Recurring concern

Unreliable reporting of heat-illness cases

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First reported 20 Jul 2015•Latest report 1 Nov 2019

Definition

What this concern includes

Includes failures in the dedicated process for identifying, recording, submitting, checking and consolidating heat-illness case reports, including missed cases and reporting arrangements that produce incomplete or inaccurate data.

Not included

Excludes failures to recognise, diagnose, treat or respond to heat illness where the reporting process is not deficient.
Excludes generic incident-reporting or data-quality failures without a specific heat-illness reporting context.
Excludes heat-exposure controls, training, guidance and operational response where no failure to report heat-illness cases is identified.
Excludes reporting processes for unrelated illnesses, injuries or hazards.

Reports: 2
Individual concerns: 3
Date range: 2015–2019
Stated actions: 3

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. Failure to refer and record heat illness cases in accordance with JSP539
2. Failure of the heat illness reporting system to produce complete and accurate data
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 2
1. Action
  Review and improve MOD incident reporting and management information for heat illness and other incidents.
  Stated by Ministry of DefenceStated in progress
2. Action
  Introduce common tri-service reporting and investigation forms with an accompanying Commander’s Guide.
  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
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
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
Failure of the heat illness reporting system to produce complete and accurate data
Wider context from the report
“• The system for reporting heat illness cases was disjointed and cases were not reported giving incorrect data. ”
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
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
Page 3 · 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
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
Page 3 · response
Published 2 January 2020
Open published response
20 Jul2015
Birmingham and Solihull
Concerns raised1
1. Disjointed reporting of heat-illness cases
This report raised 18 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 1
1. Action
  Improve heat-illness reporting through the working group and require prompt, accurate climatic-injury reporting in the exercise Medical Plan.
  Stated by Ministry of DefenceStated in progress
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
Disjointed reporting of heat-illness cases
Wider context from the report
“(8) The general system for reporting heat illness cases is disjointed and results in cases being missed and therefore not reported. Inaccurate data impedes the ability of the MOD to assess the true incidence of heat illness during exercises and to put in place any plan that’s required to mitigate ongoing risks of heat illness. ”
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
Improve heat-illness reporting through the working group and require prompt, accurate climatic-injury reporting in the exercise Medical Plan.

Verbatim wording from the response
“I acknowledge that there have been failings in the accurate recording of cases of heat illness historically. The Defence People Health Board’s Heat Illness Working Group, in collaboration with the Defence Safety Authority, is working to improve the process for reporting of heat illness and injury. Progress will be reported to the Defence People Health Board in October and I will write to you in November with an update on this important work. The revised Medical Plan for the specialist exercise requires prompt and accurate reporting of all climatic injuries, so as to enable an accurate capture of the required data.”

Source location
2015-0228-Response-by-MOD
Page 5 · 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

Failure to refer and record heat illness cases in accordance with JSP539

Failure of the heat illness reporting system to produce complete and accurate data

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.2

Concerns raised1

Disjointed reporting of heat-illness cases

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.1

Actions described in response 2

Actions described in response 1