generally do that. There is some judgment allowed as to the circumstances of the case involved.

Senator ROBB. But with respect to an unattended death, are there circumstances that you would close that case where the remains were still available even if they had to be exhumed where an autopsy had not been performed and a request that an autopsy not be performed was made by the family?

Ms. HILL. If the family asked us not to, we certainly would not. Senator ROBB. No, I understand that, but putting those cases aside.

Ms. HILL. I would again have to say it would depend on the facts of the case, because there might be a case where unusual circumstances existed-I mean, I am always afraid to eliminate any possibility. You would have to look at the case. Certainly, if we felt that it was material, we would suggest there be an autopsy.

Senator ROBB. Thank you very much, Madam Inspector General, and Mr. Chairman, I thank you. I regret that I am going to have to depart, but I will look to the record and I thank you for holding this hearing, and I thank all witnesses.

Senator KEMPTHORNE. Senator Robb, thank you.

Ms. Hill, let me ask you one more question, then I will try to get back on track so that you can complete your opening statement, then I very much want to hear from the other members.

There has been criticism of your investigators in the review process, and you heard how it was characterized, that perhaps they did not have the appearance of an objective manner but were just trying to sell the previous determination.

My question is, at what point do your investigators make contact with the family? I can see that if they only speak to the family after the review is complete, then they are there to tell them the final conclusion, and that is after the fact.

Ms. HILL. That is right.

Senator KEMPTHORNE. Do they make contact initially to say, we are now going to review your case?

Ms. HILL. Well, I have to bifurcate my answer here, between what was happening before I got there, and what has happened since.

You have hit upon an issue that was of concern to me, because as I said, there had been a process in place to do these cases, but only one case had been done when I got there under the old proc

ess.

I was very concerned, because I had found out that there were families whose cases we had had for many, many months and they had never been contacted. The response, had been that we have to take these things one at a time. We cannot get to them.

My feeling was that you should at least contact the family initially and find out their concerns. For instance, we had cases that were local cases that we really ultimately had no jurisdiction on, but since no one contacted the family right off the bat, the family might have waited months to find out that we could not do their case, and I think that is terribly unfair to these families. I mean, they are in a terrible situation to start with. They do not need that from us.

So we revamped our process and one of the things we do now is that we contact the families as soon as we get the case, as soon as we can. I am told by Mr. Mancuso who heads DCIS-he is the assistant Inspector General for Investigations-that in all but one case we have been able to contact the families, get their concerns, and in the one that we have not, it has been because the family has not been able to.

Senator KEMPTHORNE. Okay. I want to clarify, because you say you have revamped the process.

Ms. HILL. Right.

Senator KEMPTHORNE. As you pointed out in your testimony, January 1 of 1994 Congress was to receive a report.

Ms. HILL. I think it was July 1994. Yes, July of 1994 was the deadline in the statute.

Senator KEMPTHORNE. So by statute the Inspector General's Office was to have submitted that report to Congress, and it failed to do so.

Ms. HILL. That is right.

Senator KEMPTHORNE. What I want to make clear is, while there was a failure to follow a congressional statute, you did not arrive in your position until March of 1995, some 9 months later, approximately.

Ms. HILL. I can tell you, given my background, I spent 15 years working in the U.S. Senate-I am very sensitive to statutes; I know what goes into making a statute, and I am a lawyer, and I feel if it is in the statute you should comply with it. I was horrified when I found out we were 9 months behind the statutory deadline.

Senator KEMPTHORNE. I say that because-and, too, I think with the other gentleman on the panel, all of them are relatively new to their positions-while there have been problems and deficiencies, I do not feel that we then have to say that all of you must take ownership of all that may have happened before you assumed your watch.

We want to get everything out on the table that is wrong so that we can correct it, but also I am going to acknowledge that there is much that is right as well. But again, I know in looking at your backgrounds, which is extensive in criminal investigations and law enforcement, I think it is fair to say that this panel in your current positions are relatively new.

Ms. HILL. I appreciate that, Senator. I just do want to say, so that I am not totally being one-sided here, that the people who had worked on this before I got there explained to me that the reason it had been so long was first they had not had enough resources to do this, and second it was, in fairness, a totally new assignment for them. I mean, we are not homicide investigators.

Many of our people particularly in DCIS have that background because they are criminal investigators, but this was not something that an Inspector General's Office had done before.

Senator KEMPTHORNE. Which begs the question, is the Inspector General's Office the appropriate office to review the question of suicide, homicide, or accidental death?

Ms. HILL. Well, in my own view, certainly we are doing it, and I think given what we have put together we can do it and we have worked hard to try and get the expertise. But you can see what we

had to do to accomplish that. We have basically had to constitute a board which includes not only forensic scientists but also an FBI agent along with our own people. So even though we are conducting the review, it is being done with outside help, people who are experts in this area.

Senator KEMPTHORNE. Again, your testimony is part of the record, so if I could I would like to turn to the other members of the panel.

Ms. HILL. That is quite all right, Senator.

Senator KEMPTHORNE. Then again, I have more questions for everybody.

[The prepared statement of Ms. Hill follows:]

PREPARED STATEMENT SUBMITTED BY HON. ELEANOR HILL

Mr. Chairman and Members of the Subcommittee:

Thank you for the opportunity to discuss with you today my office's work regarding investigations conducted by the Military Departments with respect to self-inflicted deaths of members of the Armed Forces.

At the outset, let me say that I recognize and appreciate both the importance and the sensitivity of the issues and the cases that you are focusing on this afternoon. All of us who have worked on this issue have, inevitably and inescapably, been repeatedly touched by the pain and the frustration of the families. We know that their lives have been forever and tragically altered by the events that we have been statutorily directed to review. I want to again assure, not only the members of this Subcommittee, but also the families themselves, that we will continue to try to address their concerns about these cases as fairly, as accurately, and as expeditiously as possible.

The National Defense Authorization Act for Fiscal Year 1994 (Public Law 103160) contains Section 1185, "Investigations of Deaths of Members of the Armed Forces from Self-Inflicted Causes." Section 1185(a) requires the Secretary of Defense to review the Military Departments' procedures for investigating the deaths of members of the Armed Forces that may have been self-inflicted, and to report to the Committees on Armed Services of the Senate and House of Representatives. Section 1185(a) also requires the Secretary of Defense to issue regulations governing such investigations. Congress took this action in response to concerns expressed by surviving family members who believed that, in certain cases, the cause or manner of death had been incorrectly determined, or that facts and circumstances surrounding the death were not adequately investigated. On January 19, 1994, the Deputy Secretary directed that the Office of Inspector General conduct both the 1185(a) review and prepare the regulations required in the statute.

Section 1185(b) of the Act directs the office of the Inspector General to review investigations conducted by the Department of Defense in such cases, upon request of a family member citing "specific evidence of a material deficiency" in the investigation. In the military, these investigations are conducted by either the United States Army Criminal Investigation Command (CID), the Naval Criminal Investigative Service (NCIS) or the Air Force Office of Special Investigations (AFOS-1), collectively known as the military criminal investigative organizations (MCIOS).

Upon my confirmation as Inspector General in March 1995, I reviewed Section 1185 as it pertained to my office. Much to my dismay, I found that the report required by Section 1185(a) had not been completed and was, in fact, already 9 months behind schedule. I also found that, although a total of 44 cases had been accepted for review by our office under Section 1185(b), the review of only one case had been completed and a related report issued.

It was clear to me that the process being utilized at that time to address Section 1185 issues was not working in a timely fashion. Moreover, under the plan then in effect, it would have taken several more years to complete both the 1185(a) report and the existing 1185(b) cases. I was told that the delays had resulted from two factors: (1) the time initially required to gain expertise in an area-death investigations where the office had little prior experience and (2) insufficient resources. I immediately directed that the 1185(a) effort be promptly completed and assigned additional resources to both the 1185 (a) and (b) efforts.

By August 1995, despite some additional work on the 1185(a) report and the completion of three additional 1185(b) cases, I concluded that there was still not enough progress being achieved. As a result, I created a "task force" of sorts, with additional

management, writing, and legal resources, which was solely focused on completing the 1185(a) report as soon as possible. At the same time, I decided to transfer responsibility for the 1185(b) reviews from the Criminal Investigative Policy and Oversight Office to the Defense Criminal Investigative Service (DCIS) under the direction of Mr. Donald Mancuso, Assistant Inspector General for Investigations and the Director, DCIS.

The DCIS is the criminal investigative arm of the Department of Defense Office of the Inspector General and has at its disposal the necessary expertise, resources and organizational structure, including over 45 field offices, to best address this important and sensitive mission.

SECTION 1185(A) REPORT

Let me address the current status of our Section 1185 work, beginning with the report required by 1185(a). Our review originally focused on whether current policies, procedures, and training were adequate to ensure thorough, appropriate, and consistent criminal investigations of possible self-inflicted death cases, and whether family questions and concerns following the deaths were properly addressed.

To address the adequacy of existing policies and procedures, we first contacted a wide range of non-DOD law enforcement organizations to identify the standards they follow in conducting death investigations. Based on that information we developed a matrix of processes and steps used in the conduct of death investigations. We then reviewed the policies and procedures of the Military Departments to determine to what extent they addressed the investigative processes and steps included in the matrix.

During our review we also compiled and analyzed the concerns raised in the first 45 requests by family members for individual reviews under Section 1185(b) and found that many of the concerns stated by family members dealt with issues not directly related to the criminal investigation. Family members most often expressed concerns over the use of psychological autopsies, the administrative investigations, casualty notification and assistance, and personal property disposition. Accordingly, we expanded our review to cover these areas. In addition, we received correspondence from a member of Congress expressing concerns that the DOD publicly labeled certain deaths as suicides before an investigation had been completed. Therefore, we also reviewed the DOD and military Department policies and procedures for releasing information to the public.

Our report was issued on January 26, 1996. We found that the MCIOS already had in place adequate policies and procedures and training for death investigations. That is not to say, however, that those policies and procedures are always followed and we did identify some areas for improvement in the MCIOs implementation of policies and procedures. For instance, we recommended that all MCIOs have a comprehensive Family Liaison Program to ensure direct communication with family members until all investigative issues and concerns are reasonably resolved. I'm pleased to note that all three MCIOS now have Family Liaison Programs.

We noted that the CID and NCIS would benefit from an easy-to-use crime scene reference book similar to the AFOSI handbook. This type of crime scene handbook would help ensure proper field implementation of the existing policies and procedures. Therefore, we recommended that CID and NCIS create and issue a crime scene processing guide similar to the AFOSI.

Our report also identified improvements needed in various DOD and Military Department policies and procedures relating to psychological autopsies; administrative investigations; casualty notification and assistance; property disposition; and release of information to the public of particular importance is the issuance of an overall DOD policy for performing psychological autopsies. Psychological autopsies are most often conducted by military mental health professionals and are designed to assess a variety of factors that may have contributed to the death of the member of the Armed Forces. In effect, a psychological autopsy is an attempt to clarify why the death may have occurred. We found significant differences in how the Military Departments performed and used psychological autopsies. For instance, variations existed in when psychological autopsies were performed, who was responsible for performing them, and what qualifications individuals needed to perform them. In addition, DOD did not routinely perform management oversight or quality control reviews of psychological autopsies. Therefore, limited assurance existed that psychological autopsies were adequately performed when needed.

We recommended that the planned issuance of the overall DOD policy for conducting and using the results of psychological autopsies be expedited by the Assistant Secretary of Defense (Health Affairs). The policy should cover (1) when a psychological autopsy is to be performed, (2) who performs it (including qualifications), (3)

how the results should be used, (4) the establishment of a quality assurance review process, and (5) appropriate management oversight to ensure implementation of policy.

Our review found that many families were confused or concerned with the inconsistent presentation of information from administrative investigations which were also conducted into the death of the member of the Armed Forces. Commanders often order these investigations to determine if the death was in the line of duty and to identify any indicators which could be used in prevention and awareness programs. We recommended that, whenever possible, the MCIO criminal investigation should be conducted so as to provide as much information as possible to the commanders to satisfy administrative needs relating to the death of a member of the Armed Forces. Ideally, the need for separate administrative investigations might thereby be eliminated in many death cases. Where these investigations do occur, we recommended that they be conducted by adequately trained administrative investigating officers who should coordinate with the MCIO and with military judge advocate offices.

Our report discussed misunderstandings which occurred because of weaknesses in the implementation of the existing policies on casualty notification and assistance and disposition of personal property. Unfortunately, when casualty notification and assistance officers do not perform their assigned duties properly, misunderstandings between the family members and the Military Departments can easily occur and are often difficult, if not impossible, to rectify. Therefore, we recommended emphasizing the importance of performing the various duties associated with assisting the next of kin in death cases. We also recommended that family members be given a listing of all personal property items, including those initially deemed to be inappropriate for return, and then allow the family members a reasonable time to request that an item be returned. We recommended that the request by family members should be honored, absent some other compelling factor, such as legal restrictions on the shipment of potentially biohazardous items.

The final issue that our report addressed was release of information to the public. We found instances in which the press releases provided by Military Department Public Affairs Office personnel characterized the deaths as being from "apparent self-inflicted causes which were under investigation." Even though the DOD definition of the term "self-inflicted" includes accidental deaths, the phrase has been interpreted by the media and the public to mean the deaths are being investigated as suicides. We also did not find examples in any regulation to assist public affairs officers in issuing press releases. We recommended that the Defense Information School, where public affairs officers receive training, include instruction on the release of information concerning cause and manner of death in its training courses. We also recommended that the DOD prohibit the use of tentative or speculative conclusions in press releases, or the use of terms such as homicide, suicide, or self-inflicted; require coordination with the cognizant MCIC prior to all releases of information in death cases; and require that family members be notified prior to any public release by DOD of any name or other information concerning noncombat deaths.

While some of the report's recommendations have been implemented, we are still working with the Military Departments, the Office of the Under Secretary of Defense (Personnel and Readiness), the Office of the Assistant Secretary of Defense (Health Affairs) and the Office of the Assistant Secretary of Defense (Public Affairs) to resolve certain concerns and ensure proper implementation of the remaining recommendations.

On January 31, 1996, I issued DOD Instruction 5505.10, “Investigation of Noncombat Deaths of Active Duty Members of the Armed Forces," which established DOD policy for death investigations. This Instruction, which was effective immediately upon issuance, provides overall policy guidance for the investigation of noncombat deaths of members of the Armed Forces not medically determined to be from natural causes. 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. Minimum subject matter areas necessary for appropriate death investigation training are also specified. As recommended in the report, the Instruction also requires all MCIOs to establish a Family Liaison Program and specifies certain key program requirements that must be included.

The Instruction also provided new guidance for other issues such as public release of information and use of information provided by MCIOs for command determinations and programs. Specifically, any public release of information on this type of death will state that the cause manner of death are undetermined, unless and made Advance coordination among the cog

until an official deter