An official inquiry into the treatment of army veteran Jesse Bird has found there were significant failures by the Department of Veterans' Affairs (DVA) that increased his risk factors and that urgent changes are needed to protect other vulnerable veterans.

The inquiry's findings have not been made public but have been obtained by the ABC's 7.30 program.

Mr Bird died by suicide in June, just weeks after losing a claim for permanent impairment he had been pursuing for almost two years.

The decision came despite the Department accepting initial liability, in August 2016, for Mr Bird's post-traumatic stress disorder, major depressive disorder and alcohol abuse.

The 32-year-old Afghan war veteran had warned DVA he was suicidal and under severe financial stress.

Karen and John Bird at a memorial for Jesse ( ABC News: Michael Atkin )

He died with just $5.20 left in his bank account.

His family spoke exclusively to 7.30 in July demanding the claim decision be overturned and calling for sweeping reform to protect other vulnerable veterans.

In response, the Minister for Veterans' Affairs Dan Tehan ordered a joint inquiry to be conducted by Defence and DVA.

Jesse Bird (r) with his brother Brendan (l) and sister Kate (c) ( Supplied: Karen Bird )

It found the Department did not comply with the law, failed to do a face-to-face welfare check and declined to offer much-needed interim financial support.

Mr Bird's mother Karen and step-father John said they welcomed the findings but they needed to see evidence changes will be made.

"It is surprising they have admitted to so much wrong doing," John Bird said.

"The report confirms our suspicions that Jesse was let down extremely badly by the Department whose sole purpose was to look after him.

"We are still worried this report will join all the others about the mistreatment of veterans but the necessary changes inside the Department will never happen," Karen Bird added.

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The inquiry included high-ranking members of both departments including the Chief Operating Officer of DVA Liz Cosson and Chief of Staff of Defence Brigadier Georgeina Whelan.

They found six key points of concern:

DVA failed to comply with legislation and policy when it didn't register Jesse Bird's claim for his mental health conditions as including an incapacity payment claim. It also took 192 days to determine his claim when the benchmark is 120 days.

DVA failed to comply with legislation and policy when it didn't register Jesse Bird's claim for his mental health conditions as including an incapacity payment claim. It also took 192 days to determine his claim when the benchmark is 120 days. DVA failed to follow up with Jesse Bird during key points in his case because of problems with its computer system including when he lodged a complaint saying he was suicidal. The Department should have issued a face-to-face welfare check but didn't.

DVA failed to follow up with Jesse Bird during key points in his case because of problems with its computer system including when he lodged a complaint saying he was suicidal. The Department should have issued a face-to-face welfare check but didn't. DVA failed to offer interim permanent impairment payments despite repeated requests for them. Jesse Bird received his first and only incapacity payment after his death.

DVA failed to offer interim permanent impairment payments despite repeated requests for them. Jesse Bird received his first and only incapacity payment after his death. When the DVA delegate made determinations about Jesse Bird's case they did not discuss his various options with him contrary to policy and due to resourcing pressures.

When the DVA delegate made determinations about Jesse Bird's case they did not discuss his various options with him contrary to policy and due to resourcing pressures. Jesse Bird dropped out of counselling after two of his counsellors quit. He should have been handled as a complex case by the Veterans and Veterans Families Counselling Service but wasn't.

Jesse Bird dropped out of counselling after two of his counsellors quit. He should have been handled as a complex case by the Veterans and Veterans Families Counselling Service but wasn't. There was no connection between DVA and VVCS to ensure his wellbeing was looked after.

A picture of Jesse Bird sits next to his medals on his coffin ( ABC News )

The report says:

"The combination of Jesse's personal circumstances and continued frustration with delays and rejection increased his risk factors.

"As neither VVCS nor DVA had full visibility of the increasing risk factors … no one person understood the whole picture."

Despite being unemployed Mr Bird was never offered vocational or rehabilitation services.

The inquiry recommends 19 urgent changes to the service and experience of veterans including;

Examining the Department's non-compliance with legislation and policy to advise the Minister about any redress actions.

Examining the Department's non-compliance with legislation and policy to advise the Minister about any redress actions. Make it clear inside DVA that interim compensation payments are provided in appropriate cases.

Make it clear inside DVA that interim compensation payments are provided in appropriate cases. Identify indicators for veterans at risk to develop best practice case management models.

Identify indicators for veterans at risk to develop best practice case management models. Trial providing holistic care for veterans with an increased focus on transition support and vocational assistance.

Trial providing holistic care for veterans with an increased focus on transition support and vocational assistance. Consider compensation payments on a service related level of permanent impairment instead of delaying payments until the condition is stabilised as happened with Jesse Bird.

Consider compensation payments on a service related level of permanent impairment instead of delaying payments until the condition is stabilised as happened with Jesse Bird. Funding a trial of an independent legal advocacy service for veterans with potential compensation claims.

Karen Bird is calling on Mr Tehan to implement the changes as soon as possible.

"We are still being contacted by veterans who are battling caseworkers," she said.

"The veterans are being told there's no money for interim compensation payments and they should go to Centrelink.

"They shouldn't have to go begging for help."

Mr Tehan said the Government was committed to addressing the report's recommendations.

"In consultation with the Bird family, I asked the Departments of Veterans' Affairs, Defence and the Veterans and Veterans Families Counselling Service to thoroughly examine Jesse Bird's case.

"From this review, the Government wanted to gain a deep understanding of how we can continue to improve the Department of Veterans' Affairs and how it services veterans.

"After consulting with the Birds on the final recommendations, the Government is committed to addressing the recommendations made in the report and I will have the progress against each recommendation reviewed by an independent expert after 12 months."

If you are a veteran who needs help, or know one, you can call the Veterans and Veterans Counselling Service (VVCS) on 1 800 011 046.