1 Nov 2019 Joshua Hoole · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 5
Failure to provide and communicate correct WBGT placement requirements View source Failure to refer and record heat illness cases in accordance with JSP539 View source Failure of MATT2 to identify JSP539 as a relevant publication View source
Failure of MATT2 to clarify the continuing need to use WBGT View source Lack of acceptable WBGT guidance for GCC and RFT activities View source See 2 more concerns
This report raised 17 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.
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide and communicate correct WBGT placement requirements
Wider context from the report “15. It was established by the Coroner’s appointed expert that the WBGT at Dering Lines was in the wrong place on the 19/07/16 leading to an incorrect reading. A RPFID was raised regarding this however the inquest heard that the steps said to have taken place in the response (copy attached) have not been done. WBGT’s do not have stickers and the YouTube video does not specify that the WBGT should be in sunlight . In addition the WBGT update does not specify it should be in sunlight .
” Source location Joshua Hoole · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to refer and record heat illness cases in accordance with JSP539
Wider context from the report “9. The two cases of heat illness in the AFT were not formally reported in accordance with JSP539 . There needs to be a robust system in place to ensure cases are properly referred and recorded .
” Source location Joshua Hoole · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of MATT2 to identify JSP539 as a relevant publication
Wider context from the report “10. At pages 1.1, 1.3 it fails to refer to JSP539 as a relevant publication .
” Source location Joshua Hoole · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of MATT2 to clarify the continuing need to use WBGT
Wider context from the report “11. At pages 2.7/2.8 it does not remove the need to use a WBGT
” Source location Joshua Hoole · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of acceptable WBGT guidance for GCC and RFT activities
Wider context from the report “8. The AFT is being phased out and new tests have been introduced namely GCC (Ground Close Combat) and RFT (Role Fitness Test). The current JSP539 does not provide guidance for the acceptable wbgt for these activities yet the activities have already been introduced. JSP539 is therefore inconsistent with the new MATT2 .
” Source location Joshua Hoole · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Equip QT34 WBGT monitors with placement labels and aide-memoires, audit their siting, and provide an accessible instructional video.
Verbatim wording from the response “An Aide Memoire has been produced for use of the QT34 WBGT monitor and instruction labels ensuring the correct siting of the monitor have been distributed. This was completed in October 2019. In support, on 7 October 2019, the Physical Development audit was updated to include the requirement to assure that the labels are affixed and the aide memoire is held with every monitor. The audit also now assures correct siting of the monitors. The QT34 YouTube user guide has been edited to include direction on placing the monitor in direct sunlight and is now available on MODNet giving easy access to all Defence users. The routine and continual professional development courses for Army Physical Training Instructors includes a briefing on updated policy and guidance.” Source location 2019-0458-Response-by-MOD
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PFD Monitor interpretation Review and improve MOD incident reporting and management information for heat illness and other incidents.
Verbatim wording from the response “The disjointed reporting system identified in your PEFR following the Brecon Inquest was highlighted as an unresolved issue by the Army Inspector in his Thematic Review of the Army’s Application of Heat Illness Policy (November 2018). In 2019, a major reform of Health, Safety and Environment Protection (HSEP) policy and governance in the MOD resulted in the creation of the Defence Safety and Environment Committee (DSEC), chaired by the MOD’s Permanent Secretary. More recently, the Deputy Chief of the General Staff (DCGS) raised the matter to the DSEC Working Group directing that the MOD conduct a detailed review of the Management Information to improve the way it reports and records all incidents including those involving heat illness; this work is ongoing and will be updated at the next DSEC (23 March 2020).” Source location 2019-0458-Response-by-MOD
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce common tri-service reporting and investigation forms with an accompanying Commander’s Guide.
Verbatim wording from the response “Within the Army, and in consultation with the Royal Navy and Royal Air Force as users of the existing Incident Notification System (INS) there has been progress on improving the coordination of reporting. A common (tri-service) suite of reporting and investigation forms has been developed, and the rollout of these new forms will be accompanied by a Commander’s Guide to Reporting and Investigations; both will be issued by 1 April 2020. Future work is now focussed on designing an app-based reporting mechanism utilising the Defence Gateway portal, which will permit personnel to report using smart phones/tablets etc. A timescale for this future work is not yet confirmed.” Source location 2019-0458-Response-by-MOD
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require WBGT readings to inform risk assessments before relevant physical testing and loaded-march training through amended policy and guidance.
Verbatim wording from the response “Following a comprehensive Training Needs Analysis in October 2019, a plan is now in place to meet the immediate needs and to build safety risk management training into career training for all soldiers and officers (See para 1(b)). Reporting of incidents has been simplified, and a clear guide for commanders will accompany the launch of the new procedures in April 2020 (See para 1(c)). The mandatory requirement to take Wet Bulb Globe Temperature (WBGT) readings, in accordance with JSP539 (where there is an elevated risk of heat illness) before physical testing and loaded march training has now been included in policy, as has the need for it to inform a risk assessment (See para 1(d)). Below are more detailed answers to each of your listed concerns under this heading.” Source location 2019-0458-Response-by-MOD
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PFD Monitor interpretation Provide interim GCC and RFT testing thresholds through Army Briefing Note 076/19.
Verbatim wording from the response “Army Briefing Note (ABN) 076/19 gives interim direction and guidance with regards to GCC and RFT testing thresholds until JSP 539 is subsequently updated. The conclusion of the Institute of Naval Medicine’s Thermal Burden Project will permit further detailed guidance and work rates to be established for a range of activities in a range of different dress states. This will include specific guidance for the GCC and RFT.” Source location 2019-0458-Response-by-MOD
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20 Jul 2015 Craig Roberts and 2 others · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 4
Failure to communicate daytime WBGT readings to exercise commanders View source Failure to instruct commanders to adhere to JSP539 during specialist exercises View source Lack of clear heat-illness detection guidance for specialist exercises View source
Failure of exercise staff to understand JSP539 climatic guidance and heat-illness implications View source See 1 more concern
This report raised 15 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Measure and continuously monitor WBGT conditions at exercise locations, record changes, and notify checkpoints of required control measures.
Stated by Ministry of DefenceStated completedThe respondent said that this action was complete when they made their response on 20 July 2015. View source
Action
Issue urgent safety advice reminding Armed Forces personnel about climatic-illness information, risk assessment, prevention, and treatment.
Stated by Ministry of DefenceStated completedThe respondent said that this action was complete when they made their response on 20 July 2015. View source
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 completedThe respondent said that this action was complete when they made their response on 20 July 2015. View source
Action
Require formal Director-level waivers and documented mitigation when exercises operate outside JSP 539 parameters.
Stated by Ministry of DefenceStated completedThe respondent said that this action was complete when they made their response on 20 July 2015. View source
Action
Use a revised exercise Medical Plan requiring climatic-illness training, medic rehearsals, expert approval, and oversight for future exercises.
Stated by Ministry of DefenceStated completedThe respondent said that this action was complete when they made their response on 20 July 2015. View source See 2 more actions
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate daytime WBGT readings to exercise commanders
Wider context from the report “(11) There is no system in place to ensure that WBGT readings obtained at Sennybridge camp are communicated to exercise commanders in the area during the day .
” Source location Craig Roberts and 2 others · Prevention of Future Deaths report
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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
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear heat-illness detection guidance for 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
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of exercise staff to understand JSP539 climatic guidance and heat-illness implications
Wider context from the report “(6) Senior commanders were unaware that the staff who conducted this exercise were unaware of climatic guidance in JSP539 and therefore did not understand the implications of the weather forecast and the importance of heat illness and its treatment .
” Source location Craig Roberts and 2 others · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Measure and continuously monitor WBGT conditions at exercise locations, record changes, and notify checkpoints of required control measures.
Verbatim wording from the response “I accept that the lack of a system to obtain and monitor WBGT readings from Sennybridge Camp was a failing. Having reviewed this it has been concluded that obtaining readings from Sennybridge Camp would be of limited value in determining the climatic risks in the training area, which is some distance from and of different terrain to the camp area. WBGT readings are now taken at the command vehicle (located in the exercise area) and at the highest point in order to understand the range of conditions out on the course being used. They are continuously monitored throughout the exercise and any changes in the readings are recorded in the communications log and all check points notified of these and any control measures required as a result.” Source location 2015-0228-Response-by-MOD
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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
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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
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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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a revised exercise Medical Plan requiring climatic-illness training, medic rehearsals, expert approval, and oversight for future exercises.
Verbatim wording from the response “The Medical Plan for the exercise was completely revised in advance of the most recent iteration (June 2015). Prior to all future exercises this plan must be reviewed and signed off by the Senior Medical Officer and Chief Instructor of the Lead Regular Unit (see response to Point 7 for further detail). Oversight is provided by medical staff in HQ Specialist Military Units. The revised Medical Plan requires that a comprehensive training package on climatic illness and injury and JSP539 is established. This has improved knowledge and awareness of the JSP and climatic illness and injury. In addition, the Medical Plan has introduced a requirement for all professional medics on the exercise to conduct virtual exercises and rehearsals prior to future exercises.” Source location 2015-0228-Response-by-MOD
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtaining WBGT readings from Sennybridge Camp was considered of limited value because its distance and terrain differ from the training area.
Verbatim wording from the response “I accept that the lack of a system to obtain and monitor WBGT readings from Sennybridge Camp was a failing. Having reviewed this it has been concluded that obtaining readings from Sennybridge Camp would be of limited value in determining the climatic risks in the training area, which is some distance from and of different terrain to the camp area. WBGT readings are now taken at the command vehicle (located in the exercise area) and at the highest point in order to understand the range of conditions out on the course being used. They are continuously monitored throughout the exercise and any changes in the readings are recorded in the communications log and all check points notified of these and any control measures required as a result.” Source location 2015-0228-Response-by-MOD
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Includes failures in JSP539 or MATT2 requirements, staff understanding, WBGT use or communication, and operational response to climatic or suspected heat-illness risk during military exercises.
