Recurring concern

Unreliable recognition and response to heat illness in safety-critical operations

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First reported 8 Jun 2016•Latest report 1 Nov 2019

Definition

What this concern includes

Includes failures of controls specifically dedicated to recognising, assessing or responding to heat illness during safety-critical operations, including personnel training and confidence, recognition of signs and symptoms, decisions to withdraw or self-withdraw, emergency escalation and immediate protective measures.

Not included

Excludes generic heat exposure, fatigue or hot-environment risks where heat illness recognition or response is not the asserted unsafe condition.
Excludes the existing military-exercise heat-risk requirements concern when the assertion is limited to broader exercise heat-risk rules, WBGT controls or climatic requirements rather than recognition and response to heat illness.
Excludes generic staff training, staffing or emergency-response deficiencies unless they directly impair heat-illness recognition or response.
Excludes unrelated clinical heat illness treatment after appropriate recognition and escalation have occurred.

Reports: 2
Individual concerns: 5
Date range: 2016–2019
Stated actions: 4

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.

Chief Fire and Rescue Adviser1

Home Office1

Ministry of Defence1

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. Insufficient medic training and competence to identify heat illness
2. Inconsistency between JSP539 and MATT2 on the required response to suspected heat illness
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
  Disaggregate JSP 539 by moving heat-illness prevention guidance into JSP 375 and retaining clinical treatment guidance in JSP 539.
  Stated by Ministry of DefenceStated planned
2. Action
  Provide interim GCC and RFT testing thresholds through Army Briefing Note 076/19.
  Stated by Ministry of DefenceStated completed
Respondent positions 2
1. Position
  MATT 3-trained First Aid NCOs are considered sufficient to support annual fitness tests, provided heat illness receives adequate focus in annual training.
  Stated by Ministry of DefenceExisting arrangements considered sufficient
1. Position
  JSP 539 and MATT 2 are not inconsistent because operational activities may require pausing, while physical training activities must be terminated.
  Stated by Ministry of DefenceDisputes the concern
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
Insufficient medic training and competence to identify heat illness
Wider context from the report
“12. Currently MATT2 states the medic on a fitness test is to be MATT3 trained. Given that these medics only receive basic training as per MATT3 consideration needs to be given to have a better qualified medic who can properly identify the signs and symptoms of HI. The inquest was told by those who were MATT3 or team medic trained did not feel confident to diagnose HI and deferred to the CMT. ”
Source location
Joshua Hoole · 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
Inconsistency between JSP539 and MATT2 on the required response to suspected heat illness
Wider context from the report
“4. The current JSP539 states at annex A page 2A that the activity should be “paused” if there is a suspected case of heat illness. MATT 2 states the activity should be stopped. The publications need to be consistent with each other and the guide should be clearer. ”
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
Disaggregate JSP 539 by moving heat-illness prevention guidance into JSP 375 and retaining clinical treatment guidance in JSP 539.

Verbatim wording from the response
“A Field Guide was produced in October 2019 entitled ‘Heat Illness and Cold Injury’. This provides commanders with a short reference guide to assist in the understanding of climatic injuries. A comprehensive review of JSP 539 has been completed and the Joint Medical Group (JMG) discussed the document at the Heat Illness Working Group on 18 July 2019. Members of the JMG agreed that the JSP was long and not the easiest to read. The decision was taken to disaggregate the document. Advice and guidance on the prevention of heat injury will be removed and inserted as a new chapter in JSP 375 - Management of Health and Safety in Defence, whilst the more clinically focussed medical care required for heat and cold injuries will remain in JSP 539. This work will be completed by 31 December 2020.”

Source location
2019-0458-Response-by-MOD
Page 4 · 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
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
Page 5 · response
Published 2 January 2020
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
MATT 3-trained First Aid NCOs are considered sufficient to support annual fitness tests, provided heat illness receives adequate focus in annual training.

Verbatim wording from the response
“12. Currently MATT2 states the medic on a fitness test is to be MATT3 trained. Given that these medics only receive basic training as per MATT3, consideration needs to be given to have a better qualified medic who can properly identify the signs and symptoms of Heat Illness. The Inquest was told by those who were MATT3 or team medic trained did not feel confident to diagnose Heat Illness and deferred to the Combat Medical Technician (CMT).”

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

How this respondent position was interpreted

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

PFD Monitor interpretation
JSP 539 and MATT 2 are not inconsistent because operational activities may require pausing, while physical training activities must be terminated.

Verbatim wording from the response
“4. The current JSP539 states at Annex A page 2A that the activity should be “paused” if there is a suspected case of heat illness. MATT 2 states the activity should be stopped. The publications need to be consistent with each other and the guide should be clearer.”

Source location
2019-0458-Response-by-MOD
Page 4 · response
Published 2 January 2020
Open published response
8 Jun2016
Manchester City
Concerns raised3
1. Inadequate training and guidance to recognise the effects of heat and appropriate withdrawal steps
2. Inadequate training and guidance to enable personnel to withdraw colleagues adversely affected by heat
3. Inadequate training and guidance to enable personnel to withdraw themselves from heat exposure
This report raised 12 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
  Finalize and issue a breathing apparatus training manual covering heat-related welfare, wearer welfare, and rest and recovery procedures.
  Stated by Devon & Somerset Fire and Rescue ServiceStated in progress
2. Action
  Review the breathing apparatus operational procedures policy to strengthen guidance on heat, stress, weather, and previous exertion.
  Stated by Devon & Somerset Fire and Rescue ServiceStated in progress
AI-generated summary

Stephen Alan HUNT · 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

Stephen Alan Hunt, a firefighter, died after entering a fire at Paul's Hair and Beauty World in Manchester on 13 July 2013. He was found inside the premises after suffering heat exhaustion and hypoxia. The principal concerns included failures in communication and handover, misinterpretation of instructions, loss of telemetry and radio communications, inadequate fire risk assessments and fire safety measures, and decisions affecting firefighter safety.

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 training and guidance to recognise the effects of heat and appropriate withdrawal steps
Wider context from the report
“(1) It is suggested that all Fire and Rescue Services (FRS's) should consider the implementation of measures to reduce the risks associated with the physiological affects of working in a hot environment. In particular consideration should be given to: Duration of wears under breathing apparatus; Having regard to all relevant factors including, for example the weather, previous exertions of BA teams and individual circumstances; Training and guidance for all operational personnel to recognize the effects of heat both on themselves and on their colleagues and the appropriate steps to take upon such recognition, including withdrawal and self withdrawal. Training and guidance for all operational personnel to have the ability and confidence to ensure the withdrawal of others who may be adversely affected by heat whether by calling a BA emergency or otherwise appropriately. Training and guidance for all operational personnel to have the ability and confidence to withdraw themselves by whatever means appropriate including activating the ADSU. ”
Source location
Stephen Alan HUNT · Prevention of Future Deaths report
Page 10 · 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
Inadequate training and guidance to enable personnel to withdraw colleagues adversely affected by heat
Wider context from the report
“(1) It is suggested that all Fire and Rescue Services (FRS's) should consider the implementation of measures to reduce the risks associated with the physiological affects of working in a hot environment. In particular consideration should be given to: Duration of wears under breathing apparatus; Having regard to all relevant factors including, for example the weather, previous exertions of BA teams and individual circumstances; Training and guidance for all operational personnel to recognize the effects of heat both on themselves and on their colleagues and the appropriate steps to take upon such recognition, including withdrawal and self withdrawal. Training and guidance for all operational personnel to have the ability and confidence to ensure the withdrawal of others who may be adversely affected by heat whether by calling a BA emergency or otherwise appropriately. Training and guidance for all operational personnel to have the ability and confidence to withdraw themselves by whatever means appropriate including activating the ADSU. ”
Source location
Stephen Alan HUNT · Prevention of Future Deaths report
Page 10 · 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
Inadequate training and guidance to enable personnel to withdraw themselves from heat exposure
Wider context from the report
“(1) It is suggested that all Fire and Rescue Services (FRS's) should consider the implementation of measures to reduce the risks associated with the physiological affects of working in a hot environment. In particular consideration should be given to: Duration of wears under breathing apparatus; Having regard to all relevant factors including, for example the weather, previous exertions of BA teams and individual circumstances; Training and guidance for all operational personnel to recognize the effects of heat both on themselves and on their colleagues and the appropriate steps to take upon such recognition, including withdrawal and self withdrawal. Training and guidance for all operational personnel to have the ability and confidence to ensure the withdrawal of others who may be adversely affected by heat whether by calling a BA emergency or otherwise appropriately. Training and guidance for all operational personnel to have the ability and confidence to withdraw themselves by whatever means appropriate including activating the ADSU. ”
Source location
Stephen Alan HUNT · Prevention of Future Deaths report
Page 10 · 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
Finalize and issue a breathing apparatus training manual covering heat-related welfare, wearer welfare, and rest and recovery procedures.

Verbatim wording from the response
“A new Breathing Apparatus training manual is in the process of being finalised prior to service wide issue. This new manual has a dedicated chapter on welfare that covers areas such as – heat and humidity, heat cramps, heat exhaustion, heat stroke and burns. Also included in this manual will be the welfare of BA wearers, section B-4, from the DGfC Operational Guidance Breathing Apparatus document; this includes ideal rest and recovery procedures.”

Source location
2016-0216-Response-by-Devon-Somerset-Fire-Rescue-Service
Page 2 · response
Published 8 June 2016
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 breathing apparatus operational procedures policy to strengthen guidance on heat, stress, weather, and previous exertion.

Verbatim wording from the response
“The current BA operational procedures policy is being reviewed, to include further guidance on the physiological effects of heat and stress. The review will also consider the factors that can impact on the wearer, such as weather and previous exertion.”

Source location
2016-0216-Response-by-Devon-Somerset-Fire-Rescue-Service
Page 2 · response
Published 8 June 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Insufficient medic training and competence to identify heat illness

Inconsistency between JSP539 and MATT2 on the required response to suspected heat illness

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised3

Inadequate training and guidance to recognise the effects of heat and appropriate withdrawal steps

Inadequate training and guidance to enable personnel to withdraw colleagues adversely affected by heat

Inadequate training and guidance to enable personnel to withdraw themselves from heat exposure

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

Actions described in response 2

Respondent positions 2

Actions described in response 2