Recurring concern

Failure to ensure exercise commanders are competent in JSP539 safety requirements

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First reported 20 Jul 2015•Latest report 1 Nov 2019

Definition

What this concern includes

Includes failures of the JSP539 commander-competence process, including dissemination of JSP539 requirements, training, knowledge checks, competency verification and assurance that commanders understand and can apply the requirements for the exercises they command.

Not included

Excludes generic military training, leadership or staffing deficiencies not specifically tied to JSP539 competence or the safety of the relevant exercises.
Excludes failures in the substantive design or content of JSP539 where commander competence or implementation is not the identified unsafe condition.
Excludes operational exercise failures occurring after commanders have been reliably trained and verified, unless they also demonstrate a deficiency in the JSP539 competence-assurance process.
Excludes competence concerns involving personnel who do not command the JSP539-governed type of exercise.

Reports: 2
Individual concerns: 5
Date range: 2015–2019
Stated actions: 6

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Ministry of Defence2

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

1 Nov2019
Birmingham and Solihull
Concerns raised2
1. Inadequate commander training and understanding of JSP539
2. Lack of a system to disseminate JSP539 information and verify commanders’ knowledge
This report raised 20 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Brief commanding officers on JSP 539 through training, conferences and written communications, while inspecting units’ use of current policy.
  Stated by Ministry of DefenceStated in progress
2. Action
  Review the Unit Fitness Training Officer course to include relevant publications and provide required training.
  Stated by Ministry of DefenceStated in progress
3. Action
  Review the Unit Fitness Training Officer course and Physical Development Audit to increase focus on JSP 539 and WBGT readings.
  Stated by Ministry of DefenceStated planned
AI-generated summary

Joshua Hoole · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Joshua Hoole collapsed and died during an 8-mile, 25 kg loaded march as part of an annual fitness test at Dering Lines Barracks on 19 July 2016. He showed signs of heat illness before collapsing, and was declared deceased despite emergency treatment. The principal concerns included inadequate training and understanding of heat-illness guidance, failure to check or correctly measure the Wet Bulb Globe Temperature, inadequate communication about heat-illness cases, and failure to stop the activity when students became unwell.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate commander training and understanding of JSP539
Wider context from the report
“2. I heard evidence at the inquest that Commanders were unaware of the provision of JSP539 and how they should apply to an annual fitness test (AFT). Several said they have not been trained on the publication and those that had seen it confirmed they did not understand the full effects of it and had not been trained on it. ”
Source location
Joshua Hoole · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a system to disseminate JSP539 information and verify commanders’ knowledge
Wider context from the report
“• Commanding officers were unaware of the JSP539 and there was no clear system in place either to disseminate information or to check those commanding had the requisite knowledge. ”
Source location
Joshua Hoole · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Brief commanding officers on JSP 539 through training, conferences and written communications, while inspecting units’ use of current policy.

Verbatim wording from the response
“Having recently spent time with the families of the three soldiers who died in Brecon in 2013, the Commander Field Army has been rigorous in addressing the failure to learn lessons from this tragic event. Awareness of Joint Service Publication 539 - Heat Illness and Cold Injury: Prevention and Management (JSP 539), by commanders has improved since 2013 and since Cpl Hoole’s death, but we continue to do more. All Commanding Officers (COs) are briefed on JSP 539 during pre-employment training and, to further raise its profile, actions are being taken to reinforce the importance of its content (See para 1a). A significant amount of work has recently been completed to address the training shortfall in the matter of risk assessments.”

Source location
2019-0458-Response-by-MOD
Page 1 · response
Published 2 January 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the Unit Fitness Training Officer course to include relevant publications and provide required training.

Verbatim wording from the response
“Headquarters Royal Army Physical Training Corps, as the Training Requirements Authority is conducting a review of the content of the Unit Fitness Training Officer course. This review will ensure that all relevant publications are included in the”

Source location
2019-0458-Response-by-MOD
Page 6 · response
Published 2 January 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the Unit Fitness Training Officer course and Physical Development Audit to increase focus on JSP 539 and WBGT readings.

Verbatim wording from the response
“It is the instructions contained in MATT 2 and AGAI Vol 1 Ch 7 that provide commanders on the ground with the necessary information and guidance on how to safely conduct an AFT. JSP 539 is the top level, overarching, publication and MATT 2 and AGAI Vol 1 Ch 7 are complementary single service policy documents that provide additional information to commanders. MATT 2 and AGAI Vol 1 Ch 7 make specific references to direction and guidance contained in JSP 539. In order to increase awareness of JSP 539, the Army is conducting a review of the Unit Fitness Training Officer course (training) and the Physical Development Audit (assurance) to ensure that both include an increased focus on JSP 539 and WBGT Monitor readings. This review will be complete by 30 March 2020.”

Source location
2019-0458-Response-by-MOD
Page 4 · response
Published 2 January 2020
Open published response
20 Jul2015
Birmingham and Solihull
Concerns raised3
1. Failure to verify requisite knowledge and training of exercise commanders
2. Failure to instruct commanders to adhere to JSP539 during specialist exercises
3. Lack of JSP539 training for senior commanders
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Issue urgent safety advice reminding Armed Forces personnel about climatic-illness information, risk assessment, prevention, and treatment.
  Stated by Ministry of DefenceStated completed
2. Action
  Provide JSP 539, heat-illness, and treatment training to commanders and specialist units, with Directing Staff training and student procedural declarations.
  Stated by Ministry of DefenceStated completed
3. Action
  Require formal Director-level waivers and documented mitigation when exercises operate outside JSP 539 parameters.
  Stated by Ministry of DefenceStated completed
AI-generated summary

Craig Roberts and 2 others · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Craig Roberts, James Dunsby and Edward Maher were reserve soldiers taking part in a specialist-unit selection test march in the Brecon Beacons in July 2013. The report identifies concerns about heat-illness guidance, training and risk assessment, communication of weather information, medical planning, emergency response, tracking of slow or static candidates, and the failure to implement lessons from previous incidents.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to verify requisite knowledge and training of exercise commanders
Wider context from the report
“(4) Senior commanders had received no training before this tragedy on JSP539. There was no clear system for disseminating information to different regiments and no means to check those commanding this type of exercise had the requisite knowledge and training. ”
Source location
Craig Roberts and 2 others · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to instruct commanders to adhere to JSP539 during specialist exercises
Wider context from the report
“(3) Witnesses at the inquest confirmed that before this tragedy they were unaware of the main guidance for heat illness namely JSP539– joint service code of practice - climatic illness and injury in the armed forces Version 2:1 November 2012. Some witnesses in a very senior position – AA and SR44 – claimed, respectively, that this guidance was not applicable to this endurance exercise. Others ████████ and ████████ confirmed it was the current guidance and no separate guidance had been issued for exercises with this specialist group. I am concerned that the MOD still do not have a clear plan and guidance for the detection of heat illness in this type of exercise and have failed to instruct commanders of the importance of adhering to JSP539 for this type of activity. ”
Source location
Craig Roberts and 2 others · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of JSP539 training for senior commanders
Wider context from the report
“(4) Senior commanders had received no training before this tragedy on JSP539. There was no clear system for disseminating information to different regiments and no means to check those commanding this type of exercise had the requisite knowledge and training. ”
Source location
Craig Roberts and 2 others · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Issue urgent safety advice reminding Armed Forces personnel about climatic-illness information, risk assessment, prevention, and treatment.

Verbatim wording from the response
“JSP 539 provides the principles which should be applied by all UK Armed Forces in order to minimise the risk of climatic injuries. To ensure all commanders are aware of the importance of adhering to JSP 539, the Defence Safety Authority recently issued an Urgent Safety Advice notice on Climatic Illness and Injury Awareness and Prevention. This advice reminds Armed Forces personnel of the sources of information and risk assessments to be undertaken in order to try and prevent and treat heat illness (and cold injury).”

Source location
2015-0228-Response-by-MOD
Page 3 · response
Published 20 July 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide JSP 539, heat-illness, and treatment training to commanders and specialist units, with Directing Staff training and student procedural declarations.

Verbatim wording from the response
“Commanders of Specialist Military Units are all now briefed on JSP 539 as part of their pre-appointment training. All specialist units will now receive appropriate training packages on JSP 539, heat illness and its treatment. If a requirement to operate outside the parameters of JSP 539 is identified by the Directing Staff, then a formal waiver must be issued by Director Specialist Military Units. This approval requires an explanation of the measures in place to justify such a deviation as well as the operational necessity for them.”

Source location
2015-0228-Response-by-MOD
Page 3 · response
Published 20 July 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require formal Director-level waivers and documented mitigation when exercises operate outside JSP 539 parameters.

Verbatim wording from the response
“Commanders of Specialist Military Units are all now briefed on JSP 539 as part of their pre-appointment training. All specialist units will now receive appropriate training packages on JSP 539, heat illness and its treatment. If a requirement to operate outside the parameters of JSP 539 is identified by the Directing Staff, then a formal waiver must be issued by Director Specialist Military Units. This approval requires an explanation of the measures in place to justify such a deviation as well as the operational necessity for them.”

Source location
2015-0228-Response-by-MOD
Page 3 · response
Published 20 July 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Inadequate commander training and understanding of JSP539

Lack of a system to disseminate JSP539 information and verify commanders’ knowledge

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised3

Failure to verify requisite knowledge and training of exercise commanders

Failure to instruct commanders to adhere to JSP539 during specialist exercises

Lack of JSP539 training for senior commanders

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Actions described in response 3

Actions described in response 3