Recurring concern

Failure to reliably screen and identify sickle cell trait in selection candidates

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First reported 6 Dec 2019•Latest report 24 Oct 2022

Definition

What this concern includes

Includes failures in the dedicated sickle cell trait screening and identification process for candidates undergoing military or comparable selection, including determining screening eligibility, conducting pre-selection or urgent retrospective testing, recording results, communicating status across responsible services and using reliable candidate-identification controls before strenuous exercise.

Not included

  • Excludes general medical screening or candidate health-assessment deficiencies where sickle cell trait is not the material concern.
  • Excludes failures in managing exertional collapse after sickle cell trait risk has been reliably identified and appropriate precautions are in place.
  • Excludes generic staff training, documentation, communication or incident-investigation deficiencies unless they directly impair sickle cell trait screening or identification during selection.
  • Excludes screening or management of other haemoglobin conditions unless the assertion explicitly concerns the same sickle cell trait selection process.
Reports
2

Distinct published reports

Individual concerns
7

A report can raise multiple concerns

Date range
2019–2022

First to latest report issue date

Stated actions
15

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Capita PLC2
Ministry of Defence2
Capita Business Services Ltd1

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. Birmingham and Solihull

    AI-generated summary

    Kamil Iddrisu and Youngson Nkhoma · 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

    Kamil Iddrisu and Youngson Nkhoma collapsed during separate military selection runs at Whittington Barracks and later died after being taken to hospital. Both were found to have metabolic acidosis, acute kidney injury, rhabdomyolysis and sickle cell trait; the final causes of death remained under investigation, with the most likely cause of collapse described as sickle cell trait combined with military exercise. The principal concern was the risk of death or harm to non-UK selection candidates, including the need to consider screening for sickle cell trait.

    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

    Lack of a standardised method for identifying SCT candidates during selection

    Wider context from the report

    “Sickle cell trait (SCT) screening process and identifying SCT in candidates: 1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective. 2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective. Training and Education 1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT. 2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable . 3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT. 4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate. Reporting and investigation 1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process. 2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective. 3. There is no system to audit whether incidents are being correctly processed and investigated. 4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically. 5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety. 6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses. Medical response: 1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale. 2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation. ”

    Source location

    Kamil Iddrisu and Youngson Nkhoma · 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 staff awareness of SCT-associated risks during selection and RFT assessments

    Wider context from the report

    “Sickle cell trait (SCT) screening process and identifying SCT in candidates: 1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective. 2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective. Training and Education 1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT. 2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable . 3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT. 4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate. Reporting and investigation 1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process. 2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective. 3. There is no system to audit whether incidents are being correctly processed and investigated. 4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically. 5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety. 6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses. Medical response: 1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale. 2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation. ”

    Source location

    Kamil Iddrisu and Youngson Nkhoma · 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

    Increased risk of death or collapse during military exercise for people with sickle cell trait

    Wider context from the report

    “2. Consideration should be given to all non UK selection candidates who have been through the process already having an urgent blood test to check whether they have sickle cell trait. If a person has sickle cell trait they are a significant increased risk of death/collapse during military exercise. ”

    Source location

    Kamil Iddrisu and Youngson Nkhoma · Prevention of Future Deaths report
    Page 1 · 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 follow the SCT screening process before high-risk candidates undertake the 2km run

    Wider context from the report

    “Sickle cell trait (SCT) screening process and identifying SCT in candidates: 1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective. 2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective. Training and Education 1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT. 2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable . 3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT. 4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate. Reporting and investigation 1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process. 2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective. 3. There is no system to audit whether incidents are being correctly processed and investigated. 4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically. 5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety. 6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses. Medical response: 1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale. 2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation. ”

    Source location

    Kamil Iddrisu and Youngson Nkhoma · 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 urgent sickle cell trait testing for previously processed non-UK selection candidates

    Wider context from the report

    “2. Consideration should be given to all non UK selection candidates who have been through the process already having an urgent blood test to check whether they have sickle cell trait. If a person has sickle cell trait they are a significant increased risk of death/collapse during military exercise. ”

    Source location

    Kamil Iddrisu and Youngson Nkhoma · Prevention of Future Deaths report
    Page 1 · 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 SCT screening for Air Force and Navy candidates

    Wider context from the report

    “Sickle cell trait (SCT) screening process and identifying SCT in candidates: 1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective. 2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective. Training and Education 1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT. 2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable . 3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT. 4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate. Reporting and investigation 1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process. 2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective. 3. There is no system to audit whether incidents are being correctly processed and investigated. 4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically. 5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety. 6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses. Medical response: 1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale. 2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation. ”

    Source location

    Kamil Iddrisu and Youngson Nkhoma · 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

    Use the Family Origins Questionnaire to screen all Army assessment-centre candidates for sickle cell trait risk before the 2000-metre run.

    Verbatim wording from the response

    “b. Action taken since the issue of HM Senior Coroner's PFDR. The PFDR was issued on 6 Dec 19; earlier that day the Deputy Chief of the General Staff (DCGS) – the Army's Principal Personnel Officer – directed that the Army (on medical advice) implement a screening process to identify those candidates who are SCT positive prior to participating in the 2000m best effort run. This is being conducted in two phases:”

    Source location

    2019-0416-Response-by-MOD
    Page 2 · response
    Published 30 December 2019

    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

    Blood-test candidates identified by the questionnaire as being at high risk of sickle cell trait before they undertake the 2000-metre run.

    Verbatim wording from the response

    “(2) Stage 2 – Blood Test. The FOQ will identify those candidates who will need to undergo a blood test to determine if they are SCT positive or negative.⁷”

    Source location

    2019-0416-Response-by-MOD
    Page 3 · response
    Published 30 December 2019

    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

    Standardize Sickle Cell Trait wristband design across the Army, Royal Navy and Royal Air Force.

    Verbatim wording from the response

    “The Army have shared their wristband design with the Royal Air Force and the Royal Navy. The Royal Air Force and the Royal Navy have decided to adopt the Army’s approach to and design of wristbands in their entirety. This is covered under Matters of Concern 1b.”

    Source location

    2019-0416 - Response from Secretary of State for Defence and Capita
    Page 8 · response
    Published 30 December 2019

    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

    Issue interim sickle-cell-trait training guidance and awareness information across all initial training establishments, including prevention, recognition and treatment measures.

    Verbatim wording from the response

    “a. Action taken since the issue of HM Senior Coroner's PFDR. The Interim Training Direction (Annex E) was issued to the Army Recruiting and Initial Training Command (ARITC) training establishments¹² by Director Operations on 13 Dec 19, with specific direction for the information to be briefed to or seen by all training staff, including Physical Training Instructors and medical staff. The SCT”

    Source location

    2019-0416-Response-by-MOD
    Page 4 · response
    Published 30 December 2019

    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

    Revise and circulate Army-wide policy on preventing, recognising and managing exertional collapse, including sickle-cell-trait risks and treatment.

    Verbatim wording from the response

    “c. The Army’s Personnel Directorate has revised and circulated Army-wide the relevant policy to ensure that the prevention, recognition and effective handling of anybody suffering from Exertional Collapse, from any cause, is fit for purpose. AGAI Vol 1 Ch 7 (Annex F) has been updated with a new paragraph called Risk of Exertional Collapse. The revised document includes information on SCT positive personnel, including risk factors, recognition and treatment. The policy changes have been directed to the Army’s Chain of command through an Army Briefing Note, at Annex G.”

    Source location

    2019-0416-Response-by-MOD
    Page 5 · response
    Published 30 December 2019

    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 enhanced Sickle Cell Trait and exertional-collapse training, candidate-identification procedures, quarterly simulations and induction education for assessment staff.

    Verbatim wording from the response

    “In three cases, other measures failed, these are therefore classified as ‘near miss’ incidents. Two of these took place at a facility administered by the Army, and additional controls have now been introduced, including enhanced staff training and awareness of Sickle Cell Trait and exertional collapse, and procedural changes that ensure that Sickle Cell Trait candidates are clearly identifiable. One case took place at a Recruiting Group Assessment Centre (Pirbright), and specific enhancements have been introduced at this site, including an amendment to the Assessment Centre loading process that prevents high-risk Family Origin Questionnaire candidates from attending an Assessment Centre until blood test results are known, therefore removing the potential for at-risk candidates to undertake the run.”

    Source location

    2019-0416 - Response from Secretary of State for Defence and Capita
    Page 3 · response
    Published 30 December 2019

    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

    Suspend the 2000-metre best-effort run for Commonwealth candidates pending revised safety arrangements.

    Verbatim wording from the response

    “(2) The 2000m RFT(E) best effort run was suspended on 28 Nov 19 for all CW candidates. CW candidates completed the rest of the selection activities as normal. As a result, approx. 150 candidates were placed ‘on hold’ pending a way forward.⁵”

    Source location

    2019-0416-Response-by-MOD
    Page 2 · response
    Published 30 December 2019

    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

    Deliver a bespoke four-week pre-conditioning course for sickle-cell-trait-positive candidates, using progressive training and individual heart-rate monitoring before the 2000-metre run.

    Verbatim wording from the response

    “The Senior Health Advisor (Army) was also able to draw on contemporary US Armed Forces experience of managing SCT risk, provided through the British Medical Liaison Officer in Washington, to advise that a progressive 4-week pre-conditioning course for SCT positive candidates will reduce the risk to ALARP.”

    Source location

    2019-0416-Response-by-MOD
    Page 3 · response
    Published 30 December 2019

    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

    Assess and assure the pre-conditioning course, incorporating lessons learned and improvements into subsequent courses.

    Verbatim wording from the response

    “How these individuals perform and the effectiveness of the course in supporting them to meet the Army entry standards will be the subject of ongoing assessment and assurance. Lessons learned and improvements will be incorporated into the next course due to start in Feb 20.”

    Source location

    2019-0416-Response-by-MOD
    Page 3 · response
    Published 30 December 2019

    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

    Develop advice for serving soldiers on sickle-cell-trait and exertional-collapse risk, including bespoke advice for identified sickle-cell-trait-positive personnel.

    Verbatim wording from the response

    “e. Work is also underway to develop the advice that will be given to all serving soldiers. In addition, those who have been identified as SCT positive will be given bespoke advice.”

    Source location

    2019-0416-Response-by-MOD
    Page 5 · response
    Published 30 December 2019

    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

    Prevent unscreened or high-risk candidates from attending assessment centres or undertaking the Role Fitness Test.

    Verbatim wording from the response

    “Following a post-inquest review of Sickle Cell Trait risk management by six sigma qualified professionals, additional process control measures have been established to prevent high risk or unknown Family Origin Questionnaire candidates from attending an Assessment Centre. Individuals will not be loaded onto the course prior to being screened through the Family Origin Questionnaire or receiving their Sickle Cell Trait blood test results. This measure has been put into place to ensure that there is no prospect of such a candidate attempting the Role Fitness Test (Entry). If the candidate’s Sickle Cell Trait status is positive or is not known prior to the Role Fitness Test (Entry), they will not participate in the Role Fitness Test (Entry) Multi-Stage Fitness Test.”

    Source location

    2019-0416 - Response from Secretary of State for Defence and Capita
    Page 2 · response
    Published 30 December 2019

    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

    Mandate and operate two-stage Sickle Cell Trait screening for all Army, Royal Navy and Royal Air Force recruits and potential recruits.

    Verbatim wording from the response

    “Updated policy (Defence Instructions and Notice (DIN 2022DIN06-021) was issued on 04 November 2022, that mandates that all military recruits or potential military recruits, across the Army, Royal Navy and Royal Air Force, be screened for Sickle Cell Trait. The screening process for identifying Sickle Cell Trait is split into two stages:”

    Source location

    2019-0416 - Response from Secretary of State for Defence and Capita
    Page 5 · response
    Published 30 December 2019

    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

    Issue revised Standing Operating Instruction 20 governing responses when candidates become unwell during assessment-centre events.

    Verbatim wording from the response

    “Following the request, Recruiting Group has issued revised guidance (Standing Operating Instructions 20), which details how to respond if a candidate becomes unwell during an Assessment Centre event. The document details that Recruiting Group Doctors (Capita staff) should assist in an emergency as a ‘Good Samaritan’ drawing upon paragraph 26 of the General Medical Council’s ‘Good Medical Practice’ guidance which states that ‘You must offer help if emergencies arise in clinical settings or in the community, taking account of your own safety, your competence and the availability of other options for care’.”

    Source location

    2019-0416 - Response from Secretary of State for Defence and Capita
    Page 17 · response
    Published 30 December 2019

    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

    Maintain generic exertional-collapse clinical policy and review it annually for coherence with Sickle Cell Trait guidance.

    Verbatim wording from the response

    “There is joint clinical policy in place for exertional collapse including Joint Service Publication 950 Leaflet 2-4-4: Exertional Heat Illness: Acute Treatment (v1.3 February 2022).”

    Source location

    2019-0416 - Response from Secretary of State for Defence and Capita
    Page 18 · response
    Published 30 December 2019

    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

    Continue reviewing and refining Sickle Cell Trait screening and risk-management processes, with twice-yearly assurance scrutiny.

    Verbatim wording from the response

    “From an Army perspective, the Sickle Cell Trait screening process for all streams of candidates continues to be reviewed and refined on a regular basis (and informed where necessary, by the outcomes of any Joint Lessons Learnt Panel, Clinical Oversight Board or Learning Account recommendations) within the four Soldier Assessment Centres and the Army Officer Selection Board. Similarly, Recruiting Group and Army Recruiting and Initial Training Command have reviewed the Sickle Cell Trait risk-management process and associated Risk Assessments for moving a candidate from the initial stages of recruiting activity through to the Pre-Service Medical Assessment and Role Fitness Test (Entry).”

    Source location

    2019-0416 - Response from Secretary of State for Defence and Capita
    Page 4 · response
    Published 30 December 2019

    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

    Nine reported incidents involved no risk of harm because manual checks of candidates’ Sickle Cell Trait status worked as intended.

    Verbatim wording from the response

    “In addition, a thorough review has now been completed of each of the twelve incidents identified following Recruiting Group’s Business Assurance Review. In all cases, the medical screening component worked as intended. However, in nine instances, a post-screening control measure failed due to an administrative error; Defence Recruitment System record was not updated, or an error was made in completing/recording pre-service screening medical outcomes. However, other measures such as manual checks of an individual’s Sickle Cell Trait status worked as intended, so there was no risk of harm to the candidates involved.”

    Source location

    2019-0416 - Response from Secretary of State for Defence and Capita
    Page 3 · response
    Published 30 December 2019

    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

    The Sickle Cell Trait screening process is considered as safe and effective as practicable, subject to twice-yearly scrutiny.

    Verbatim wording from the response

    “Accordingly, the Sickle Cell Trait screening process is now deemed to be as safe and as effective as it can practicably be and will be subject to twice-yearly scrutiny by both the Recruiting Group assurance team, and Army-directed assurers.”

    Source location

    2019-0416 - Response from Secretary of State for Defence and Capita
    Page 4 · response
    Published 30 December 2019

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    Kamil Iddrisu and Youngson Nkhoma · 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

    Kamil Iddrisu and Youngson Nkhoma collapsed during separate military selection runs at Whittington Barracks and later died after being taken to Good Hope Hospital. Both were found to have sickle cell trait, metabolic acidosis, acute kidney injury and rhabdomyolysis, and the final causes of death remained under investigation. The principal concern was that non-UK candidates may be at serious risk of collapse, harm or death during military exercise without screening for sickle cell trait.

    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 urgently test previously processed non-UK selection candidates for sickle cell trait

    Wider context from the report

    “2. Consideration should be given to all non UK selection candidates who have been through the process already having an urgent blood test to check whether they have sickle cell trait. If a person has sickle cell trait they are a significant increased risk of death/collapse during military exercise. ”

    Source location

    Kamil Iddrisu and Youngson Nkhoma · Prevention of Future Deaths report
    Page 1 · 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

    Prevent unscreened or high-risk candidates from attending assessment centres or undertaking the Role Fitness Test.

    Verbatim wording from the response

    “Following a post-inquest review of Sickle Cell Trait risk management by six sigma qualified professionals, additional process control measures have been established to prevent high risk or unknown Family Origin Questionnaire candidates from attending an Assessment Centre. Individuals will not be loaded onto the course prior to being screened through the Family Origin Questionnaire or receiving their Sickle Cell Trait blood test results. This measure has been put into place to ensure that there is no prospect of such a candidate attempting the Role Fitness Test (Entry). If the candidate’s Sickle Cell Trait status is positive or is not known prior to the Role Fitness Test (Entry), they will not participate in the Role Fitness Test (Entry) Multi-Stage Fitness Test.”

    Source location

    2019-0416 - Response from Secretary of State for Defence and Capita
    Page 2 · response
    Published 30 December 2019

    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

    Nine reported incidents involved no risk of harm because manual checks of candidates’ Sickle Cell Trait status worked as intended.

    Verbatim wording from the response

    “In addition, a thorough review has now been completed of each of the twelve incidents identified following Recruiting Group’s Business Assurance Review. In all cases, the medical screening component worked as intended. However, in nine instances, a post-screening control measure failed due to an administrative error; Defence Recruitment System record was not updated, or an error was made in completing/recording pre-service screening medical outcomes. However, other measures such as manual checks of an individual’s Sickle Cell Trait status worked as intended, so there was no risk of harm to the candidates involved.”

    Source location

    2019-0416 - Response from Secretary of State for Defence and Capita
    Page 3 · response
    Published 30 December 2019

    Open published response
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Data last updated 7 September 2026