Coroner says DVA acted contrary to law and policy in Jessie Bird case

A Victorian coroner has handed down her formal inquest report into the death of former Australian infantry soldier Jesse Bird.

FILE PHOTO (August 2009): Private Jesse Bird interacts with a local at a vehicle check point while deployed with Mentoring and Reconstruction Task Force 2 (MRTF2) in Afghanistan. Photo by Corporal Rachel Ingram.

On 27 June 2017, Jesse Stephen Bird, a 32-year-old army veteran, was found deceased in his home in St Kilda, surrounded by his service medals, military equipment and documentation relating to his service history, mental health issues and Department of Veterans’ Affairs (DVA) claims

It was apparent that Jesse Bird had taken his own life.

Victorian Coroner Jacqui Hawkins examined the case and handed down her formal findings on 7 April 2020.

She found that Jesse had a history of psychological injuries, including post-traumatic stress disorder (PTSD), associated with his service in the army – that Jesse’s mental health had deteriorated in the years leading up to his death in the setting of financial and emotional stressors that were exacerbated by delays and difficulties he faced in claiming financial support and compensation from DVA for his service-related psychological injuries – and that DVA had acted contrary to law and policy.

Coroner Hawkins said her inquest examined Jesse’s experiences during his army service, subsequent transition from the army to civilian life, and navigation of the DVA compensation system.

“Having investigated the death of Jesse Stephen Bird, and having held an inquest in relation to Jesse’s death on 2-3 May 2019 and 4 February 2020 at Melbourne, I make the following findings, pursuant to section 67(1) of the Coroners Act,” Coroner Hawkins said in her report.

(a) that the identity of the deceased was Jesse Stephen Bird, born on 1 November 1984;

(b) that Jesse died at 3/45 Wellington Street, St Kilda, sometime between 25 June 2017 and 27 June 2017 from 1(a) neck compression in the circumstances of hanging;

(c) in the circumstances described [in an earlier part of the report].

I find that Jesse experienced difficulty in his transition from Defence to civilian life.

I further find that he suffered from mental ill health directly linked to traumatic experiences he was exposed to in Afghanistan.

Jesse’s mental health issues, including his diagnosis of PTSD, caused him difficulties in maintaining interpersonal relationships and obtaining and maintaining sustainable and meaningful employment, which resulted in significant financial instability.

I further find that Jesse’s personal difficulties were exacerbated by the frustrations he experienced in interacting with, and navigating, DVA’s complex compensation and rehabilitation system.

Despite the medical care Jesse received, together with the love and support that was provided by his family, friends and advocates, I find that Jesse intentionally ended his own life in the setting of mental ill health and significant financial and emotional stressors.

I acknowledge that DVA conceded that there were failures surrounding the management of Jesse’s case and that these failures contributed to Jesse’s decision to end his life.

My investigation revealed that a practice had been established within DVA that was contrary to law and policy.

The scope and nature of my investigation meant that I was unable to delve deeper into an examination of the whole DVA compensation system. However, I am satisfied that subsequent reforms have been implemented to identify and remedy any residual systemic issues in the claims process.

I am further satisfied that there seems to be a genuine commitment by DVA to improving their systems and processes.

Jesse’s death was the catalyst for comprehensive system-wide review and reform of DVA and Defence processes.

I was extremely impressed with the evidence of Major General Fox and Ms Cosson who have both served in the Australian military and bring with them essential operational and lived experience.

I am encouraged by the commitment both Defence and DVA have made to continually improving their organisations.

I am unable to say whether Jesse’s death would have been prevented had these reforms been in force at the time of Jesse’s claim.

However, it is apparent that there have been improvements in veterans’ experiences of the DVA claims processes since Jesse’s death as a consequence of these reforms.


The full text of the Coroner’s Inquest into Jesse Bird’s suicide can be found here .









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Posted by Brian Hartigan

Managing Editor Contact Publishing Pty Ltd PO Box 3091 Minnamurra NSW 2533 AUSTRALIA

3 thoughts on “Coroner says DVA acted contrary to law and policy in Jessie Bird case

  • 19/04/2020 at 1:53 pm

    Coroner Quote:

    “My investigation revealed that a practice had been established within DVA that was contrary to law and policy.”

    Due to (1) the enormously limited scope of her investigation and (2) the overwhelming game of misdirection put forward by Defence and DVA – i.e. the government’s “helpful” sleight-of-hand relationship building effort made to appear compassionate – the Victorian Coroner could not do a deep dive into DVA trade-craft i.e. she did not investigate the routine and common practices’ consciously conceived, engineered, sanctioned and implemented from the highest levels within DVA’s legal area, Senior Executive Staff (SES), Executive level (EL), and DVA’s in-house permanent legal contractor and law firm tasked with making the entire Veteran Compensation System (VCS) a layered and complex riddle through a tiered and cyclic maladministration loop that undermined and removed the two Veteran Evidence Standards that underpin the Defence Service Contract/Veteran Compensation (we have your back) legal jurisdiction: i.e. (a) the Balance of Probabilities (BoP) and (b) Reasonable Hypothesis (RH) evidence standards that DVA Legal and its in-house permanent law firm and The Commissions (eg MRCC) engineered out of existence, by installing a cyclic compounding criminal evidence test that exceeds the criminal evidence standard, beyond reasonable doubt.

    Deafening Silence:

    If you read the Victorian Coroner’s own report what screams the loudest for me is:

    1. The Victorian Coroner actually regurgitates Defence and in particular, DVA’s marketing and puffery without any fact checking,

    2. The Coroner fails to clearly spell out that both (A) DVA and (B) The Commissions (two very separate legal entities) ‘Operated well beyond legal power’ and did so by virtue of,

    3. installing by administrative stealth, a compounding veteran’ evidence standard contrary to primary statute, veteran’ legislation and relevant case law.

    Beyond Power – the ongoing need for a Royal Commission:

    The simple truth is: many (i) veteran’ completed and (ii) veteran’ attempted suicides, have occurred as a direct result of deliberate exhaustion methods DVA and their legal teams created and installed right across DVA’s systems, practice, foot print and culture——the beyond power ‘compounding-cyclic evidence test’ being only one of those methodologies.

    A true Royal Commission would serve in not only exposing that Jessie is one of many directly impacted by these secret changes to the ADF service contract, it would expose the fact that senior public servants, The Commissions and law firms (all separate legal entities) have played a key role in design, installation, training and litigation support i.e. wasting public funds fighting veterans, to reinforce their illegal ‘Beyond Power’ practice and fake veteran evidence tests that has additionally seen many other forms of ‘Beyond Power’ practice installed e.g. secret sub-contracted law firms performing and writing so-called ‘independent internal reconsideration determinations’ for DVA Delegates.

    Moreover, every veteran’ attempted suicide and veteran’ completed suicide that has followed any DVA alleged ‘Independent Internal Reconsideration Determination’ should be thoroughly investigated in order to discover the true decision maker…. no wonder Government and Minister Chester are pulling out all stops e.g. creating veteran division, in order to prevent a REAL Royal Commission.

    (1) Lest We Forget 1RAR veteran Jessie Bird…. (2) the other 500 plus veterans’ who completed suicide Jan 2001 to current day…… and (3) the 1000+ veterans who as “Clients of DVA” additionally attempted to kill themselves Jan 2001 to current day.

  • 19/04/2020 at 11:40 am

    The PM announced a permeant Commission into Veterans Suicide and an Advocate recently. As usual, the Government is full of announcements but low on action. Where is the Commissioner or Advocate????. Have they gone AWOL????
    When is the DVA going to accept responsibility for their actions???? I would hope that some day some one will have the intestinal fortitude to lodge a criminal/civil case against them. The Government is lacking on taking responsibility in these matters. I wrote to the PM in December 2019 regarding the Veterans Suicide matter etc. I only received a BS reply yesterday. How many more Veterans need to commit suicide before the Government takes disciplinary action against the shinny bums hiding in the DVA bubble?????

  • 19/04/2020 at 10:49 am

    And yet no charges laid! What’s new?


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