Editor’s note: This report contains discussion of suicide. Troops, veterans and family members experiencing suicidal thoughts can call the 24-hour Suicide and Crisis Lifeline at 988 or 1-800-273-8255, texting 838255 or visiting VeteransCrisisLine.net.

The suicides of four sailors assigned to the same unit in Virginia within a span of 28 days late last year were not directly connected, according to a service investigation released Thursday. But the losses all involved sailors who had accessed Navy mental health services and were dealing with “family, financial, medical and career-related factors.”

Electronics Technician 2nd Class Kody Decker died by suicide on Oct. 29 and Electronics Technician Seaman Cameron Armstrong took his life on Nov. 5, while Machinist’s Mate Fireman Deonte Autry died by suicide on Nov. 14.

All three men were 22-years-old. Twelve days later, on Nov. 26, Fire Controlman 2nd Class Janelle Holder, 39, ended her life as well.

The investigating team assessed that “access to personally owned firearms and unwillingness to surrender access to lethal means, to include the use of gun locks, was a causal factor in the deaths.”

All four were in their first enlistment as they grappled with various life challenges.

The sailors were all in a limited-duty, or LIMDU, status at the Mid-Atlantic Regional Maintenance Center in Virginia, a sprawling command responsible for overseeing the area’s ship maintenance and a place to put sailors who required LIMDU status.

There was a lack of communication between MARMC coordinators and military treatment facilities, and this “fractured” situation led to “blind spots” when it came to LIMDU sailors seeking mental health assistance, which investigators cited as a contributing factor in the deaths.

Limited-duty sailors were also not properly managed or monitored within the command.

When the sailors accessed Navy mental health services they all appeared to receive “timely and dedicated medical care for their respective condition,” according to the report.

While command climate surveys at MARMC were not filled out by many of the sailors or civilians working there, interviews done by investigators did not reveal a toxic command climate.

Since the deaths, MARMC has added on-site mental health and resiliency counselors, along with chaplains, to address “a need that was unfulfilled prior to the four deaths.”

Because large regional maintenance centers are fast-paced, industrial environments, they are not well-suited for managing and overseeing LIMDU sailors, investigators wrote.

If the Navy wishes to keep putting limited-duty sailors at the Mid-Atlantic and Southwest Regional Maintenance centers, the investigation found, it will need to beef up billets to address oversight shortfalls.

MARMC struggled to implement the Navy’s suicide prevention program, but investigators noted that those struggles reflect “broader issues that have been documented across the Navy regarding the effectiveness” of that prevention effort.

The investigation recommends 25 reforms to how the regional maintenance centers look after such sailors, as well as reforms to better track these sailors elsewhere in the Navy.

Navy spokeswoman Lt. Alyson Hands said Thursday that implementing the full list of recommendations “will take time and resourcing.”

“The Navy will continue to work diligently with our partners in Congress to ensure full and timely funding for the critical steps to ensure our Sailors receive the quality of service they deserve,” Hands said.

Already, MARMC has received additional chaplains and other support personnel and is approved to hire additional mental health counselors, she said, and gun locks have been provided to hundreds of command members.

A long-term campaign is being planned so that MARMC leadership can better understand morale and mental health crises, and a cross-Navy effort is in the works to better care for and track sailors who find themselves in a limited-duty status.

“Suicide is complex and rarely the result of a single stressor,” Rear Adm. Eric Ver Hage, who commands the Navy Regional Maintenance Center, wrote in his endorsement of the investigation. “It is often difficult to pinpoint the specific cause of suicide, but based on this investigation, to understand the causal and contributing factors in these four cases, we have taken steps to effect positive lasting change within the MARMC and greater (Regional Maintenance Center) populations to prevent similar tragedy in the future.”

ET2 Kody Decker

Earlier in 2022, Decker had been an “early promote” recommendation, with his supervisor noting his “outstanding” work as a petty officer third class aboard the amphibious assault ship Bataan.

He was posthumously promoted to second class after his death and left behind a wife and 8-month-old son, according to the investigation.

Shipmates remembered “his outgoing personality, infectious attitude and strong communication skills.”

But the investigation suggests life on Bataan took a toll on the young sailor. The ship was high tempo “even when the ship was in-port, with no time off,” and that harsh environment was listed as a contributing factor to his mental health stressors.

Decker first sought help in August and started going to therapy after experiencing suicidal ideations and relying on alcohol as a coping mechanism.

“Decker stated that he was worried that his suicidal ideations might progress into actions in the future,” the investigation states. “He also admitted to keeping a loaded firearm at his bedside for protection and was resistant to having his personal firearms secured.”

During five days of inpatient therapy, Decker said he was thinking of leaving the military and becoming an electrician.

After reporting to MARMC in August, he continued to receive mental health care and the investigation notes “steady improvement in his mental health” after leaving sea duty.

“A potential intervention opportunity” was missed when the command official in charge of drug and alcohol abuse treatment was not informed of Decker’s alcohol abuse diagnosis.

On the evening of Oct. 29, Decker was found dead in his vehicle in the parking lot of a Kroger grocery store in Virginia Beach.

ETSN Cameron Armstrong

Shipmates remembered Armstrong as a quiet sailor who generally kept to himself in the workspace, but who enjoyed anime videos and sometimes spoke of the admiration he had for his spouse.

But Armstrong struggled with obesity, and the investigation found that the restrictions put in place during the early stages of the COVID-19 pandemic negatively impacted his physical and mental health.

He reported being anxious and depressed in 2019.

In 2021, he told a mental health provider “that the military was a major stressor to him, that he wanted to get out of the Navy, and that he often does not want to get out of bed.”

“The provider stated that further evaluation was necessary to determine suitability for continued military service,” the investigation states.

After arriving at MARMC, Armstrong answered “yes” when a supervisor asked if he wanted to kill himself.

That supervisor put Armstrong in touch with the MARMC suicide prevention coordinator and arranged to meet him at the ER.

There, Armstrong told his supervisor he no longer wanted to kill himself and just wanted to go on leave, and his supervisor told him that was fine.

Investigators noted that “continuity of care” was a contributing factor in Armstrong’s death, but that the young man was also “occasionally a noncompliant or uncooperative medical patient.”

Marital stress also played a role in his issues.

“Potential intervention opportunities were missed when ETSN Armstrong was not provided the full range of support during periods of crisis,” according to the investigation.

He was not referred to a mental health program or screened for alcohol dependency, which might have provided command officials with a better understanding of what he was going through.

Armstrong was also issued consecutive physical fitness assessment waivers with no follow-on action and was non-deployable for more than 12 consecutive months, These moments were listed as missed chances to intervene and help him further.

He was found dead by a civilian friend in his Norfolk apartment on Nov. 5.

MMFN Deonte Autry

Autry was remembered as a caring young man who looked after those around him.

“He could draw a crowd with his sense of humor,” the investigation states. “He was an optimistic, bubbly guy that loved to joke around. He talked about his family and visiting them.”

Neurological issues led Autry to leave the carrier George Washington and report to MARMC in a LIMDU status after he lost consciousness on the carrier while on watch.

Medical providers never communicated any medical concerns or patient information about Autry to MARMC.

Despite the health issues and multiple seizures, Autry’s lead petty officer recalled him “seeming excited and happy” about his upcoming medical appointments.

He was found dead in his Newport News apartment Nov. 14 after he didn’t show up for work.

Roughly 20 sailors attended his Nov. 26 funeral in Marshville, North Carolina, including old friends from George Washington and new friends he made at MARMC.

Investigators were unable to determine if his medical condition and prescribed medications played a role in his death.

“Leading up to the day of his suicide, there were no findings that point to a reason or crisis event in MMFN Autry’s life that would create a concern for or a suspicion of suicide,” the investigation states.

FC2 Janelle Holder

Holder enlisted at the age of 39. She had always wanted to serve but weight issues had prevented that earlier in her life.

She reported to the guided-missile destroyer Gonzalez and was remembered as a “key contributor” to the combat systems missile division.

Holder first sought help in March 2020 at Naval Medical Center Portsmouth, Virginia, claiming suicidal ideation.

Despite her struggles, Holder was ranked first out of 17 petty officers third class in her division and was dubbed a “top notch operator” in her June 2021 evaluation.

But suicidal thoughts continued. She continued to seek treatment, at one point asking for a new provider because the old one had suggested administrative separation and she wanted to stay in the Navy.

She also suffered from a herniated disc and “debilitating back pain” that impacted her quality of life and left her bedridden at times once she was on LIMDU and transferred to MARMC.

Holder took her life on the evening of Nov. 26.

Geoff is the managing editor of Military Times, but he still loves writing stories. He covered Iraq and Afghanistan extensively and was a reporter at the Chicago Tribune. He welcomes any and all kinds of tips at geoffz@militarytimes.com.

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