During our review, we found that family members making requests under 1185(b) most often expressed concerns over the use of psychological autopsies, administrative investigations, casualty notification and assistance, and personal property disposition, some of which you have heard about before in the previous panel. Accordingly, we expanded our review to cover those areas. Our report was issued on January 26, 1996. [Report, "Inspector General, Department of Defense, Review of Department of Defense Policies and Procedures for Dealth Investigations." Full report retained in committee files.] INSPECTOR GENERAL DEPARTMENT OF DEFENSE, Arlington, Virginia, January 26, 1996. Memorandum for Secretary of the Army, Secretary of the Navy, Secretary of the Air Force, Under Secretary of Defense (Personnel and Readiness), Assistant Secretary of Defense (Health Affairs), Assistant Secretary of Defense (Public Affairs), Department of Defense General Counsel Subject: Report on Department of Defense Policies and Procedures for Death Investigations The subject final report is provided for your use. It responds to Section 1185(a) of the National Defense Authorization Act for Fiscal Year 1994 (P.L. 103-160). The Act required the Secretary of Defense to review the Military Departments' procedures for investigating deaths of members of the Armed Forces that may have resulted from self-inflicted causes. The Act also required the Secretary to issue regulations for conducting investigations of these deaths. Management comments on a draft of this report were considered in preparing the final report. As discussed in Chapter A of the report, the Army disagreed with our recommendation to develop an investigative aid, a pocket-size guide to assist investigators in processing crime scenes during death investigations. The Air Force already has such a guide, and the Navy is in the process of implementing one. The Army should reconsider its position on this recommendation and adopt a similar guide. We appreciate the courtesies extended to our staff during this review. Should you have questions, please contact Mr. Jack Montgomery, telephone number_703-6048700, Office of the Assistant Inspector General for Policy and Oversight, Room 725, 400 Army Navy Drive, Arlington, Virginia 22202–2884. ELEANOR HILL REVIEW OF DEPARTMENT OF DEFENSE POLICIES AND PROCEDURES FOR DEATH C. Administrative Investigations 31 D. Casualty Notification and Assistance, and Disposition of Personal 38 E. Release of Information to the Public 50 ........... 55 Part III — Management Comments Appendix A - National Defense Authorization Act for Fiscal Year 1994 ities Appendix C - Policy and Procedure Documents Reviewed Appendix D Sites Visited and Agencies Contacted Appendix E Training for Criminal Investigators [Full report retained in committee files.] We found that the MCIO's, that is, the military criminal investigative organizations, already had in place adequate policies and procedures and training for death investigations. I might say, we came to that conclusion after we contacted numerous civilian law enforcement agencies that had experience in death investigations-such as, New York City, Dallas, Baltimore, Philadelphia. We contacted experts, known experts in the field, reviewed those books, those documents and we compared what the MCIO's have in place, and I stress, in place, to what the accepted standards were in the field. This is not to say, however, that those policies and procedures are always followed, and we did identify some areas for improvement in the MCIO's implementation of policies and procedures. I do not want to go into all of them because of time considerations, but I will just mention, for instance, we did recommend that each of the MCIO's should have in place a family liaison program which would ensure direct communication with family members until all investigative issues are reasonably resolved. I am pleased to note that at least at this point in time all three MCIO's do have a family liaison program now in place. Our report also recommended improvements in procedures relating to psychological autopsies, administrative investigations, casualty notification and assistance, property disposition, and release of information to the public. Again, due to time constraints, that is all detailed in my statement. I will not go through all of that because I do want to talk about the instruction we issued and also about the 1185(b) cases. As I mentioned, the statute called for a regulation to be issued, and that task was delegated to us. On January 31 of this year Í issued DOD Instruction 5505.10, entitled, Investigation of Noncombat Deaths of Active Duty Members of the Armed Forces. The instruction was effective immediately upon issuance. It provides overall policy guidance for the investigation of noncombat deaths not medically determined to be from natural causes. Among other things, the instruction requires that this type of death be investigated as a potential homicide until evidence establishes otherwise, and that all MCIO agents assigned to these cases be properly trained. The instruction sets out certain specific areas of training that are required. Again, it goes into other things but, in the interest of time, they are in my statement. Turning to 1185(b), which I know is a matter of concern to the families, let me just bring you up to date on where we are on that. Upon receipt of the 1185 mission in August 1995, the DCIS immediately formed the Special Investigative Review Office, whose sole purpose is to review and, if necessary, to reinvestigate disputed unattended death cases that have been conducted by the MCIO's. A review board was also instituted so that each request would receive a comprehensive examination. The board consists of the director and deputy director of the DCIS, the supervisor of the Special Investigative Review Office, the chief medical examiner of the Armed Forces Institute of Pathology and, at my request to the director of the FBI, a representative from the FBI who is a senior forensic scientist for the Bureau. We also have representatives on the board from our own Office of General Counsel, so that we have legal expertise involved in this from the beginning. Each new request is carefully reviewed by all board members, who then meet with the assigned investigator to discuss specific concerns and to finalize an investigative plan. I might add that the members of the board personally review all the documents, the material that the agents collect, including the complaints of the families. They are aware of the concerns the families raise and they guide the agents in how to address those concerns. Since the transfer of this mission to DCIS just 1 year ago, a total of 23 final reports have been issued, bringing the total number of completed cases to 27. We are continuing to receive requests under the act, and we now have a total of 28 open matters under our review, four of which have been opened within the last 5 months. I want to just say a few words about what we do when we investigate these cases. These cases often require a huge amount of field work and coordination with the MCIO's in order to locate and review closed investigative files and to identify witnesses and available evidence. Many cases also require coordination with local authorities and even with foreign Governments. Our agents have found it necessary to interview witnesses throughout the United States, Canada, Europe, Asia, and Central and South America. The work frequently involves locating and obtaining forensic testing of evidence for acts that occurred as much as 14 years ago. To date, we have found that the majority of investigations were adequately conducted by the MCIO's, and that the cause and manner of death in all but one case were properly established. In the one disputed case, we found that the manner of death was accidental, in our view, rather than suicide. This is not to say that we have not found deficiencies in several cases involving the failure to properly collect evidence, obtain forensic testing, interview witnesses, and adequately coordinate with family members. Senator, I feel compelled, having listened to some of the testimony this morning and comments about the complicity of our of fice, to point out that many of the deficiencies that were mentioned were discovered by our office and were pointed out in our reports, including, for example, the case Mr. Rush referred to about the pen, where there were no prints taken and where the pen was lost. That was discovered by Inspector General agents in our review. So we have in many of these cases pointed out numerous deficiencies and brought them to the attention of the MCIO's. Senator KEMPTHORNE. Ms. Hill, let me get a clarification there, right there. You have pointed out deficiencies, and because of those deficiencies, where there is—and if we reiterate the list that you just said, the lack of evidence, the lack of contacting witnesses, can we conclude that because of a list of deficiencies that exist, that you cannot come to any other conclusion than the original investigation because there is no evidence? Ms. HILL. Senator, it varies by case. In many of these cases where there was something that was not done, for instance, interviewing a witness, or not doing handwriting samples on a note, or taking prints, we have been able to go back and find the witnesses and interview them, or to send the documents out for examination. We have done that. To the extent that we can do what was not done, we have done it. Senator KEMPTHORNE. That gives you new evidence. Ms. HILL. That gives us new evidence, and in some of those cases the new evidence has supported the finding of suicide. Senator KEMPTHORNE. But because in some instances there is the absolute loss of evidence Ms. HILL. That is right. Senator KEMPTHORNE. -you cannot overturn. Ms. HILL. We cannot always answer the concern of the family as to what some other step might have told us. For instance, with the pen in the case he was talking about, they did lose a pen, and in that case there was a suicide note. Obviously, had they had the pen and done fingerprints on that pen we would have potentially either very good evidence of a suicide, or we would have some indication that maybe something was amiss, but we do not have the pen. We cannot create it. We cannot do anything to overturn that, but in that particular case we found other things that we felt supported sufficiently the suicide finding. On the other hand, the families may still have concerns that this does not sound right, or that there must have been somebody else involved, but you cannot overturn a case just on a concern. You have to be able to have some evidence to support that, and that is where we have had problems coming up with that, with the exception of one case, where we did in one case overturn the finding because we disagreed with it. Senator KEMPTHORNE. Senator Robb. Senator ROBB. May I just ask you one question? You said that I think you issued a final report in some 23 cases. Ms. HILL. Individual cases. It is up to 27-23 in the last year. Senator ROBB. I am sorry, that is right, and you have 28 pending, or whatever the case may be. Ms. HILL. Right. Senator ROBB. Does a final report include those instances that you just described where there is simply insufficient information or evidence to come to a different conclusion, and if, for whatever reason, some new evidence should turn up, that could potentially be reopened, in terms of the final determination? In other words, you say final as though it is a conclusion based on all the evidence, and I assume you at some point say this is based on all the available evidence. Ms. HILL. Right. Well, we issue the report when we feel we have done everything we can do to follow up on the family concerns and whatever else the evidence and our review of the investigative file leads us to do. I can tell you we have had at least one instance of a case which in fact was talked about this morning, where we were about ready to issue the final report and the family came in with additional evidence. We then delayed issuing the final report and went out and tried to speak to the individuals involved and verify what the family was giving us and verify, to the extent we felt we could, their concerns in that area. So we have tried to be as fair and as open as possible with the families we know this is a difficult situation. I do not envy their situation at all. I feel for them, but we are really limited by the facts and the evidence, and we have to be able to draw a conclusion based on what at this point in time we can come up with, which in some cases, as I said, is 14 years after the incident. Senator ROBB. Of the 27 cases that you have closed or issued a final report, can you give us some indication of how many of the families involved have accepted that as closure and how many of the families have not? Ms. HILL. I can give you that for the record to the extent we have it. Some of the families get the report and we do not hear back from them. Some of them we have heard from with favorable responses, some we have heard back with negative responses, and some we have no responses. If you want that, we can do our very best to get whatever we can in terms of numbers. [The information referred to follows:] Of the 27 cases completed under Section 1185(b), the Office of the Inspector General has received one response from the requesting family member accepting of the results of the report and three responses from requesting family members critical of the reports' findings. Of the remaining cases, no response has been received to date. Senator ROBB. Out of the total number of cases of unattended deaths, I think Dr. Sabow figured it was 3,000 over a 10-year period, I understand that the 55 cases that you refer to would constitute the universe of those where family members have not accepted in one form or another the findings, is that correct? Ms. HILL. I think it is 3,087 suicide cases in the same time period from the beginning of the time where they could have submitted them under 1185(a) to the end of 1994. The figure is from our 1185(a) report, and, of those cases, we have received to date 55 requests where families have complained that there was a deficiency in the investigation. Senator ROBB. One last question, Mr. Chairman, and I apologize, I am being called out here and I may not be able to return. I do not want to hold anyone up. The question of autopsies, are autopsies routinely performed in all cases of unattended deaths? Are they performed only under certain circumstances? Are they performed with the request of families? How do you handle that part of the investigation? Ms. HILL. I am not an expert on autopsies, but I can tell you from our review of these cases and the work we did on our 1185(a) report, we have had all types of cases. We have had cases where there were autopsies done, some were not done by the Department of Defense, but by local authorities. That happens quite often. We have had cases where families specifically requested there not be an autopsy, and one was not done. I think it is much like the issue that was discussed in the previous panel, that is, the recommendation that everything be mandatory, each one of these steps. My own experience in law enforcement, with any number of law enforcement agencies over the years, is that if you mandated every step in an investigation you would have to change things throughout Federal law enforcement, local law enforcement, and State law enforcement, because they do not |