruled the death of a Defence Force service person at a New Zealand military base was self-inflicted.
The service person had been engaged in mental health services prior to and during their enlistment with the NZDF, and was the subject of an internal investigation at the time of their death in 2013.
Their name and identifying details have been suppressed.
Coroner Marcus Elliot made a series of recommendations following a hearing in 2023, which have now been released in reserved findings.
They have been split into three categories - investigations, support and information sharing.
The coroner said when the NZDF was conducting internal investigations that "potentially places the status of personnel in jeopardy" (for example, disciplinary charges, investigation, the prospect of a medical discharge, or seizure of belongings), it should ensure the person under investigation was being adequately supported.
This included "a clear and timely explanation of the process, including the likely timeframe and potential outcomes" being communicated to the affected person, that searches and seizures "are reasonable" and it was made clear what was being alleged.
NZDF should also ensure "the matter is resolved without undue delay and that, where there are welfare concerns for the personnel involved, the investigation is expedited", Elliot said.
His recommendations extended to include a person subject to an ongoing investigation who had been identified as "suffering from mental health issues".
"The medical officer overseeing the person should identify the potential stressors which may increase suicidal risk and formulate a plan to address them," Elliot said.
"Support should be offered at those times during the investigation which may engender additional stress (for example, interviews)."
Mental health risk should "always be taken into account in operational decisions relating to the person's activities", the coroner said.
He also recommended that junior military leaders were "equipped with adequate skills and resources to identify mental health issues, to provide informal support to troops and to refer them for medical assistance (including urgent assistance) where appropriate".
Elliot acknowledged that NZDF had already made a number of changes since 2013, and recognised that some of his recommendations were already part of current practice and policies.
The NZDF Mental Health Strategy and implementation plan was released in 2015 with input from medical and mental health professionals.
The strategy and plan had since been refreshed in 2017 and 2020.
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