Chapter 1 Service and Sacrifice
Introduction
1.1
On 15 June 2012 the Minister for Defence Science and Personnel, the Hon
Warren Snowdon MP, asked the Committee to inquire into and report on the Care
of Australian Defence Force Personnel Wounded and Injured on Operations.
Context
1.2
As the Department of Defence (Defence) submitted to the Committee,
service in the Australian Defence Force (ADF) is demanding and unique. Defence
members may be required to work long hours, shift work and irregular hours
under harsh environmental conditions. As well as facing the possibility of
service in hostile areas, Defence members participate in other forms of
operational activities where a degree of personal risk still exists.[1]
1.3
The ADF has now been continually involved in Operations for over a
decade. The 2011-12 Defence Annual Report lists 17 separate Operations that
the ADF conducted in that period.[2] Since 1999, ADF
personnel have undertaken some 134,000 individual deployments, and no doubt many
have deployed on numerous occasions.[3]
1.4
While many of these Operations are carried out in benign environments, a
number are not. Consequently, there have been a number of ADF personnel killed
or wounded on Operations in recent times. The return to Australia and the
support to the families of those personnel tragically killed on Operations is
highly publicised, however, the management and support of those personnel who
are wounded is not so widely discussed.
1.5
The Minister for Defence Science and Personnel wanted the Committee to
assure itself that appropriate care and support is being given to ADF personnel
wounded on Operations in support of Australian objectives.
1.6
Since Operation SLIPPER (the ADF’s contribution to the war in
Afghanistan) commenced, 251 ADF members have been wounded in action in
Afghanistan (see also Appendix D). The types of injuries sustained can be
broadly categorised as:[4]
n Amputations;
n Fractures;
n Gunshot wounds;
n Hearing loss;
n Lacerations/contusions;
n Concussion/traumatic
brain injury;
n Penetrating
fragments; and
n Multiple severe
injuries.
1.7
This does not include those returning from Operations suffering psychological
injuries. Defence advised that acute psychological injury has not previously
been included in the ADF definition of battle casualties. However there are
circumstances where acute psychological conditions arise as a result of direct
contact with the enemy or as a result of direct exposure to the consequences of
enemy action. Criteria have been developed to provide a framework to classify
acute psychological casualties as battle casualties. The casualty must have a
clear diagnosis of acute psychological illness, be unable to perform their
duties on operations, and require medical return to Australia for their condition
within one month of exposure.
1.8
Members who develop mental health conditions on deployment but not as a
result of direct contact with the enemy or subsequent consequences of the
contact or post-deployment are not classified as battle casualties.[5]
1.9
The Department of Veterans’ Affairs (DVA) submitted that they have a
strong and proud history of supporting those men and women who have offered
service to our nation and the families who have made sacrifices to support
them. Over the course of its 94 years of operation, DVA claims to have
developed considerable knowledge and skills in understanding the risks and
effects arising from the unique and demanding nature of military service.
1.10
DVA is currently transforming its service delivery models to meet the
emerging needs of the contemporary cohort of veterans and their families. This
cohort is part of a broader base of clients for the Department, from veterans
and war widows aged over one hundred years old, to children as young as one
year old. DVA has an ongoing role in the care and support for this wide range
of clients.[6]
2013 Wounded in Action incidents in
Afghanistan
1.11
As at 22 April 2013, six ADF personnel have suffered wounds as a result
of battle in 2013; two were wounded in an improvised explosive device detonation,
three were wounded in small arms fire incidents and one was wounded as a
consequence of the conduct of operations.
1.12
As for the types of injuries sustained, one has suffered a gunshot
wound, four have suffered fragmentation wounds, and one suffered other injuries.[7]
Injuries sustained
1.13
Committee members were deeply moved by the stories of individuals who
contributed to the inquiry who have suffered a variety of injuries, wounds and
poor health as a result of their operational service. These included the effects
of an improvised explosive device (IED) causing a shattered femur,
hearing loss and loss of bowel control;[8] IEDs causing crushed
vertebrae[9] and other spinal
injuries;[10] IEDs causing shattered
limbs and traumatic brain injury;[11] IEDs causing shrapnel
injury;[12] multiple gunshot wounds;[13]
badly twisted ankles and subsequent compounded injuries;[14]
falls on patrol causing back and shoulder injuries;[15]
aircraft accidents and resultant serious, life-threatening/-changing injuries;[16]
knee injuries;[17] back injuries incurred
on exercise;[18] and bulged disks and
ankle injuries,[19] and other back injuries,[20]
caused by the requirement to carry heavy loads.
1.14
A large number of witnesses and submissions testified to the
debilitating effects of anger, depression, post-traumatic stress,
post-traumatic stress disorder (PTSD), and other mental health issues,[21]
and this will be addressed at length in the report.
‘You won’t be soldiering on. You’ve got PTSD.’ They
explained it all to me, and they went through the checklist of all the
symptoms: the lockjaw, the anger, the shakes, the shortness of breath, the
sleepless nights — I was getting on average two hours sleep a night — the
recurring dreams and everything.[22]
1.15
The Committee unreservedly salutes these and every other service member
wounded or injured on operations, whether physically or psychologically, and
thanks them for their service and sacrifice.
Issues
1.16
The issues considered in the course of the Inquiry included whether the
support systems for ADF personnel wounded on Operations are adequate both
immediately after injury and during return to Australia.
1.17
It also considered whether the ongoing support and care for ADF
personnel wounded on Operations provided by Defence and DVA is adequate. The Committee
also examined how these individuals are transitioned back into the workplace,
where possible, or into civilian life if they can no longer return to service.
Aim
1.18
The aim of the Inquiry was to ensure that appropriate systems and
processes are in place to optimise the potential for ADF personnel wounded or
injured on Operations to return to active duty or, at the very least, to lead a
satisfying and productive life post-wounding.
Definitions
Wounded
1.19
For the purpose of the Inquiry, any ADF member who is serving in
war-like conditions and is hurt during contact with the enemy is said to have
been ‘wounded’.
Injured
1.20
For the purpose of the Inquiry, any ADF member hurt in an incident that
has not been the result of enemy action in warlike conditions is said to have
been ‘injured’.
1.21
Defence advises that they use a similar series of definitions,
submitting that an ADF member who is serving in war-like conditions and is hurt
during contact with the enemy is said to have been ‘wounded’ and is defined as
a battle casualty. An ADF member who is hurt in an incident on operations that
has not been the result of enemy action is said to have been ‘injured’ and is
defined as a non-battle casualty. Defence submitted that the management of
wounded and injured is the same regardless of cause and follows the same
medical treatment system.
1.22
Defence also submitted that psychological injury is currently their most
difficult area for the provision of health care and the lessons learnt in Operation
SLIPPER have been and are applied to other operations and exercises.[23]
1.23
The Committee has not needed to distinguish between individuals based on
whether they were wounded or injured in relation to their post-incident care,
rights or treatment.
Committee comment
1.24
The Committee notes the Defence definition of psychological battle
casualties, however as shall be seen in the course of this report, the Committee
highlights that psychological damage from a combat incident can manifest much
later than one month after exposure.
Conduct of the Inquiry
1.25
The Committee received 36 submissions and five supplementary submissions
from organisations and the general public. Published submissions are available
on the Committee’s website. A list of all submissions and exhibits is included
at Appendixes A and B.
1.26
After hearing from Defence and DVA, the two Departments most responsible
for care of wounded and injured veterans in Canberra on Tuesday 9 October 2012,
the Committee travelled to Darwin to conduct its first closed hearing to talk
to two roundtable groups of soldiers. One group involved soldiers hurt during
contact with the enemy – wounded soldiers – and one involved soldiers hurt in
an incident not as a result of enemy action but still in warlike conditions –
injured soldiers – in order to understand the impact on the individual.
1.27
The Committee then commenced a series of public hearings involving
organisations supporting wounded and injured ADF or former-ADF members in
Canberra, Melbourne, Adelaide and Brisbane. In all 59 individuals came before
the Committee to give evidence. The list of witnesses is at Appendix C.
1.28
The Committee also invited Major General (MAJGEN) (Retired) John
Cantwell AO DSC to give evidence regarding his personal, and now public, battle
with PTSD, as detailed in his recently published book Exit Wounds.
General Cantwell, a former Commander of Australian Forces in the Middle East
Area of Operations (MEAO) and Deputy Chief of Army, gave very compelling
evidence and the Committee thanks him for his candour.
1.29
The Committee asked both Defence and DVA to reappear later in the
Inquiry in order to discuss some of the issues that had arisen during the
evidence gathering process, and finished up in Brisbane where it had begun,
talking to wounded and injured soldiers.
1.30
The Committee has been mindful to remember that recovery from wounds and
injuries, both visible and invisible, is an issue facing thousands of
Australians, and importantly their families, who have volunteered to risk their
lives in the national interest.
Structure of the report
1.31
The report is structured in a chronological order which broadly reflects
the terms of interest.
1.32
Chapter two begins by detailing the responsibilities of the Defence and
DVA in the care of wounded and injured soldiers. It then follows the path of
the wounded or injured soldier from provision of first aid in the immediate
aftermath of their injury, their transport to a medical facility, and the
in-theatre care provided to them. It considers the preparation individuals
receive prior to deployment, and begins to address how families of the wounded
and injured are included in the repatriation and recovery process.
1.33
Chapter three investigates the aeromedical evacuation process, be it via
Germany as is sometimes the case dependent on the severity of the injuries, or
direct to Australia. It also looks at the case management and support provided
to the family. It also considers the tax and leave entitlement implications of
an early return to Australia for the wounded soldier.
1.34
Chapter four addresses the rehabilitation of physical injuries, Defence
health care responsibilities, and rehabilitation and support programs available
to the individual.
1.35
Chapter five looks specifically at mental health issues, including PTSD and
also at broader mental health concerns. It considers psychological
rehabilitation, support provided to families and looks at an Army initiative
that combines physical and mental rehabilitation. It also considers how mental
health fits within a military culture.
1.36
Chapter six considers the three main outcomes available to an ADF member
wounded or injured on Operations; a return to work, re-mustering to a generally
less demanding specialisation, or discharge from the ADF. It looks at the
medical classification process and related policy, and begins to closely
consider the role that DVA plays in the recuperation process and looks at some
options for improving identification of service related illness and access to
health care.
1.37
Chapter seven considers the veteran who returns from operations and,
knowingly or unknowingly, is carrying physical or mental scars for which they
do not receive treatment. It looks at the topical issue of delayed onset
mental health conditions.
1.38
Chapter eight looks more closely at the role of the DVA, their claims
and compensation process, longer term support infrastructure and case
management.
1.39
Chapter nine ends the report with an acknowledgment of the many organisations
in Australia, many of which contributed to the Inquiry, that directly or
indirectly support our wounded and injured veterans, and looks at some wider
support considerations.