A System on Trial: Why a Closed Mindset is Failing Our Veterans and Their Families

ByTom Sherwood, CEO, Oliver Blackford MD, Clinical Lead, Sentra AI

Executive Summary

The 'One is Too Many' (OiTM) report gave a voice to the families left behind by veteran suicide. Through their narrative, the authors highlighted a devastating truth; they spoke of not being heard, valued, or empowered. They spoke of watching their loved ones decline while feeling powerless within a passive and disjointed care system. Their testimony is not just a collection of tragic stories; it is an indictment of the status quo. It is the evidence we must now present alongside a stark fact from the report itself: 52.9% of veterans who died by suicide had already been identified as vulnerable and were connected to services.

We would like to put forward the motion that this catastrophic outcome is not a question of resource intensity, but of a fundamentally flawed approach. A system that produces such results is not merely insufficient; its core philosophy is wrong. By deconstructing the key themes of failure identified in the OiTM report—from a lack of knowledge and "passive care" to "compassion fatigue" and "family exclusion"—we will demonstrate how a closed, analogue mindset is demonstrably failing. It is time to ask the hard question: Is the current model of care, in its refusal to innovate, actively contributing to these preventable deaths?

1. The Indictment: Family Testimony and the 52.9% Failure Rate

Before we can discuss strategy, we must confront the testimony. The OiTM study captured a painful pattern in family stories: witnessing the slow disintegration of a loved one while feeling helpless. They tried to intervene and be part of the solution, but what did the system offer? The report is unequivocal in its indictment, revealing that families experienced "passive care, often disjointed, uncoordinated, with frequent deficits in compassion and understanding." Rather than being treated as crucial allies, they were relegated to the role of bystanders. The report gives this failure a name: "Family exclusion." It is a foundational and undeniable failure.

If family testimony is the witness statement, then the 52.9% statistic is the incontrovertible evidence that the current care system is on trial. Over half of these tragic deaths occurred while individuals were supposedly within the circle of care, a fact which reveals this to be a profound failure of efficacy, not simply one of access. This failing approach comes at a staggering operational cost, stretching charities, NHS trusts, and healthcare providers to their breaking point. As a result, veterans can face waits of up to nine months for therapy, leaving them and their families in an extended state of unsupported risk. This is not a sustainable model; it is a system clogged by its own inefficiency, failing both those who have served and the dedicated staff striving to help them.

2. Deconstructing the Failure: A Systemic Breakdown

The OiTM report's analysis provides a clear framework for understanding how this failure occurs. The "superordinate themes" derived from family narratives are not separate issues; they are interconnected components of a single, systemic collapse.

2.1 The Foundation of Failure: Lack of Knowledge and Passive Care

The root of the system's dysfunction, as identified by the OiTM report, is a fundamental "Lack of knowledge, training, and education." Many service providers lack a foundational understanding of military culture, the nuances of complex presentations like co-morbid PTSD and substance misuse, and the specific language and stressors of service life.

This lack of knowledge directly contributes to the second major failing: "Passive Care." Clinicians, lacking the confidence to engage effectively, default to a reactive "wait and see" strategy. They fail to conduct thorough initial assessments or monitor for early signs of deterioration, offering no pre-emptive support during the critical transition from military to civilian life. The system doesn't initiate action; it merely awaits a crisis. This passivity stems not from indifference, but from a workforce inadequately equipped with the specialised knowledge necessary to care for the veteran community.

2.2 The Human Cost: Compassion Fatigue and Family Exclusion

When a system doesn't understand its patients, it inevitably grows frustrated by them. This leads to the third theme: "Compassion Fatigue." The veteran, often returning with complex needs like substance misuse or aggression — coping mechanisms for trauma — becomes the "unpopular patient" or “the frequent flyer” in emergency or mental health care services. The family narratives describe dismissive and disrespectful attitudes from providers. This is not just poor bedside manner; it is a symptom of a system burnt out by cases it feels ill-equipped to handle, leading to premature discharge and disengagement.

This fatigue directly reinforces the most painful failure: "Family Exclusion." Instead of being seen as a vital resource with unparalleled insight, the family is treated as an additional complication. The report details how their input on symptoms is dismissed, how "confidentiality is used as a barrier" to shut down communication, and how there is a complete "lack of carer/family support and safeguarding." The very people who could provide the most valuable intelligence are actively pushed away.

2.3 The Structural Collapse: Poor Accessibility and Communication

The final layers of failure are structural. "Poor service accessibility and availability" means that even when a veteran seeks help, the system is not built for them. Eligibility criteria are too limited to address complex co-morbidities. Treatment facilities are often not military-specific or trauma-informed, defaulting to generic approaches. This is compounded by long delays and a lack of prioritisation, leaving veterans feeling abandoned.

This is all held together by the fifth theme: "Poor collaboration and communication between services." The lack of integrated support, transparency, and care continuity creates the "revolving door" of repeated referrals. This process is not just inefficient; it is actively harmful, forcing veterans and their families to retell their traumatic stories to a succession of disconnected providers, leading to the "re-traumatisation" the report highlights.

3. The Consequence: A Broken, Episodic Model

The cumulative result of these failures is a fragmented, episodic system focused on short-term crisis stabilisation, not long-term well-being. Even the best-resourced charities, constrained by this model, offer interventions like 12 intense sessions. While crucial for immediate survival, this approach is a hallmark of the problem. What happens after session 12? The veteran is often discharged back into the same environment, with no follow-up or relapse prevention. The mindset is focused on treating the acute clinical episode, not healing the person's life.

4. Reimagining Care: Technology to Break the Cycle

The current process is broken because its mindset is closed and its structure is analogue. To break it open, we must reimagine how care is delivered. Technology is the disruptive force required, not to replace clinicians, but to finally build the integrated, continuous, and family-inclusive system the OiTM report proves is necessary.

• Solving the Knowledge Gap: Technology provides the means to deliver on-demand, military-specific training and psychoeducation to clinicians at scale, thereby directly addressing the critical "Lack of Knowledge" that underpins the system's failures.

• Combating Passive Care: Digital tools enable continuous, low-touch monitoring of well-being, allowing for proactive engagement and early intervention. This shatters the reactive "wait and see" model.

• Empowering the Unheard: Secure, private digital platforms can give families a voice, allowing them to share observations and concerns without breaching clinical confidentiality. This directly combats "Family Exclusion" and turns bystanders into partners.

• Creating Continuity: Technology can create a unified thread of support that bridges the gaps between different services. It can automate follow-up, provide support during the nine-month waiting periods, and end the "revolving door" of re-traumatisation. It builds the communication and collaboration that the current system lacks.

5. A Call for a New Mindset

This is not a proposal for a single product, but a challenge to the entire sector. The failures laid bare in the 'One is Too Many' report are the direct result of an analogue, fragmented, and closed model of care, struggling to meet the needs of a complex, digital-age problem. The path forward requires a radical shift from a closed, clinician-centric model to an open, collaborative, and family-integrated ecosystem. Achieving this at scale is impossible without embracing technology. The tools to build a more responsive, inclusive, and effective system now exist; the only remaining barrier is the will to change.

6. Conclusion: A Verdict and a New Path

The evidence is clear, and the testimony is heartbreaking. A 52.9% failure rate among those already connected to services serves as a verdict on a system that, in its current form, is not fit for purpose. Its mindset is too closed, its processes too rigid, and its exclusion of the family is a fatal flaw. We can no longer afford to merely tinker around the edges. We must have the courage to declare that the current approach is fundamentally wrong. It is time to honour the families' testimony by reimagining the care we provide, and embracing technology is the essential, unavoidable first step on that path.