A Navy investigation into four sailors assigned to the Mid-Atlantic Regional Maintenance Center who died by suicide found no causal links.
All four sailors who died were on limited duty at Mid-Atlantic Regional Maintenance Center, although their reasons differed. Three of them were seeking mental health resources prior to their deaths. They were all in their first enlistment, according to the investigation.
Access to mental health services was not a factor in the deaths, according to the investigation, although it noted that a lack of a medical department at the maintenance center led to a communication breakdown between medical facilities and the command. MARMC does not have a chaplain or embedded mental health professional assigned to the facility.
“A properly staffed medical department, to include an individual with a clinical (i.e., Independent Duty Corpsman/IDC-like) background, could promote improved continuity of care and serve as a central POC to facilitate the monthly meetings between the [Medical Treatment Facility] and the Command to review LIMDU cases and discuss issues or concerns related to patient care,” according to the report.
MARMC was also ill-equipped to handle suicidal sailors, according to the report. The maintenance center had not run a suicide prevention drill in three years, and it did not have plans for reintegrating sailors who had displayed suicide-related behaviors or what actions to do after a suicide.
Two of the sailors that exhibited suicide-related behaviors were not referred to the Navy’s Sailor Assistance and Intercept for Life, which offers constant contact for sailors who are demonstrating suicide ideation and offers additional mental health support.
“SAIL referrals were not made in either of the above cases due to a lack of clarity regarding the definition of an SRB,” according to the report.
The investigation report defines suicide-related behaviors as self-harming behavior, suicide ideation or a suicide attempt.
If SAIL was implemented properly at MARMC, it could better prevent suicides, according to the investigation.
The report also noted that there is a lack of handoffs between commands and MARMC for sailors on limited duty, which makes it harder to assess sailor needs and risks. MARMC leadership also need to be more attentive to sailors who request leave when experiencing crisis, as this can prevent someone from intervening at a critical point, according to the report.
The four sailors all died within a month of each other from gunshot wounds, and the report noted that firearms access was an issue, highlighting that the sailors did not surrender firearms as a safety precaution or use gun locks as an added safety measure, according to the Navy’s investigation into the deaths.
The Department of Defense’s Independent Review Commission on Suicide noted the use of firearms in suicides in their 2023 report. The commission recommended a number of changes about firearms, including ones to the sale of firearms on DOD property.
Gun locks were offered to some of the sailors who died, but the sailors refused, according to the investigation.
One of the recommendations in the report is to develop a screening for sailors who are in crisis before granting personal leave.
Other recommendations include having suicide prevention and awareness as part of the indoctrination and assessing MARMC’s staffing to make sure there are enough people to oversee the limited duty sailors.
The investigation does not recommend punitive action against MARMC or its leadership.