Concerns raised 1 Failure to warn employees exposed to Nitrobenzene and other explosives to get tested View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Peter Edwin Spencer GURNEY · 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
Peter Edwin Spencer Gurney had an unwitnessed fall at home on 19 September 2025 and was pronounced deceased at the scene; the inquest concluded that he died of heart failure contributed to by co-morbidities including terminal bladder cancer. A substantive concern was that current and former employees exposed to Nitrobenzene and other explosives had not been warned to get tested, despite possible links to bladder cancer.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to warn employees exposed to Nitrobenzene and other explosives to get tested
Wider context from the report “The MOD is aware that there are current concerns around the possible link between exposure to Nitrobenzene and other explosives and bladder cancer. The MOD has been aware of this for some time. Evidence heard at the Inquest was that neither active or past employees, who have been subject to this exposure through their work , have been warned to get tested . Unfortunately by the time Mr Gurney realised he had bladder cancer the disease had taken hold and it had become inoperable.
” Open source report
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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 MOD will not promote bladder cancer testing without strong evidence, because screening may cause false results, unnecessary interventions, anxiety or false reassurance.
Verbatim wording from the response “In line with established national screening guidance, the MOD does not consider it appropriate to indirectly or directly promote medical testing for bladder cancer in EOD personnel, in the absence of clear supporting evidence. Screening for cancer can carry risks including false positives leading to unnecessary interventions, or false negatives providing a false sense of” Source location Response from Secretary of State for Defence
Open published response
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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 Occupational causation and future action have been referred to IMEG, with decisions dependent on its advice and emerging medical evidence.
Verbatim wording from the response “The question of occupational causation has been referred to the Independent Medical Expert Group (IMEG) which is currently developing its expert medical advice. It is expected to identify areas where further research is required.” Source location Response from Secretary of State for Defence
Open published response
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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 There is insufficient evidence to establish a causal link between bladder cancer and occupational nitrobenzene exposure in EOD personnel.
Verbatim wording from the response “The Ministry of Defence (MOD) takes the welfare of our veterans extremely seriously and closely monitors any emerging issues that may be of consequence to this community. Any actions taken by the MOD must be based on robust evidence.” Source location Response from Secretary of State for Defence
Open published response
15 Oct 2025 Malik BUNTON · Prevention of Future Deaths report North Yorkshire and York
View report summary
Concerns raised 8 Failure to obtain an account from a key hospital-attending colleague View source Failure to verify the accuracy of Clinical Care Review records View source Delays and obstructions in gathering evidence from key witnesses View source Delays in providing key witness statements to the Service Inquiry panel View source Failure to ensure participants understand formal Clinical Care Review processes View source Failure to preserve potentially important service email evidence View source Failure to obtain or record a clear contemporaneous account of GP consultations View source Insufficient inquiry into incidents and involved personnel View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Malik BUNTON · 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
Malik Bunton was found suspended from a ligature on 17 July 2023, and his death was confirmed at the scene. The inquest concluded that he died as a result of suicide, following earlier incidents involving suicidal intent and self-harm concerns. The principal concerns related to insufficient inquiry into an earlier incident, weaknesses in the Defence Medical Service Clinical Care Review process, and delays or obstructions in gathering important evidence.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain an account from a key hospital-attending colleague
Wider context from the report “3. There were inexplicable delays and some apparent deliberate obstructions to the gathering of important evidence from key witnesses. This impacted on the extent and quality of evidence ultimately available to both the Service Inquiry and the inquest. Examples of this were –
- The long delays in obtaining formal accounts from key witnesses either in writing or via an interview process.
- The absence of any account from Mr Bunton’s colleague who attended hospital with him following the 26 March 2023 incident . Such an account would have informed the process of inquiry referred to at point 1 above as well as the Service Inquiry and inquest.
- The decision to delete Mr Bunton’s service email account without consideration of its potential importance in the context of a suspected suicide.
- Withholding statements of two key witnesses from the Service Inquiry panel for some months following Mr Bunton’s death.
- The absence of a clear and contemporaneous account of the 11 July 2023 GP consultation, either in the Clinical Care Review document and/or a separate formal account of events obtained from the doctor concerned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to verify the accuracy of Clinical Care Review records
Wider context from the report “2. There were weaknesses in the Clinical Care Review process undertaken by the Defence Medical Service following Mr Bunton’s death. While the review of the 11 July 2023 consultation occurred very promptly after Mr Bunton’s death, the GP involved in the consultation was unaware that her informal discussion of the case with a senior colleague was being captured as part of a formal review process. She was also never asked to check the accuracy of the contents of the review document produced following this discussion , which compromised the accuracy of the review document itself , as well as impacting on evidence subsequently available to the Service Inquiry and the inquest. The purpose of the Clinical Care Review process is to identify any concerns around clinical decision-making and mitigate the risk of recurrence of the same, and should therefore be based on a clear and verified record of events.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Delays and obstructions in gathering evidence from key witnesses
Wider context from the report “3. There were inexplicable delays and some apparent deliberate obstructions to the gathering of important evidence from key witnesses . This impacted on the extent and quality of evidence ultimately available to both the Service Inquiry and the inquest. Examples of this were –
- The long delays in obtaining formal accounts from key witnesses either in writing or via an interview process.
- The absence of any account from Mr Bunton’s colleague who attended hospital with him following the 26 March 2023 incident. Such an account would have informed the process of inquiry referred to at point 1 above as well as the Service Inquiry and inquest.
- The decision to delete Mr Bunton’s service email account without consideration of its potential importance in the context of a suspected suicide.
- Withholding statements of two key witnesses from the Service Inquiry panel for some months following Mr Bunton’s death.
- The absence of a clear and contemporaneous account of the 11 July 2023 GP consultation, either in the Clinical Care Review document and/or a separate formal account of events obtained from the doctor concerned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Delays in providing key witness statements to the Service Inquiry panel
Wider context from the report “3. There were inexplicable delays and some apparent deliberate obstructions to the gathering of important evidence from key witnesses. This impacted on the extent and quality of evidence ultimately available to both the Service Inquiry and the inquest. Examples of this were –
- The long delays in obtaining formal accounts from key witnesses either in writing or via an interview process.
- The absence of any account from Mr Bunton’s colleague who attended hospital with him following the 26 March 2023 incident. Such an account would have informed the process of inquiry referred to at point 1 above as well as the Service Inquiry and inquest.
- The decision to delete Mr Bunton’s service email account without consideration of its potential importance in the context of a suspected suicide.
- Withholding statements of two key witnesses from the Service Inquiry panel for some months following Mr Bunton’s death .
- The absence of a clear and contemporaneous account of the 11 July 2023 GP consultation, either in the Clinical Care Review document and/or a separate formal account of events obtained from the doctor concerned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure participants understand formal Clinical Care Review processes
Wider context from the report “2. There were weaknesses in the Clinical Care Review process undertaken by the Defence Medical Service following Mr Bunton’s death. While the review of the 11 July 2023 consultation occurred very promptly after Mr Bunton’s death, the GP involved in the consultation was unaware that her informal discussion of the case with a senior colleague was being captured as part of a formal review process . She was also never asked to check the accuracy of the contents of the review document produced following this discussion, which compromised the accuracy of the review document itself, as well as impacting on evidence subsequently available to the Service Inquiry and the inquest. The purpose of the Clinical Care Review process is to identify any concerns around clinical decision-making and mitigate the risk of recurrence of the same, and should therefore be based on a clear and verified record of events.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to preserve potentially important service email evidence
Wider context from the report “3. There were inexplicable delays and some apparent deliberate obstructions to the gathering of important evidence from key witnesses. This impacted on the extent and quality of evidence ultimately available to both the Service Inquiry and the inquest. Examples of this were –
- The long delays in obtaining formal accounts from key witnesses either in writing or via an interview process.
- The absence of any account from Mr Bunton’s colleague who attended hospital with him following the 26 March 2023 incident. Such an account would have informed the process of inquiry referred to at point 1 above as well as the Service Inquiry and inquest.
- The decision to delete Mr Bunton’s service email account without consideration of its potential importance in the context of a suspected suicide .
- Withholding statements of two key witnesses from the Service Inquiry panel for some months following Mr Bunton’s death.
- The absence of a clear and contemporaneous account of the 11 July 2023 GP consultation, either in the Clinical Care Review document and/or a separate formal account of events obtained from the doctor concerned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain or record a clear contemporaneous account of GP consultations
Wider context from the report “3. There were inexplicable delays and some apparent deliberate obstructions to the gathering of important evidence from key witnesses. This impacted on the extent and quality of evidence ultimately available to both the Service Inquiry and the inquest. Examples of this were –
- The long delays in obtaining formal accounts from key witnesses either in writing or via an interview process.
- The absence of any account from Mr Bunton’s colleague who attended hospital with him following the 26 March 2023 incident. Such an account would have informed the process of inquiry referred to at point 1 above as well as the Service Inquiry and inquest.
- The decision to delete Mr Bunton’s service email account without consideration of its potential importance in the context of a suspected suicide.
- Withholding statements of two key witnesses from the Service Inquiry panel for some months following Mr Bunton’s death.
- The absence of a clear and contemporaneous account of the 11 July 2023 GP consultation , either in the Clinical Care Review document and/or a separate formal account of events obtained from the doctor concerned .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Insufficient inquiry into incidents and involved personnel
Wider context from the report “1. There was insufficient inquiry made of Mr Bunton and those service personnel most closely involved with the 26 March 2023 incident as to the circumstances in which it occurred . While it was accepted that Mr Bunton chose to minimise the incident, it could easily have been established by proper inquiry of these parties that Mr Bunton had sent a concerning message before entering the water with suicidal intent, and then been taken by the police to hospital where he was offered psychiatric assessment. The results of these inquiries would have better informed subsequent oversight of Mr Bunton’s welfare by his Chain of Command.
” Open source report
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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 Subject all suspected RAF suicides to immediate fact-finding investigations led by Station Commanders to gather relevant evidence promptly.
Verbatim wording from the response “Nevertheless, we acknowledge the need for a more robust post incident process within the RAF that gathers relevant material in the immediate hours and days following an event. To address this, the Head People and Families Support, as the RAF lead for personnel welfare, has directed that all suspected suicides within the RAF will now be subject to an immediate fact-finding investigation. This process is designed to ensure timely, compassionate, and thorough understanding of the circumstances surrounding such incidents. Responsibility for gathering this evidence and conducting an initial investigation will rest with the Station Commander and will be formally brought into the RAF Postvention Suicide Response policy as a matter of urgency.” Source location Response from Ministry of Defence
Open published response
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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 Apply independent scrutiny to clinical care reviews to identify learning recommendations and establish implementation plans.
Verbatim wording from the response “On receipt of your report, the Defence Medical Services (DMS) conducted a review of the CCR undertaken after AS1 Bunton’s death. I can confirm that the CCR was shared by the Senior Medical Officer with the GP. Unfortunately, due to the passage of time, the GP was unable to recall this fact at the inquest. However, I am assured that the correct process was followed in relation to the CCR, and that independent scrutiny was applied to ensure early recommendations for learning were identified and implementation plans were put in place.
Defence Primary Healthcare regularly review their policies and processes, and recent and separate work has focused on enhancing the approach to clinical reviews of serious healthcare incidents. A key development is the introduction of an early” Source location Response from Ministry of Defence
Open published response
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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 further direction and guidance to avoid delays in providing statements to Service Inquiry panels.
Verbatim wording from the response “Regarding the delay in providing statements to the Service Inquiry panel, I understand that the statements in question were prepared for the inquest, and I am assured that the delay arose from a desire to adhere to the appropriate disclosure processes. However, further direction and guidance has been issued to ensure such delays are avoided in the future. Furthermore, the Defence Inquests Unit is working to implement a process to retain, where appropriate, the email accounts of deceased service personnel. This will allow for the retrieval of relevant data, should it be required for inquests.” Source location Response from Ministry of Defence
Open published response
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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 Implement a process to retain, where appropriate, deceased service personnel’s email accounts for potential inquest evidence retrieval.
Verbatim wording from the response “Regarding the delay in providing statements to the Service Inquiry panel, I understand that the statements in question were prepared for the inquest, and I am assured that the delay arose from a desire to adhere to the appropriate disclosure processes. However, further direction and guidance has been issued to ensure such delays are avoided in the future. Furthermore, the Defence Inquests Unit is working to implement a process to retain, where appropriate, the email accounts of deceased service personnel. This will allow for the retrieval of relevant data, should it be required for inquests.” Source location Response from Ministry of Defence
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 Incorporate immediate fact-finding investigations for suspected RAF suicides into the RAF Postvention Suicide Response policy.
Verbatim wording from the response “Nevertheless, we acknowledge the need for a more robust post incident process within the RAF that gathers relevant material in the immediate hours and days following an event. To address this, the Head People and Families Support, as the RAF lead for personnel welfare, has directed that all suspected suicides within the RAF will now be subject to an immediate fact-finding investigation. This process is designed to ensure timely, compassionate, and thorough understanding of the circumstances surrounding such incidents. Responsibility for gathering this evidence and conducting an initial investigation will rest with the Station Commander and will be formally brought into the RAF Postvention Suicide Response policy as a matter of urgency.” Source location Response from Ministry of Defence
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 existing Clinical Care Review process is considered robust, with independent scrutiny identifying learning and mitigating recurrence risks.
Verbatim wording from the response “On receipt of your report, the Defence Medical Services (DMS) conducted a review of the CCR undertaken after AS1 Bunton’s death. I can confirm that the CCR was shared by the Senior Medical Officer with the GP. Unfortunately, due to the passage of time, the GP was unable to recall this fact at the inquest. However, I am assured that the correct process was followed in relation to the CCR, and that independent scrutiny was applied to ensure early recommendations for learning were identified and implementation plans were put in place.
Defence Primary Healthcare regularly review their policies and processes, and recent and separate work has focused on enhancing the approach to clinical reviews of serious healthcare incidents. A key development is the introduction of an early” Source location Response from Ministry of Defence
Open published response
26 Sep 2025 Catherine Moore · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 15 Unclear JAMES forms and user interface for maintenance and repair information View source Lack of a JAMES mechanism for feedback to the referrer View source Lack of referrer details for checking referral reasons View source Lack of a formal searchable database for serious or recurrent issues View source Failure to support locating and extracting JAMES data for governance and systems audits View source Lack of a process for inspection of MOD vehicle maintenance and repairs View source Lack of a testing process for MOD vehicle maintenance and repairs View source Lack of formal JAMES space for further maintenance suggestions View source Lack of a formal process for real-time feedback on ineffective or incorrect vehicle repairs View source Unclear rationale and scheduling for some JAMES processes View source Failure to maintain distinct time and date records for different tasks View source Limited recording of reasons for JAMES entry and associated mechanical issues View source Insufficient recording of maintenance and repair work details View source Lack of a process for checking MOD vehicle maintenance and repairs View source Lack of an audit process for MOD vehicle maintenance and repairs View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Catherine Moore · 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
Catherine Moore died from traumatic injuries after a road traffic collision between an MOD Land Rover and an HGV, in which the HGV crossed the central reservation and crushed her car. The report found that defective steering, associated with inadequate maintenance and repair of the MOD Land Rover, contributed to the collision and her death. Concerns included unclear and limited information in the JAMES maintenance system, and the absence of formal processes for inspecting, auditing, providing feedback on, and testing MOD vehicle repairs and maintenance.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Unclear JAMES forms and user interface for maintenance and repair information
Wider context from the report “1. With regards to JAMES and its function supporting maintenance and repair of the MOD Land Rover:
The terminology and descriptors on JAMES forms were very difficult to understand and it was unclear how data could be extracted for governance purposes.
There are no details of the referrer if checks are needed with regards to the reasons for the referral.
There is no check in the system allowing feedback to the referrer
Limited reasons were given for entry into JAMES e.g. for failure of a vehicular part. This may limit the breadth of maintenance and /or repair with regards to any mechanical issues associated with the fault.
There are limited details of work done other than task closed or fully fit i.e. few details on how a repair was done or what difficulties with the repair may have been encountered.
There is little formal space on system for suggestions with regards to further work or maintenance on the matter attended to and repaired.
There is lack of clarity on how to locate data and information on the maintenance and repairs.
There was no evidence of ability or/to process or extract data from JAMES to facilitate systems and process audits
The rationale and/or schedule in JAMES for some processes for e.g. ad hoc inspections was unclear.
The user interface is unclear.
The tabling and format are unclear.
There was repetition of identical time and dates attached to different tasks.
There is no formal searchable database e.g. for serious or recurrent issues and themes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a JAMES mechanism for feedback to the referrer
Wider context from the report “1. With regards to JAMES and its function supporting maintenance and repair of the MOD Land Rover:
The terminology and descriptors on JAMES forms were very difficult to understand and it was unclear how data could be extracted for governance purposes.
There are no details of the referrer if checks are needed with regards to the reasons for the referral.
There is no check in the system allowing feedback to the referrer
Limited reasons were given for entry into JAMES e.g. for failure of a vehicular part. This may limit the breadth of maintenance and /or repair with regards to any mechanical issues associated with the fault.
There are limited details of work done other than task closed or fully fit i.e. few details on how a repair was done or what difficulties with the repair may have been encountered.
There is little formal space on system for suggestions with regards to further work or maintenance on the matter attended to and repaired.
There is lack of clarity on how to locate data and information on the maintenance and repairs.
There was no evidence of ability or/to process or extract data from JAMES to facilitate systems and process audits
The rationale and/or schedule in JAMES for some processes for e.g. ad hoc inspections was unclear.
The user interface is unclear.
The tabling and format are unclear.
There was repetition of identical time and dates attached to different tasks.
There is no formal searchable database e.g. for serious or recurrent issues and themes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of referrer details for checking referral reasons
Wider context from the report “1. With regards to JAMES and its function supporting maintenance and repair of the MOD Land Rover:
The terminology and descriptors on JAMES forms were very difficult to understand and it was unclear how data could be extracted for governance purposes.
There are no details of the referrer if checks are needed with regards to the reasons for the referral.
There is no check in the system allowing feedback to the referrer
Limited reasons were given for entry into JAMES e.g. for failure of a vehicular part. This may limit the breadth of maintenance and /or repair with regards to any mechanical issues associated with the fault.
There are limited details of work done other than task closed or fully fit i.e. few details on how a repair was done or what difficulties with the repair may have been encountered.
There is little formal space on system for suggestions with regards to further work or maintenance on the matter attended to and repaired.
There is lack of clarity on how to locate data and information on the maintenance and repairs.
There was no evidence of ability or/to process or extract data from JAMES to facilitate systems and process audits
The rationale and/or schedule in JAMES for some processes for e.g. ad hoc inspections was unclear.
The user interface is unclear.
The tabling and format are unclear.
There was repetition of identical time and dates attached to different tasks.
There is no formal searchable database e.g. for serious or recurrent issues and themes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal searchable database for serious or recurrent issues
Wider context from the report “1. With regards to JAMES and its function supporting maintenance and repair of the MOD Land Rover:
The terminology and descriptors on JAMES forms were very difficult to understand and it was unclear how data could be extracted for governance purposes.
There are no details of the referrer if checks are needed with regards to the reasons for the referral.
There is no check in the system allowing feedback to the referrer
Limited reasons were given for entry into JAMES e.g. for failure of a vehicular part. This may limit the breadth of maintenance and /or repair with regards to any mechanical issues associated with the fault.
There are limited details of work done other than task closed or fully fit i.e. few details on how a repair was done or what difficulties with the repair may have been encountered.
There is little formal space on system for suggestions with regards to further work or maintenance on the matter attended to and repaired.
There is lack of clarity on how to locate data and information on the maintenance and repairs.
There was no evidence of ability or/to process or extract data from JAMES to facilitate systems and process audits
The rationale and/or schedule in JAMES for some processes for e.g. ad hoc inspections was unclear.
The user interface is unclear.
The tabling and format are unclear.
There was repetition of identical time and dates attached to different tasks.
There is no formal searchable database e.g. for serious or recurrent issues and themes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to support locating and extracting JAMES data for governance and systems audits
Wider context from the report “1. With regards to JAMES and its function supporting maintenance and repair of the MOD Land Rover:
The terminology and descriptors on JAMES forms were very difficult to understand and it was unclear how data could be extracted for governance purposes.
There are no details of the referrer if checks are needed with regards to the reasons for the referral.
There is no check in the system allowing feedback to the referrer
Limited reasons were given for entry into JAMES e.g. for failure of a vehicular part. This may limit the breadth of maintenance and /or repair with regards to any mechanical issues associated with the fault.
There are limited details of work done other than task closed or fully fit i.e. few details on how a repair was done or what difficulties with the repair may have been encountered.
There is little formal space on system for suggestions with regards to further work or maintenance on the matter attended to and repaired.
There is lack of clarity on how to locate data and information on the maintenance and repairs.
There was no evidence of ability or/to process or extract data from JAMES to facilitate systems and process audits
The rationale and/or schedule in JAMES for some processes for e.g. ad hoc inspections was unclear.
The user interface is unclear.
The tabling and format are unclear.
There was repetition of identical time and dates attached to different tasks.
There is no formal searchable database e.g. for serious or recurrent issues and themes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for inspection of MOD vehicle maintenance and repairs
Wider context from the report “2. With reference to repair and maintenance of the MOD Land Rover:
There is no process with regards to inspection , checking, audit, feedback and testing of MOD vehicle maintenance and repairs
There is no formal process for real time feedback to e.g. Motor Transport on ineffective/incorrect repairs/maintenance
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a testing process for MOD vehicle maintenance and repairs
Wider context from the report “2. With reference to repair and maintenance of the MOD Land Rover:
There is no process with regards to inspection, checking, audit, feedback and testing of MOD vehicle maintenance and repairs
There is no formal process for real time feedback to e.g. Motor Transport on ineffective/incorrect repairs/maintenance
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of formal JAMES space for further maintenance suggestions
Wider context from the report “1. With regards to JAMES and its function supporting maintenance and repair of the MOD Land Rover:
The terminology and descriptors on JAMES forms were very difficult to understand and it was unclear how data could be extracted for governance purposes.
There are no details of the referrer if checks are needed with regards to the reasons for the referral.
There is no check in the system allowing feedback to the referrer
Limited reasons were given for entry into JAMES e.g. for failure of a vehicular part. This may limit the breadth of maintenance and /or repair with regards to any mechanical issues associated with the fault.
There are limited details of work done other than task closed or fully fit i.e. few details on how a repair was done or what difficulties with the repair may have been encountered.
There is little formal space on system for suggestions with regards to further work or maintenance on the matter attended to and repaired.
There is lack of clarity on how to locate data and information on the maintenance and repairs.
There was no evidence of ability or/to process or extract data from JAMES to facilitate systems and process audits
The rationale and/or schedule in JAMES for some processes for e.g. ad hoc inspections was unclear.
The user interface is unclear.
The tabling and format are unclear.
There was repetition of identical time and dates attached to different tasks.
There is no formal searchable database e.g. for serious or recurrent issues and themes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal process for real-time feedback on ineffective or incorrect vehicle repairs
Wider context from the report “2. With reference to repair and maintenance of the MOD Land Rover:
There is no process with regards to inspection, checking, audit, feedback and testing of MOD vehicle maintenance and repairs
There is no formal process for real time feedback to e.g. Motor Transport on ineffective/incorrect repairs/maintenance
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Unclear rationale and scheduling for some JAMES processes
Wider context from the report “1. With regards to JAMES and its function supporting maintenance and repair of the MOD Land Rover:
The terminology and descriptors on JAMES forms were very difficult to understand and it was unclear how data could be extracted for governance purposes.
There are no details of the referrer if checks are needed with regards to the reasons for the referral.
There is no check in the system allowing feedback to the referrer
Limited reasons were given for entry into JAMES e.g. for failure of a vehicular part. This may limit the breadth of maintenance and /or repair with regards to any mechanical issues associated with the fault.
There are limited details of work done other than task closed or fully fit i.e. few details on how a repair was done or what difficulties with the repair may have been encountered.
There is little formal space on system for suggestions with regards to further work or maintenance on the matter attended to and repaired.
There is lack of clarity on how to locate data and information on the maintenance and repairs.
There was no evidence of ability or/to process or extract data from JAMES to facilitate systems and process audits
The rationale and/or schedule in JAMES for some processes for e.g. ad hoc inspections was unclear.
The user interface is unclear.
The tabling and format are unclear.
There was repetition of identical time and dates attached to different tasks.
There is no formal searchable database e.g. for serious or recurrent issues and themes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain distinct time and date records for different tasks
Wider context from the report “1. With regards to JAMES and its function supporting maintenance and repair of the MOD Land Rover:
The terminology and descriptors on JAMES forms were very difficult to understand and it was unclear how data could be extracted for governance purposes.
There are no details of the referrer if checks are needed with regards to the reasons for the referral.
There is no check in the system allowing feedback to the referrer
Limited reasons were given for entry into JAMES e.g. for failure of a vehicular part. This may limit the breadth of maintenance and /or repair with regards to any mechanical issues associated with the fault.
There are limited details of work done other than task closed or fully fit i.e. few details on how a repair was done or what difficulties with the repair may have been encountered.
There is little formal space on system for suggestions with regards to further work or maintenance on the matter attended to and repaired.
There is lack of clarity on how to locate data and information on the maintenance and repairs.
There was no evidence of ability or/to process or extract data from JAMES to facilitate systems and process audits
The rationale and/or schedule in JAMES for some processes for e.g. ad hoc inspections was unclear.
The user interface is unclear.
The tabling and format are unclear.
There was repetition of identical time and dates attached to different tasks.
There is no formal searchable database e.g. for serious or recurrent issues and themes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Limited recording of reasons for JAMES entry and associated mechanical issues
Wider context from the report “1. With regards to JAMES and its function supporting maintenance and repair of the MOD Land Rover:
The terminology and descriptors on JAMES forms were very difficult to understand and it was unclear how data could be extracted for governance purposes.
There are no details of the referrer if checks are needed with regards to the reasons for the referral.
There is no check in the system allowing feedback to the referrer
Limited reasons were given for entry into JAMES e.g. for failure of a vehicular part. This may limit the breadth of maintenance and /or repair with regards to any mechanical issues associated with the fault.
There are limited details of work done other than task closed or fully fit i.e. few details on how a repair was done or what difficulties with the repair may have been encountered.
There is little formal space on system for suggestions with regards to further work or maintenance on the matter attended to and repaired.
There is lack of clarity on how to locate data and information on the maintenance and repairs.
There was no evidence of ability or/to process or extract data from JAMES to facilitate systems and process audits
The rationale and/or schedule in JAMES for some processes for e.g. ad hoc inspections was unclear.
The user interface is unclear.
The tabling and format are unclear.
There was repetition of identical time and dates attached to different tasks.
There is no formal searchable database e.g. for serious or recurrent issues and themes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Insufficient recording of maintenance and repair work details
Wider context from the report “1. With regards to JAMES and its function supporting maintenance and repair of the MOD Land Rover:
The terminology and descriptors on JAMES forms were very difficult to understand and it was unclear how data could be extracted for governance purposes.
There are no details of the referrer if checks are needed with regards to the reasons for the referral.
There is no check in the system allowing feedback to the referrer
Limited reasons were given for entry into JAMES e.g. for failure of a vehicular part. This may limit the breadth of maintenance and /or repair with regards to any mechanical issues associated with the fault.
There are limited details of work done other than task closed or fully fit i.e. few details on how a repair was done or what difficulties with the repair may have been encountered.
There is little formal space on system for suggestions with regards to further work or maintenance on the matter attended to and repaired.
There is lack of clarity on how to locate data and information on the maintenance and repairs.
There was no evidence of ability or/to process or extract data from JAMES to facilitate systems and process audits
The rationale and/or schedule in JAMES for some processes for e.g. ad hoc inspections was unclear.
The user interface is unclear.
The tabling and format are unclear.
There was repetition of identical time and dates attached to different tasks.
There is no formal searchable database e.g. for serious or recurrent issues and themes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for checking MOD vehicle maintenance and repairs
Wider context from the report “2. With reference to repair and maintenance of the MOD Land Rover:
There is no process with regards to inspection, checking , audit, feedback and testing of MOD vehicle maintenance and repairs
There is no formal process for real time feedback to e.g. Motor Transport on ineffective/incorrect repairs/maintenance
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of an audit process for MOD vehicle maintenance and repairs
Wider context from the report “2. With reference to repair and maintenance of the MOD Land Rover:
There is no process with regards to inspection, checking, audit , feedback and testing of MOD vehicle maintenance and repairs
There is no formal process for real time feedback to e.g. Motor Transport on ineffective/incorrect repairs/maintenance
” Open source report
Concerns raised 4 Lack of readily available, fully funded, long-term rehabilitation and substance-abuse recovery for veterans with PTSD View source Lack of formal clinical mental-health assessment at discharge View source Failure to inquire into possible PTSD or other reasons for illicit drug use after an operational tour View source Lack of veteran awareness of regimental welfare staff and their role in the veteran support landscape View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Aeran Luke Sebastian Taylor · 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
Aeran Luke Sebastian Taylor, a former Army serviceman diagnosed with PTSD, died at his home in Crawley on 27 October 2023. The inquest found that multiple substances combined to a fatal toxic effect, likely resulting from an accidental overdose. Concerns included the lack of mental-health assessment at discharge, limited awareness of veteran welfare support, and insufficient long-term rehabilitation and substance-abuse recovery services for veterans with PTSD.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of readily available, fully funded, long-term rehabilitation and substance-abuse recovery for veterans with PTSD
Wider context from the report “Despite the introduction of Op Courage and sharing of information between - and recognised efforts by - MoD, NHS and organisations such as Combat Stress to treat individuals, there appears to remain a lack of readily available, fully funded, long term rehabilitation and substance abuse recovery for veterans with PTSD at risk , notably for those only diagnosed well after leaving the Armed Forces, and/or who are ‘long term cases’ for whom treatment has not succeeded and/or who have relapsed after and despite such interventions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of formal clinical mental-health assessment at discharge
Wider context from the report “There appears to have been no formal, clinical assessment of mental health at point of discharge , which may have identified the emergence of PTSD. I understand this may now be routine, or more prevalent, but there remains a community of veterans at risk for whom no such assessment may have been in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to inquire into possible PTSD or other reasons for illicit drug use after an operational tour
Wider context from the report “When found to have taken illicit drugs months after completing an operational tour, there appears to have been no inquiry or check as to possible correlation with potential PTSD or other reasons for the behaviour , such as a lack of effective post-tour decompression .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of veteran awareness of regimental welfare staff and their role in the veteran support landscape
Wider context from the report “I heard evidence of a lack of awareness of regimental welfare staff and the role such organisations can play in supporting veterans . Again, those now serving may be more aware but there appears to be a community of veterans at risk who remain unaware, including as to how such organisations fit and work within the overall veteran support landscape .
” 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 Ensure continued efforts to increase awareness of regimental welfare associations among current and former personnel.
Verbatim wording from the response “Raising awareness of the support available will include the promotion of regimental welfare associations, whom I agree have an important role to play. While membership is voluntary, each Regimental or Corps Headquarters in the Army has an Association or equivalent for its serving personnel and veterans. In Mr Taylor’s regiment, the RRF, everyone who has served is entitled to be a member and receive support from the Regimental Charity, The Fusiliers Aid Society (FAS), who I understand did provide Mr Taylor with support. I know that the RRF ensure that all Fusiliers are briefed on joining and discharge on the support available to them. However, I accept that does not mean support and awareness is universal, but I would highlight that Regimental and Corps Headquarters are working to increase awareness of their Associations to current and former personnel. I will ensure that this continues.” Source location Response from Ministry of Defence
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 Post-transition healthcare for veterans is delivered by statutory health services in collaboration with the third sector.
Verbatim wording from the response “The delivery of support for veterans, including long term treatment, is a multi-agency effort. On discharge, the MOD makes every effort to ensure individuals are appropriately transitioned into civilian life and that aftercare is in place should this be required. Support” Source location Response from Ministry of Defence
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 Existing discharge assessments and Structured Mental Health Assessments are considered sufficient to identify possible links between service and drug-related behaviour.
Verbatim wording from the response “It is evident from Mr Taylor’s service records that checks were made as part of the discharge process to establish any mitigating factors which may have led to his drug use. Mr Taylor was interviewed following a positive compulsory drug test and his mental health was reviewed by the Medical Officer as part of his release medical. No significant concerns were noted on the contemporaneous record to indicate a possible correlation with potential PTSD, or other reasons for the behaviour. As you highlight, clinical mental health assessments are routine and since 2012, all personnel at discharge medicals or boards potentially leading to discharge undergo a Structured Mental Health Assessment (SMHA).” Source location Response from Ministry of Defence
Open published response
29 Nov 2024 Charlie Anthony OWEN · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 7 Failure of VRM case conferences to consider post-return check-ins with soldiers posing a risk of self-harm View source Lack of mandatory suicide prevention training for army welfare officers and welfare NCOs View source Failure to facilitate necessary additional support for soldiers posing a risk View source Failure to share protective factors and safety actions with the Chain of Command View source Insufficient focus in VRM training on reducing risk and preventing suicide View source Failure to know where soldiers posing a risk are located View source Failure of the VRM process to adequately document information shared at case conferences View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Charlie Anthony OWEN · 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
Charlie Anthony Owen was found deceased in his room at Combermere Barracks on 11 September 2023, after previously making and aborting two attempts to end his life in the context of relationship breakdown. The inquest identified concerns about inadequate sharing of risk-management information, insufficient consideration of welfare checks and protective factors on his return to barracks, and gaps in Army training and Vulnerability Risk Management processes.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure of VRM case conferences to consider post-return check-ins with soldiers posing a risk of self-harm
Wider context from the report “I heard evidence that the army VRM guidance does not invite those attending case conferences to consider 'checking in' or meeting those assessed as posing a risk of self-harm on return to their unit .
In this inquest no consideration was given to this possibility even though Charlie posed an elevated level of risk and had been initially placed under the VRM process whilst at home. This gives rise to a concern that the army does not know where soldiers who pose a risk are and does not facilitate additional support that may be necessary.
I accept the evidence I heard that different units will have different requirements but this would not prevent them from giving consideration of this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory suicide prevention training for army welfare officers and welfare NCOs
Wider context from the report “I heard that suicide prevention training is not mandatory for army welfare officers/welfare NCOs . This gives rise to a concern that those specifically tasked to deal with people who are most likely to pose a risk of suicide or self harm are not best equipped to identify this and assist the individual .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to facilitate necessary additional support for soldiers posing a risk
Wider context from the report “I heard evidence that the army VRM guidance does not invite those attending case conferences to consider 'checking in' or meeting those assessed as posing a risk of self-harm on return to their unit.
In this inquest no consideration was given to this possibility even though Charlie posed an elevated level of risk and had been initially placed under the VRM process whilst at home. This gives rise to a concern that the army does not know where soldiers who pose a risk are and does not facilitate additional support that may be necessary .
I accept the evidence I heard that different units will have different requirements but this would not prevent them from giving consideration of this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to share protective factors and safety actions with the Chain of Command
Wider context from the report “I was concerned to hear that when a risk management and safety plan has been prepared by the Defence mental health services the information contained about relevant protective factors and safety actions is not necessarily shared with the Chain of Command . There is no prompt on the relevant template to remind of team of the potential benefit of sharing this information or requesting consent from the individual in question to do so which gives rise to a concern that this important information is not shared .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Insufficient focus in VRM training on reducing risk and preventing suicide
Wider context from the report “I heard evidence regarding the VRM process training. I am concerned that there is insufficient focus in that training on the actual aim including reducing risk and preventing suicide . A better understanding of risks and the purpose of VRM seems likely to assist those tasked with running it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to know where soldiers posing a risk are located
Wider context from the report “I heard evidence that the army VRM guidance does not invite those attending case conferences to consider 'checking in' or meeting those assessed as posing a risk of self-harm on return to their unit.
In this inquest no consideration was given to this possibility even though Charlie posed an elevated level of risk and had been initially placed under the VRM process whilst at home. This gives rise to a concern that the army does not know where soldiers who pose a risk are and does not facilitate additional support that may be necessary.
I accept the evidence I heard that different units will have different requirements but this would not prevent them from giving consideration of this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure of the VRM process to adequately document information shared at case conferences
Wider context from the report “Witnesses for the army have noted that information sharing between medical and command personnel poses challenges. I am concerned that the VRM process does not require adequate documentation of the information shared .
The lack of detail contained within the case conference notes hindered this inquest’s ability to establish precisely what risk information was shared. This gives rise to a concern that audits of effectiveness and potential learning points are being missed.
” 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 Establish a working group to review all aspects of mental-health and wellbeing training, including suicide prevention, risk understanding and Vulnerability Risk Management.
Verbatim wording from the response “Suicide prevention training is already mandatory for Army Welfare Officers. I am sorry that this did not come through clearly at the inquest. This is clearly a point of concern and therefore, a working group is being established to fully review all aspects of the training for mental health and wellbeing. I expect the recommendations to be published by April 25 to inform an update to training policy in the following quarter. Your comments concerning a greater focus upon suicide prevention; understanding risk, and the purpose of VRM, will be included within this review.” Source location Response from Ministry of Defence
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 Consider directing units on information to capture, record, share and retain during and after case conferences.
Verbatim wording from the response “Your concern about the adequacy of record keeping and the sharing of the risk management plan will be factored into the policy review of the Army’s VRM Process and templates will be amended accordingly. Additionally, consideration will be given to directing units on what information should be captured, recorded, shared, and kept, during and after case conferences.” Source location Response from Ministry of Defence
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 Publish recommendations from the mental-health and wellbeing training review.
Verbatim wording from the response “Suicide prevention training is already mandatory for Army Welfare Officers. I am sorry that this did not come through clearly at the inquest. This is clearly a point of concern and therefore, a working group is being established to fully review all aspects of the training for mental health and wellbeing. I expect the recommendations to be published by April 25 to inform an update to training policy in the following quarter. Your comments concerning a greater focus upon suicide prevention; understanding risk, and the purpose of VRM, will be included within this review.” Source location Response from Ministry of Defence
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 Update training policy using the published recommendations.
Verbatim wording from the response “Suicide prevention training is already mandatory for Army Welfare Officers. I am sorry that this did not come through clearly at the inquest. This is clearly a point of concern and therefore, a working group is being established to fully review all aspects of the training for mental health and wellbeing. I expect the recommendations to be published by April 25 to inform an update to training policy in the following quarter. Your comments concerning a greater focus upon suicide prevention; understanding risk, and the purpose of VRM, will be included within this review.” Source location Response from Ministry of Defence
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 Army’s Vulnerability Risk Management policy and amend associated templates to improve risk-plan recording and sharing.
Verbatim wording from the response “The policy that supports the Army’s VRM Process is currently undergoing a comprehensive review. The plan is to reissue the policy by the end of March 2025. I expect this to further improve the process, while also making it easier to understand and action.” Source location Response from Ministry of Defence
Open published response
15 Oct 2024 Paul Anthony CHASE · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Lack of mental health, alcoholism and addiction support, treatment and therapy for veterans across service stages View source Insufficient resources causing delays in veterans' access to support and treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Paul Anthony CHASE · 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
Paul Anthony Chase, also known as Paul Anthony Malone, was found deceased hanging in Woolton Woods, Liverpool, on 13 March 2024; the post-mortem examination found the cause of death to be hanging. He had a history of post-traumatic stress disorder and cocaine use, and the inquest concluded that he died by suicide. The report raised concerns about limited mental health, alcoholism and addiction support for veterans, including waits of up to 18 months for some services.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health, alcoholism and addiction support, treatment and therapy for veterans across service stages
Wider context from the report “The lack of mental health/alcoholism/addiction support, treatment and therapy provided to veterans whilst they are:
1. Serving within the armed forces.
2. Undergoing intensive combat training whilstserving within the armed forces.
3. When they are released from the armed forces.
The availability of resources appears to be extremely limited with some ex-veterans having to wait 18 months before a place is available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Insufficient resources causing delays in veterans' access to support and treatment
Wider context from the report “The lack of mental health/alcoholism/addiction support, treatment and therapy provided to veterans whilst they are:
1. Serving within the armed forces.
2. Undergoing intensive combat training whilstserving within the armed forces.
3. When they are released from the armed forces.
The availability of resources appears to be extremely limited with some ex-veterans having to wait 18 months before a place is available .
” Open source report
4 Jul 2024 Harry Peter DUNN · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 2 Failure of driving training to cover wrong-way driving risks View source Lack of UK driving familiarisation and training for diplomatic personnel View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Harry Peter DUNN · 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
Harry Dunn died shortly after arriving at hospital following a head-on collision between his motorcycle and a car on 27 August 2019. The principal concern was that diplomatic personnel based at RAF Croughton were not provided with driver familiarisation or training, and that subsequent training may not have specifically covered the risks of wrong-way driving.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure of driving training to cover wrong-way driving risks
Wider context from the report “(5) Written evidence submitted by the US Embassy and read out at the inquest advised that since Mr Dunn’s death driver training was now provided to all personnel, including family members, assigned to the US Mission wherever they are based in the UK. In addition at RAF Croughton further training was provided for newly arrived US Personnel which included a mandatory local conditions driver safety briefing focussed on the dangers of wrong – way driving.
(6) However the evidence heard at the inquest as to the content of that briefing / training was at odds with what had been described by the US Embassy. Specifically I was told that the driving training being provided did not specifically cover the risks of wrong way driving .
(7) That creates a concern for me as to a risk of future deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of UK driving familiarisation and training for diplomatic personnel
Wider context from the report “(2) In terms of driver training provision there was a distinction between what was provided to the US Military and what was provided, or rather not provided, to Diplomatic personnel . The input provided to the US military personnel amounted to a driver briefing and the completion of a UK theory driving test. Nothing was provided to the diplomatic personnel .
(3) ████████ had received no familiarisation or any other form of training between her arrival in the UK on 24 July 2019 and the accident on 27 August 2019. Prior to the accident she had passed a thorough arrow signalling to a driver if they happened to be overtaking to get back to the left hand side. However, ████████ had not yet familiarised herself with the UK Highway Code and neither had she been trained in the differences in and significance of road signs in the UK .
” Open source report
7 Feb 2024 James Colin Day · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Difficult access to mental health support for service personnel with severe PTSD during service and following discharge View source Failure to provide adequate mental health support for service personnel with severe PTSD during service and following discharge View source Failure to recognise the significance of service-related traumatic events on the mental health of service personnel with severe PTSD View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Colin Day · 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
James Colin Day, who had developed severe post-traumatic stress disorder after serving in Afghanistan, collapsed and died on Malvern Road on 6 May 2023. The report describes concerns that mental health support for service personnel with severe PTSD, both during service and after discharge, was patchy and difficult to access, and that he used alcohol and prescribed medication to cope with his symptoms.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Difficult access to mental health support for service personnel with severe PTSD during service and following discharge
Wider context from the report “The inquest heard evidence that James Day had served his country as a member of the armed services. He had been deployed to Afghanistan as part of his service where he had witnessed traumatic events that had led to him developing post-traumatic stress disorder. He needed support to help him deal with the trauma. However that had not been provided in such a way whilst he was serving to allow him to deal with his PTSD. He had subsequently left the army and had continued to struggle to cope with his PTSD. He used alcohol and prescribed medication to try and cope with the severe symptoms of his PTSD.
The inquest heard that support for service personnel with severe PTSD such as Mr Day whilst they were still serving and following discharge was patchy, difficult to access and did not appear to recognise how significant the impact of events they had witnessed whilst serving could be on their mental health.
The inquest heard that better mental health support whilst serving and following discharge may have avoided Mr Day having to turn to self-medication to try and have respite from his PTSD symptoms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate mental health support for service personnel with severe PTSD during service and following discharge
Wider context from the report “The inquest heard evidence that James Day had served his country as a member of the armed services. He had been deployed to Afghanistan as part of his service where he had witnessed traumatic events that had led to him developing post-traumatic stress disorder. He needed support to help him deal with the trauma. However that had not been provided in such a way whilst he was serving to allow him to deal with his PTSD. He had subsequently left the army and had continued to struggle to cope with his PTSD. He used alcohol and prescribed medication to try and cope with the severe symptoms of his PTSD.
The inquest heard that support for service personnel with severe PTSD such as Mr Day whilst they were still serving and following discharge was patchy , difficult to access and did not appear to recognise how significant the impact of events they had witnessed whilst serving could be on their mental health.
The inquest heard that better mental health support whilst serving and following discharge may have avoided Mr Day having to turn to self-medication to try and have respite from his PTSD symptoms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the significance of service-related traumatic events on the mental health of service personnel with severe PTSD
Wider context from the report “The inquest heard evidence that James Day had served his country as a member of the armed services. He had been deployed to Afghanistan as part of his service where he had witnessed traumatic events that had led to him developing post-traumatic stress disorder. He needed support to help him deal with the trauma. However that had not been provided in such a way whilst he was serving to allow him to deal with his PTSD. He had subsequently left the army and had continued to struggle to cope with his PTSD. He used alcohol and prescribed medication to try and cope with the severe symptoms of his PTSD.
The inquest heard that support for service personnel with severe PTSD such as Mr Day whilst they were still serving and following discharge was patchy, difficult to access and did not appear to recognise how significant the impact of events they had witnessed whilst serving could be on their mental health .
The inquest heard that better mental health support whilst serving and following discharge may have avoided Mr Day having to turn to self-medication to try and have respite from his PTSD symptoms.
” 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 the overall level of support provided to Service Personnel and Veterans.
Verbatim wording from the response “Considering this, and the suite of mental health services that do exist for the Armed Forces community, I do not feel there is an immediate need to change MOD policies in response to your Regulation 28 Report. However, that is not to assume everything is perfect, and I am committed to improving the overall level of support given to both Service Personnel and Veterans. I can assure you, and Mr Day’s family, that if there are any significant improvements that can be identified, steps will be taken to implement them.” Source location Response from Ministry of Defence
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 Existing mental health services mean there is no immediate need to change MOD policies.
Verbatim wording from the response “Considering this, and the suite of mental health services that do exist for the Armed Forces community, I do not feel there is an immediate need to change MOD policies in response to your Regulation 28 Report. However, that is not to assume everything is perfect, and I am committed to improving the overall level of support given to both Service Personnel and Veterans. I can assure you, and Mr Day’s family, that if there are any significant improvements that can be identified, steps will be taken to implement them.” Source location Response from Ministry of Defence
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 report may reflect an incomplete understanding of MOD medical history and support because MOD was not an interested person.
Verbatim wording from the response “In the specific case of Mr Day, I am concerned that the Ministry of Defence (MOD) were not considered an Interested Person at the inquest. This means your Regulation 28 Report may be based on an incomplete understanding of Mr Day’s medical history and the support that was provided to him by the MOD. I have asked the Head of the Defence Inquests Unit (DIU) to provide you separately with the details of the support Mr Day did receive.” Source location Response from Ministry of Defence
Open published response
28 Jul 2023 BENJAMIN DAVID MCQUEEN · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Inconsistency in minimum safety pressure requirements for diver breathing apparatus View source Lack of spare breathing apparatus cylinders in the safety boat View source Unavailability of a defibrillator for dive support staff on safety boats or land View source Inappropriate acceleration of safety-critical dive training for a high-ranking naval visit View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
BENJAMIN DAVID MCQUEEN · 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
Benjamin McQueen drowned on 14 November 2018 during a military diving exercise in Portland Harbour, Dorset, after experiencing complications during the dive and being recovered unconscious from the seabed. The concerns included the lack of a spare breathing-apparatus cylinder for the stand-by diver, accelerated safety-critical training, the absence of a dedicated defibrillator, and inconsistent minimum safety-pressure guidance for breathing apparatus.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Inconsistency in minimum safety pressure requirements for diver breathing apparatus
Wider context from the report “(4) There is an inconsistency regarding the minimum safety pressure level for the relevant diver’s breathing apparatus as between the maintenance manual which DE&S is responsible and all other policy and safety guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of spare breathing apparatus cylinders in the safety boat
Wider context from the report “(1) A stand-by diver was present at the dive exercise and he was deployed to try to find and rescue Ben. However, the stand-by diver had to surface having run out of breathable gas before Ben was found. A spare breathing apparatus cylinder was not carried in the safety boat for the stand-by diver (or other divers) to use in the event that the stand-by diver’s main cylinder ran out.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a defibrillator for dive support staff on safety boats or land
Wider context from the report “(3) Ben was lifted unconscious from the sea bed and Cardio Pulmonary Resuscitation was immediately started. A defibrillator was also applied, but this was only available because it was carried by a Harbour Patrol vessel which came to assist. I am concerned that in such safety-critical military diving training, the dive support staff did not have available to them a defibrillator of their own either on the supporting safety boats or on land. This did not cause or contribute to Ben’s death but could lead to future fatalities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Inappropriate acceleration of safety-critical dive training for a high-ranking naval visit
Wider context from the report “(2) The progression of the dive training in which Ben was engaged was safety-critical. The progression of training was accelerated for several reasons, one of which was a visit by a high-ranking naval officer. The concern of the instructing staff was to polish the drills ahead of that visit and to take the pressure off the dive students by allowing them to practise the dive with relevant equipment ahead of the visit. This acceleration of safety-critical training in part because of such a visit was not appropriate.
” 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 Cascade an Urgent Safety Notice to training authorities and providers requiring safety-critical training to remain progressive and protected from inappropriate acceleration.
Verbatim wording from the response “MOD Response.
The DDS is committed to taking a systemic approach to reviewing and updating the safety policy documents and renewing the management of Health and Safety in Defence. An Urgent Safety Notice has been cascaded across all Training Requirements Authorities and Training Delivery Authorities, to ensure that all Training Providers are clear on the requirement to protect our Service Personnel. The Defence Safety Authority as an independent regulator, investigator and assurer for Health, Safety and Environmental Protection (HS&EP) will continue to safeguard and uphold the message within the Urgent Safety Notice.” Source location Response from Ministry of Defence
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 Update JSP 286 with minimum standby-diver cylinder requirements and guidance on immediate availability of a second diving life-support set.
Verbatim wording from the response “MOD Response.
The MOD has conducted a comprehensive examination of all MOD diving activities, reviewing the lateral freedoms in policy that allowed a dive supervisor to choose the most appropriate cylinder for the standby diver to conduct his duties (including the search for a lost diver). The conclusion was this shall be replaced with clearer direction. The following update to Policy (JSP 286) has now been conveyed to all stakeholders in a Dive Related Instruction (DRI), stating:” Source location Response from Ministry of Defence
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 Formally review JSP 822 and JSP 375 to incorporate requirements for safe, progressive training and management of changes to training time, content, or resources.
Verbatim wording from the response “To achieve this, all Training Activity Owners with responsibility for safety critical training have sought assurance from their Training Providers that this direction is understood and will be adhered to. Further, with continued direction and guidance from Talent Skills Learning and Development (TSLD) and DDS, both training policy (JSP 822) and health and safety policy (JSP 375) will undergo a formal review with updates to encapsulate this narrative and its application within training, to ensure enduring and coherent policy going forward.” Source location Response from Ministry of Defence
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 Ensure all ab initio high-risk dive training sites have a defibrillator available at immediate notice.
Verbatim wording from the response “After consideration and consultation with INM and the MDCC, I am assured that all ab initio (high risk) dive training sites have a defibrillator available at immediate notice. Further, military subject matter experts in conjunction with their civilian and NATO counterparts will now undertake a review of best medical practice and evidence of the effective use of defibrillators and their application in a military maritime environment, specifically for a drowned victim.” Source location Response from Ministry of Defence
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 Obtain assurance from Training Providers that the direction on protecting safety-critical training is understood and will be followed.
Verbatim wording from the response “To achieve this, all Training Activity Owners with responsibility for safety critical training have sought assurance from their Training Providers that this direction is understood and will be adhered to. Further, with continued direction and guidance from Talent Skills Learning and Development (TSLD) and DDS, both training policy (JSP 822) and health and safety policy (JSP 375) will undergo a formal review with updates to encapsulate this narrative and its application within training, to ensure enduring and coherent policy going forward.” Source location Response from Ministry of Defence
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 Align minimum abort-pressure figures across diving policies and maintenance guidance at 50 bar, and cascade the resulting direction across the dive community.
Verbatim wording from the response “MOD Response.
Recognising that the Divers Policy (JSP286) stipulated an increase in abort pressure to that given in the Maintenance Policy (BR2807) as an added safety measure, MDCC and DE&S have now reviewed these Policies and aligned their figures. Direction has now cascaded across the dive community highlighting the changes within these Policies, stating the minimum abort pressure as 50 Bar. This change to the maintenance manual aligns across all diving systems within Defence for commonality and ease of reference, preventing any potential confusion.” Source location Response from Ministry of Defence
Open published response
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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 Carrying a second dive set in safety boats is not required where doing so is impracticable, with the nearest safe location acceptable instead.
Verbatim wording from the response “• ‘When SCADE is employed by the standby diver within un-marked swimming operations, consideration within the Dive Project Plan / Risk Assessment must be given as to the availability of a second Diving Life Support Equipment (DLSE) at immediate notice. The second DLSE should be located within the dive safety boat, however, if this is not practicable, then at the nearest safe location to the dive site’.” Source location Response from Ministry of Defence
Open published response
5 Jun 2023 Jonathan “Jonny” Philip Cole [JC] · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 11 Lack of understanding of services available for Veterans View source Insufficiently robust Trust investigation and review process View source Failure to ensure soldiers receive appropriate mental health treatment and diagnosis View source Insufficient training and experience of Veterans UK Medical Advisors View source Insufficient DCMH clinician influence in vulnerability risk management for suicidal soldiers View source Failure to identify and address suicide risk for Veterans View source Lack of understanding by Trust mental health practitioners of appropriate referral services for Veterans View source Lack of understanding or effort in obtaining military DCMH medical records View source Failure to assist Veterans in accessing appropriate services View source Insufficient availability of psychiatrists and psychologists accessible to serving personnel View source Rejection of PTSD claims despite evidence from other medical professionals without consultant diagnosis View source See 8 more concerns
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 this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Expand mental-health recruitment advertising beyond NHS Jobs through targeted adverts and strengthened communication of the employment offer.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023. View source
Action
Increase validation checks and analysis of Medical Advisor quality-monitoring files and feed findings into continuing professional development.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023. View source
Action
Establish and develop the Defence Health Care Recovery Group to integrate and oversee mental-health, occupational-health and rehabilitation delivery.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023. View source
Action
Run monthly peer case-discussion groups and in-house continuing professional development for Medical Advisors, including specialist medical input.
Stated completedThe respondent said that this action was complete when they made their response on 12 June 2023. View source
Action
Deliver the Mental Health Service Improvement Project, including piloting a new care pathway and developing workforce-management and integrated-data processes.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023. View source
Action
Keep the consultant-level diagnosis requirement for mental-health compensation claims under review and provide resulting reports to the Assistant Coroner.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023. View source
Action
Identify Medical Advisor training needs through quality, tribunal, complaint and feedback information and feed findings into training.
Stated completedThe respondent said that this action was complete when they made their response on 12 June 2023. View source
Action
Implement Unified Career Management (Medical) for all Defence mental-health personnel to improve workforce planning and prioritisation.
Stated completedThe respondent said that this action was complete when they made their response on 12 June 2023. View source
Action
Implement structured initial training, case-based training and extended mentorship for new Armed Forces Compensation Scheme Medical Advisors.
Stated completedThe respondent said that this action was complete when they made their response on 12 June 2023. View source
Action
Operate VRMIS with clinician and supporting-professional access to care action plans, subject to consent, within a multidisciplinary vulnerability-risk-management process.
Stated completedThe respondent said that this action was complete when they made their response on 12 June 2023. View source See 7 more actions
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AI-generated summary
Jonathan “Jonny” Philip Cole [JC] · 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
Jonny Cole was found hanging at Old Stone Bridge, Butterley Park, on 9 August 2018, after having acted with the intention to end his life. He had PTSD, anxiety and suicidal ideation and was under the care of his local mental health trust. The report raised concerns about inadequate identification and management of his suicide risk, gaps in trauma treatment and veteran services, shortcomings in Ministry of Defence mental-health provision and compensation processes, and the robustness of the Trust’s investigation.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of services available for Veterans
Wider context from the report “5. I have a concern that there is:
a) a lack of understanding as to the appropriate services to make referrals to for Veterans by Trust mental health practitioners;
b) a lack of understanding as to services available for Veterans ;
c) too much emphasis on Veterans being solely responsible for self-referral, with no assistance to assist in accessing appropriate services;
d) A lack of understanding (or effort) as to how to request and obtain military DCMH medical records.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust Trust investigation and review process
Wider context from the report “6. I have a concern as to the quality of the Trust’s Investigation Report and that the process of review is not sufficiently robust
I acknowledge that the Trust recognises that the investigation reports provided in respect of Jonny Cole’s death were unsatisfactory and also and that the review of Rapid Response Liaison Psychiatry involvement in 2022, “was a missed opportunity to retrospectively review the investigation in its entirety”. However, it is of concern that the 2022 review was also insufficient and inadequate .
The concerning information relating to the attempt Jonny made to ligate in a tree was not analysed. ████████ told me that an attempt on life by suicide increases the risk 100-fold that you would die by suicide in the next 12 months and is the most significant risk factor in Jonny’s history that massively elevated the risk until that period of time has lapsed which requires clinical risk assessment.
The Investigation report and the updated report following review failed to identify themes of concern ², and did not reassure me that the Trust had taken an appropriate response to investigate the concerning facts of this case and to ensure lessons were learned and not repeated for other patients and appropriate audit undertaken .
I am told that the Trust is, “committed to continuing our improvement journey in this area”, however, I remain concerned that the Trust’s investigation was insufficient, lacked robustness and did not fully engage with the duty of candour .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure soldiers receive appropriate mental health treatment and diagnosis
Wider context from the report “1. I have a concern as to the number and availability of psychiatrists and psychologists within the Ministry of Defence and accessible to serving personnel. This concern extends to ensuring a soldier receives access to appropriate treatment including diagnosis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and experience of Veterans UK Medical Advisors
Wider context from the report “3. I have a concern about:
a. the training and experience of the Medical Advisors at Veterans UK providing advice under the Armed Forces Compensation Scheme .
b. rejection of claims for PTSD under the Armed Forces Compensation Scheme if there is not a formal diagnosis by a consultant psychiatrist or psychologist but evidence of PTSD within medical records from other medical professionals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Insufficient DCMH clinician influence in vulnerability risk management for suicidal soldiers
Wider context from the report “2. I have a concern that the Vulnerability Risk Management Process [Suicide Vulnerability Risk Management as was] is Unit led and that DCMH clinicians do not have a greater role in influencing the Army’s vulnerability risk management (VRM) process for suicidal soldiers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and address suicide risk for Veterans
Wider context from the report “4. I have a concern that the Trust is doing too little to identify and address the risk of suicide for Veterans .
A 2021 Nottinghamshire Suicide Prevention Action Plan to which the Trust was a partner identified for Veterans the need to, “undertake evidence review on the needs of veterans in relation to mental health and suicide, to inform future developments. Promote and raise awareness of the Op Courage MH Pathway and Armed Forces Health eLearning (commissioned by NHSE/Improvement Armed Forces Health). Ensure an ongoing dialogue with NHSE/Improvement around provision of mental health, suicide prevention and postvention. bereavement support to veterans and engage in any NHSE Midlands masterclass with Integrated Care Boards (ICBs) - date to be agreed. Identify veterans within the local Suicide Cluster Response Plan Guidance in the first annual refresh Review learning from the NHSE/Improvement review/investigation of Serious Incidents.”
Despite this, the Trust’s Suicide Prevention Strategy and Suicide Prevention Annual Plan 2020-2023 provided to me and due to be reviewed this year does not specifically touch upon Veterans. I am told that there is a commitment to ensure this is a key feature of the review already commencing within the organisation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding by Trust mental health practitioners of appropriate referral services for Veterans
Wider context from the report “5. I have a concern that there is:
a) a lack of understanding as to the appropriate services to make referrals to for Veterans by Trust mental health practitioners ;
b) a lack of understanding as to services available for Veterans;
c) too much emphasis on Veterans being solely responsible for self-referral, with no assistance to assist in accessing appropriate services;
d) A lack of understanding (or effort) as to how to request and obtain military DCMH medical records.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding or effort in obtaining military DCMH medical records
Wider context from the report “5. I have a concern that there is:
a) a lack of understanding as to the appropriate services to make referrals to for Veterans by Trust mental health practitioners;
b) a lack of understanding as to services available for Veterans;
c) too much emphasis on Veterans being solely responsible for self-referral, with no assistance to assist in accessing appropriate services;
d) A lack of understanding (or effort) as to how to request and obtain military DCMH medical records .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to assist Veterans in accessing appropriate services
Wider context from the report “5. I have a concern that there is:
a) a lack of understanding as to the appropriate services to make referrals to for Veterans by Trust mental health practitioners;
b) a lack of understanding as to services available for Veterans;
c) too much emphasis on Veterans being solely responsible for self-referral, with no assistance to assist in accessing appropriate services ;
d) A lack of understanding (or effort) as to how to request and obtain military DCMH medical records.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of psychiatrists and psychologists accessible to serving personnel
Wider context from the report “1. I have a concern as to the number and availability of psychiatrists and psychologists within the Ministry of Defence and accessible to serving personnel . This concern extends to ensuring a soldier receives access to appropriate treatment including diagnosis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Rejection of PTSD claims despite evidence from other medical professionals without consultant diagnosis
Wider context from the report “3. I have a concern about:
a. the training and experience of the Medical Advisors at Veterans UK providing advice under the Armed Forces Compensation Scheme.
b. rejection of claims for PTSD under the Armed Forces Compensation Scheme if there is not a formal diagnosis by a consultant psychiatrist or psychologist but evidence of PTSD within medical records from other medical professionals .
” 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 Expand mental-health recruitment advertising beyond NHS Jobs through targeted adverts and strengthened communication of the employment offer.
Verbatim wording from the response “This picture presents a challenge to Defence. In response, the DMS has instituted a number of projects under its transformation portfolio that aim to improve the employment offer, maximise retention and ensure the workforce is efficiently used.” Source location Response from Ministry of Defence
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 Increase validation checks and analysis of Medical Advisor quality-monitoring files and feed findings into continuing professional development.
Verbatim wording from the response “• Since early 2023 DBS is now performing an increased number of validation checks on completed MA quality monitoring files and performing improved analysis of the quality monitoring outcomes. This is being fed back into the in-house MA CPD programme.” Source location Response from Ministry of Defence
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 Establish and develop the Defence Health Care Recovery Group to integrate and oversee mental-health, occupational-health and rehabilitation delivery.
Verbatim wording from the response “The Defence Health Care Recovery Group (DHRG) is a new organisation, working to HQ Defence Primary Healthcare (DPHC)⁹, which will provide direct oversight and integration of Mental Healthcare (MH), Occupational Health (OH) and Rehabilitation delivery. The HQ element of DHRG reached Initial Operating Capability in Oct 2022, with a projected Full Operating Capability in Mar 2024. DHRG’s role is to transform extant Mental Health Delivery Services to ensure:” Source location Response from Ministry of Defence
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 Run monthly peer case-discussion groups and in-house continuing professional development for Medical Advisors, including specialist medical input.
Verbatim wording from the response “• Monthly peer AFCS case-based discussion groups which allow the MAs to ensure consistency via benchmarking and identify issues that may require further policy guidance.” Source location Response from Ministry of Defence
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 the Mental Health Service Improvement Project, including piloting a new care pathway and developing workforce-management and integrated-data processes.
Verbatim wording from the response “In conjunction with the activity above, a DMS Mental Health Service Improvement Project (MHIP) commenced in May 23 and is projected to be completed by Dec 24. It will be led by Commander DHRG and is designed to achieve the following:” Source location Response from Ministry of Defence
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 Keep the consultant-level diagnosis requirement for mental-health compensation claims under review and provide resulting reports to the Assistant Coroner.
Verbatim wording from the response “There is ongoing work to keep the requirement for a consultant level psychiatrist or clinical psychologist under review and ensure it remains an appropriate requirement for mental health claims. A further quinquennial review of the Armed Forces Compensation Scheme has been conducted which will comment on this matter when published; a copy will be made available on gov.uk and provided to HM Assistant Coroner for Derby and Derbyshire. Additionally, IMEG are again reviewing mental health as part of their seventh report, expected in early 2024. Once complete, a copy of their report will be published on gov.uk and provided to HM Assistant Coroner for Derby and Derbyshire.” Source location Response from Ministry of Defence
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 Identify Medical Advisor training needs through quality, tribunal, complaint and feedback information and feed findings into training.
Verbatim wording from the response “• Improved identification of overall MA training needs; utilising various methods including quality monitoring outcomes, tribunal outcomes, opportunistically, via complaints and through customer/colleague feedback. This feeds into the in-house MA training discussed above.” Source location Response from Ministry of Defence
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 Implement Unified Career Management (Medical) for all Defence mental-health personnel to improve workforce planning and prioritisation.
Verbatim wording from the response “The final body of work of relevance to this concern is the Unified Career Management (Medical) (UCM (Med)) which has been introduced within Defence. All DMS mental health personnel were moved to this model on 01 Jul 23. This system enables DMS, through Strategic Command, to manage the workforce across the three services, resulting in a more agile and informed approach to workforce planning which will lead to a greater ability to mutually support and proactively prioritise workforce gapping where it exists.” Source location Response from Ministry of Defence
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 Implement structured initial training, case-based training and extended mentorship for new Armed Forces Compensation Scheme Medical Advisors.
Verbatim wording from the response “The Medical Advisor in question started in DBS on 24 Oct 2013 and provided medical advice in respect of Mr Cole’s AFCS content claim on 10 Dec 2013. Given that the MA was ~6 weeks into the role, in terms of prevention, this response should focus on initial MA training and mentoring. After reviewing the case specific facts, DBS is confident that the approach to this case was not indicative of its current approach. Since the appointment of a Senior Medical Advisor in Dec 2022, a structured training programme has been implemented for all new AFCS Medical Advisors. This involves initial legislative training with the Policy Medical Advisor, followed by an intensive period of 3-4 weeks face to face case-based training with the Senior Medical Advisor or equivalently experienced MA.” Source location Response from Ministry of Defence
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 Operate VRMIS with clinician and supporting-professional access to care action plans, subject to consent, within a multidisciplinary vulnerability-risk-management process.
Verbatim wording from the response “The Vulnerability Risk Management (VRM) process was completely overhauled in 2014 and again in 2020. The major change in 2014 was the introduction of a Management Information System (Vulnerability Risk Management Information System (VRMIS)) as a Unit’s Vulnerability Risk Management Register, moving away completely from the previous paper-based system.” Source location Response from Ministry of Defence
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 AFCS legislation requires consultant-level psychiatrist or clinical psychologist diagnosis for mental disorders, and independent reviews have found that requirement appropriate.
Verbatim wording from the response “The Armed Forces Compensation Scheme legislation (available at: The Armed Forces and Reserve Forces (Compensation Scheme) Order 2011 (legislation.gov.uk)) specifies that mental disorders must be diagnosed by a clinical psychologist or psychiatrist at consultant grade; this is the case for all mental disorders, not only PTSD. The requirement for a consultant level diagnosis has been considered multiple times by the Independent Medical Expert Group (IMEG) as part of their reports on mental health, and on each occasion found to be appropriate. IMEG is an advisory non-departmental public body sponsored by the Ministry of Defence that advises the Minister for Defence People, Veterans and Service Families on medical and scientific aspects of the Armed Forces Compensation Scheme and related matters.
Their responsibilities include:” Source location Response from Ministry of Defence
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 VRM process requires medical involvement, including attendance at risk conferences and reviews, so clinicians are not excluded from managing suicidal vulnerability.
Verbatim wording from the response “Since its creation and roll-out in 2014/2015 the VRMIS specifically allows for clinicians, and other third parties who are supporting an individual, such as pastoral and welfare services, to be given read-only access to the Care Action Plan¹¹ (subject to the individual’s explicit consent). The system and process were updated and aligned to follow a multi-disciplinary approach.” Source location Response from Ministry of Defence
Open published response
28 Feb 2023 Stephen Roy Chapple and Jennifer Chapple · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 2 Issuing ceremonial or functional weapons to people leaving the Army who may have a propensity for mental health issues View source Provision of fully functional deadly weapons to people leaving the British Army View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Roy Chapple and Jennifer Chapple · 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 and Jennifer Chapple suffered significant stab wounds during a neighbour dispute and were pronounced deceased at the scene on 21 November 2021. The principal concern was that a fully functional ceremonial dagger had been presented to the assailant on leaving the British Army, placing a potentially deadly weapon in the community; the report questioned the appropriateness of such presentations, including where recipients may have mental health issues.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Issuing ceremonial or functional weapons to people leaving the Army who may have a propensity for mental health issues
Wider context from the report “The murder weapon was a ceremonial dagger that had been presented to ████████ following his retirement from the British Army. ████████ was in the British Army was 2002 – 2017 (Royal Engineers) and, on leaving, he was presented with the ceremonial dagger as a commemorative token of his service.
The dagger was not a blunt replica, it was a fully functional weapon capable of causing significant harm, injury and sadly in the Chapple’s case, death.
Please reconsider the appropriateness of providing anyone leaving the British Army, regardless of rank or status, with what is (to all intents and purposes) a deadly weapon. Such presentation/gifting has essentially put a deadly weapon in the community (where I understand it sadly remains, having never been recovered as it was removed from the scene prior to police attendance) and I am not persuaded that this is appropriate.
During the trial, evidence was adduced by ████████ defence team to allude to the poor mental health of ████████ because of combat and tours of war-torn countries. This is not an uncommon feature of those serving in and/or leaving the Army and adds further weight to my concerns around the appropriateness of such items (whether ceremonial or not) being issued in the first place, but secondly being issued to those who may have a propensity for mental health issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Provision of fully functional deadly weapons to people leaving the British Army
Wider context from the report “The murder weapon was a ceremonial dagger that had been presented to ████████ following his retirement from the British Army. ████████ was in the British Army was 2002 – 2017 (Royal Engineers) and, on leaving, he was presented with the ceremonial dagger as a commemorative token of his service.
The dagger was not a blunt replica, it was a fully functional weapon capable of causing significant harm, injury and sadly in the Chapple’s case, death.
Please reconsider the appropriateness of providing anyone leaving the British Army, regardless of rank or status, with what is (to all intents and purposes) a deadly weapon. Such presentation/gifting has essentially put a deadly weapon in the community (where I understand it sadly remains, having never been recovered as it was removed from the scene prior to police attendance) and I am not persuaded that this is appropriate.
During the trial, evidence was adduced by ████████ defence team to allude to the poor mental health of ████████ because of combat and tours of war-torn countries. This is not an uncommon feature of those serving in and/or leaving the Army and adds further weight to my concerns around the appropriateness of such items (whether ceremonial or not) being issued in the first place, but secondly being issued to those who may have a propensity for mental health issues.
” 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 Remind entitled units to verify genuine need before issuing Combat Fighting Knives and strictly investigate misappropriation for disciplinary or prosecutorial action.
Verbatim wording from the response “I consider that MOD’s existing measures are appropriate, however, I have written to the General Officers Commanding the Units entitled to demand/issue Combat Fighting Knives, in order to remind them:” Source location Response from Ministry of Defence
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 Inform Service chiefs of the murder and remind them to scrutinise potentially lethal-item issues and strictly investigate misappropriation for deterrent sanctions.
Verbatim wording from the response “I consider existing restrictions upon gifting of MOD property to be sufficient, however, I have written to the Service chiefs in order to inform them of this horrific murder and remind them of their duty to ensure that misappropriation of MOD items is identified and investigated. Moreover, that the issue of potentially lethal items should be scrutinised to ensure genuine requirement, and that misappropriation of such items, including combat knives of any type, should be thoroughly investigated and the strictest sanctions applied as a future deterrent.” Source location Response from Ministry of Defence
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 Existing MOD controls on issuing and gifting Combat Fighting Knives are considered appropriate and sufficient to address the concern.
Verbatim wording from the response “I consider that MOD’s existing measures are appropriate, however, I have written to the General Officers Commanding the Units entitled to demand/issue Combat Fighting Knives, in order to remind them:” Source location Response from Ministry of Defence
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 A standing order prohibiting gifts of Combat Fighting Knives would have limited utility because such knives are widely available commercially and legally.
Verbatim wording from the response “There is a tradition within the MOD of presenting leaving gifts to individuals when they exit the Armed Forces. A Combat Fighting Knife as part of a presentation display is one of many gifts that may be presented to a Service person departing military units associated with the Commando role, especially with 3 Commando Brigade such items are provided using non-public funds such as a collection from colleagues. Combat Fighting Knifes and associated display materials are widely available from a range of suppliers commercially within the UK subject to an age check. Whilst the military chain of command could issue a Standing Order prohibiting Service personnel gifting specific items such as Combat Fighting Knives to Service leavers, such an Order would be of limited utility.” Source location Response from Ministry of Defence
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 Combat Fighting Knives are not generally provided to departing personnel; they are restricted to those requiring them for specific combat roles.
Verbatim wording from the response “Matter of Concern 1 – “Please reconsider the appropriateness of providing anyone leaving the British Army, regardless of rank or status, with what is (to all intents and purposes) a deadly weapon.”” Source location Response from Ministry of Defence
Open published response
24 Oct 2022 Kamil Iddrisu and Youngson Nkhoma · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 19 Lack of a mechanism to broadcast a medical emergency by tannoy at the base View source Lack of a standardised method for identifying SCT candidates during selection View source Lack of understanding of the significance of cola-coloured urine as an indicator View source Failure of the clinical oversight board to review or audit near misses View source Lack of Army representation on the clinical oversight board View source Lack of staff awareness of SCT-associated risks during selection and RFT assessments View source Lack of a system for obtaining urgent medical attention at the Lichfield base View source Increased risk of death or collapse during military exercise for people with sickle cell trait View source Failure to follow the SCT screening process before high-risk candidates undertake the 2km run View source Lack of a clearly identifiable person responsible for reviewing and investigating health and safety incidents View source Lack of understanding of the unpredictable risks associated with SCT View source Lack of pre-selection sickle cell trait screening for non-UK selection candidates View source Failure to investigate near misses when they occur View source Use of parallel incident reporting forms on separate IT systems View source Lack of urgent sickle cell trait testing for previously processed non-UK selection candidates View source Lack of SCT screening for Air Force and Navy candidates View source Lack of a system to audit incident processing and investigation View source Lack of clear lines of responsibility for organisation-wide health and safety risk assessment and incident information gathering View source Unresolved or unclear functionality problems in the Casper incident reporting system View source See 16 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism to broadcast a medical emergency by tannoy at the base
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the significance of cola-coloured urine as an indicator
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure of the clinical oversight board to review or audit near misses
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of Army representation on the clinical oversight board
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for obtaining urgent medical attention at the Lichfield base
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a clearly identifiable person responsible for reviewing and investigating health and safety incidents
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the unpredictable risks associated with SCT
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of pre-selection sickle cell trait screening for non-UK selection candidates
Wider context from the report “1. Consideration should be given to all non UK selection candidates being screened for sickle cell trait before embarking on any selection process . A blood test can be undertaken to assess whether candidates have sickle cell trait.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate near misses when they occur
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Use of parallel incident reporting forms on separate IT systems
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to audit incident processing and investigation
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of clear lines of responsibility for organisation-wide health and safety risk assessment and incident information gathering
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Unresolved or unclear functionality problems in the Casper incident reporting system
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.
” Open source report
10 Aug 2022 Neil David James McDougall · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 5 Lack of mental health assessment for personnel leaving the Army View source Culture and stigma discouraging personnel from seeking help for suffering View source Lack of individual post-tour debriefing for open discussion of experiences and trauma View source Suicide and poor mental health among ex-military personnel following active service View source Failure of the post-tour debrief process to encourage discussion of distressing or harrowing service experiences View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Neil David James McDougall · 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
Neil David James McDougall, a former serviceman with a history of mental health problems following active military service and alcohol misuse, was discovered deceased at home on 23 February 2021. The inquest concluded the death was accidental and involved toxicity. Concerns included the lack of individual post-deployment debriefing, the absence of mandatory mental health assessment during Army discharge, and the coordination of support for departing personnel.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health assessment for personnel leaving the Army
Wider context from the report “(2) I was told that on leaving the Army all leavers go through a “Re-Settlement” process. This transitional process involves mandatory courses that assist with re-integration back into civilian life and endeavour to provide leavers with ‘life skills’ such as CV writing, interview techniques/preparation etc to assist leavers in gaining employment once outside of the Army.
The mandatory transitioning arrangements only apply to ‘skills’ and I was told that it is entirely possible to ‘walk out of the door’ without any mental health assessment whatsoever , with the Army appearing to rely on the availability of services provided within the community and/or by charitable organisations that the Army can either signpost the leaver to, or they can access for themselves once a civilian.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Culture and stigma discouraging personnel from seeking help for suffering
Wider context from the report “(1) I was told that the de-brief for serving personnel after returning from a Tour is undertaken as part of a group. There appeared to be some limitations to this process. I was told that there are no 1-to-1 sessions in which personnel can openly talk about their experiences and trauma, which is something that they may be reluctant to do in an open setting for fear of going against the grain or culture of being physically and mentally resilient. The debrief or recovery process itself appeared to centre more around the consumption of alcohol rather than the encouragement to talk about any distressing or harrowing experiences of active combat and service and I remain concerned that the culture/stigma does not lend itself to those suffering taking the first step and effectively raising their hands and asking for help .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of individual post-tour debriefing for open discussion of experiences and trauma
Wider context from the report “(1) I was told that the de-brief for serving personnel after returning from a Tour is undertaken as part of a group . There appeared to be some limitations to this process. I was told that there are no 1-to-1 sessions in which personnel can openly talk about their experiences and trauma , which is something that they may be reluctant to do in an open setting for fear of going against the grain or culture of being physically and mentally resilient. The debrief or recovery process itself appeared to centre more around the consumption of alcohol rather than the encouragement to talk about any distressing or harrowing experiences of active combat and service and I remain concerned that the culture/stigma does not lend itself to those suffering taking the first step and effectively raising their hands and asking for help.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Suicide and poor mental health among ex-military personnel following active service
Wider context from the report “(4) I am concerned by the level of suicides amongst ex-military personnel and I do not believe that Neil was an exceptional case, he is representative of the rising figures and statistics; ex-military (predominantly men) who suffer from poor mental health as a result of active service .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure of the post-tour debrief process to encourage discussion of distressing or harrowing service experiences
Wider context from the report “(1) I was told that the de-brief for serving personnel after returning from a Tour is undertaken as part of a group. There appeared to be some limitations to this process. I was told that there are no 1-to-1 sessions in which personnel can openly talk about their experiences and trauma, which is something that they may be reluctant to do in an open setting for fear of going against the grain or culture of being physically and mentally resilient. The debrief or recovery process itself appeared to centre more around the consumption of alcohol rather than the encouragement to talk about any distressing or harrowing experiences of active combat and service and I remain concerned that the culture/stigma does not lend itself to those suffering taking the first step and effectively raising their hands and asking for help.
” Open source report
7 Dec 2021 Jonathan Harvey Bayliss · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 2 Failure of Hawk TMk1/1A simulator training to reflect the aerodynamic effects of a fitted smoke pod View source Lack of artificial stall warning capability during low-speed, low-altitude manoeuvring View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jonathan Harvey Bayliss · 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
On 20 March 2018, a Royal Air Force Hawk aircraft crashed at RAF Valley during a training exercise involving a Practiced Engine Failure After Take Off manoeuvre. The engineer, Corporal Jonathan Bayliss, did not eject and was declared dead at the scene. The substantive concerns included the absence of an artificial stall warning capability in the aircraft and simulator training that did not accurately reflect the effects of a smoke pod.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure of Hawk TMk1/1A simulator training to reflect the aerodynamic effects of a fitted smoke pod
Wider context from the report “It was recommended by the Service Inquiry that the Hawk TMk1/1A simulator training accurately reflects an aerodynamic model of a RAF aircraft aircraft with smoke pad fitted, given that this may soon become the only Hawk Mk1/1A operated by the RAF and the current training simulator did not have the effect of a smoke pod fitted . Whilst there are developments in this respect there is no new synthetic trainer in place as yet .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of artificial stall warning capability during low-speed, low-altitude manoeuvring
Wider context from the report “As identified by the Service Inquiry the cause of the crash was the aircraft stalling with insufficient height to recover. It was also recognised that the aircraft may in certain circumstances stall without pre-stall buffet . The pre-stall buffet remains the warning sign to the pilot of an impending stall . The Service Inquiry recommended that urgent investigations be undertaken into the incorporation of an artificial stall warning capability in the Hawk Mk 1 to provide sufficient warning to pilots during low speed low altitude manoeuvring . Whilst a feasibility assessment and cost benefit analysis have been undertaken a final decision is yet to be made as to whether or not the recommendations will be adopted . The current out of service date for the said aircraft is at least 2030. A number of RAF Aerobatic Team pilots will be flying every year (including a small number of new arrivals each year) and some circumn engineers are still being flown in the said aircraft.
” 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 Complete analysis and evaluation supporting a combined artificial stall warning and Angle of Attack gauge.
Verbatim wording from the response “Matters of Concern 1 – “As identified by the Service Inquiry, the cause of the crash was the aircraft stalling with insufficient height to recover. It was also recognised that the aircraft may in certain circumstances stall without pre-stall buffet. The pre-stall buffet remains the warning sign to the pilot of an impending stall. The Service Inquiry recommended that urgent investigations be undertaken into the incorporation of an artificial stall warning capability in the Hawk T Mk1 to provide sufficient warning to pilots during low-speed low-altitude manoeuvring. Whilst a feasibility assessment and cost benefit analysis have been undertaken a final decision is yet to be made as to whether or not the recommendation will be adopted.”” Source location 2021-0413-Response-from-Ministry-of-Defence_Published
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 Fit a combined artificial stall warning and Angle of Attack gauge to remaining RAFAT Hawk T Mk1 aircraft, including required testing and evaluation.
Verbatim wording from the response “As you observe, further analysis and evaluation has been carried out after the sad death of Corporal Bayliss. I am pleased to say that this has concluded that the incorporation of a combined ASWS and Angle of Attack (AoA) gauge to enhance stall mitigation is feasible and proportionate. The RAF will now take forward work to fit a combined ASWS and AoA gauge to the remaining RAFAT Hawk T Mk1 aircraft. This will require significant test and evaluation, which will be a high priority. The exact timescales for test, evaluation, development and embodiment of the combined ASWS/AoA gauge will be determined this year.” Source location 2021-0413-Response-from-Ministry-of-Defence_Published
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 Identify options and develop procurement planning for a bespoke RAFAT Hawk Synthetic Training Facility at RAF Waddington.
Verbatim wording from the response “The Ministry of Defence (MOD) recognises that the Hawk Synthetic Training Facility at RAF Valley provides a generic platform for procedural and emergency training, for pilots that operate all types of Hawk T Mk1 aircraft. The retirement of the ‘black’ Hawk T Mk1, which includes 736 Royal Naval Air Squadron and Number 100 Squadron, on 31 March 2022, provides an opportunity to deliver a bespoke Hawk Synthetic Training Facility for RAFAT pilots. The RAF has begun to identify potential RAFAT focused Hawk Synthetic Training Facility options, to be co-located with the Team at their new home of RAF Waddington. The new Facility will correctly reflect the aerodynamic model of a RAFAT aircraft, with a smoke pod fitted. A detailed procurement timeline is being developed, with the expectation that the new Facility will be in place by 2025.” Source location 2021-0413-Response-from-Ministry-of-Defence_Published
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 RAFAT Hawk Synthetic Training Facility accurately modelling an aircraft with a smoke pod, expected by 2025.
Verbatim wording from the response “The Ministry of Defence (MOD) recognises that the Hawk Synthetic Training Facility at RAF Valley provides a generic platform for procedural and emergency training, for pilots that operate all types of Hawk T Mk1 aircraft. The retirement of the ‘black’ Hawk T Mk1, which includes 736 Royal Naval Air Squadron and Number 100 Squadron, on 31 March 2022, provides an opportunity to deliver a bespoke Hawk Synthetic Training Facility for RAFAT pilots. The RAF has begun to identify potential RAFAT focused Hawk Synthetic Training Facility options, to be co-located with the Team at their new home of RAF Waddington. The new Facility will correctly reflect the aerodynamic model of a RAFAT aircraft, with a smoke pod fitted. A detailed procurement timeline is being developed, with the expectation that the new Facility will be in place by 2025.” Source location 2021-0413-Response-from-Ministry-of-Defence_Published
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 Update and test the Hawk Synthetic Training Facility software to model a RAFAT Hawk T Mk1 aircraft with a smoke pod.
Verbatim wording from the response “Prior to this being completed, it is important that RAFAT pilots can train synthetically on an aircraft that is truly representative of the one they fly. MOD has therefore taken steps to ensure that, following the retirement of the ‘black’ Hawk T Mk1 aircraft, the current Hawk Synthetic Training Facility software is updated to closely reflect the aerodynamic model of a RAFAT aircraft with a smoke pod fitted. A period of test and evaluation will be required, although it is expected that the remodelling of the software to replicate a RAFAT Hawk T Mk1” Source location 2021-0413-Response-from-Ministry-of-Defence_Published
Open published response
6 Dec 2021 Alexander Charles George Tostevin · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Lack of independence in service mental health care View source Primacy of DCMH views in multidisciplinary risk assessment View source Absence of a composite risk assessment and care plan View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alexander Charles George Tostevin · 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
Corporal Alexander Charles George Tostevin died on 18 March 2018 after a significant deterioration in his mental health and while under the care of the Royal Navy Department of Community Mental Health and Welfare Team. A risk management email containing significant disclosures was not seen until the following week, resulting in a missed opportunity to reassess his risk before the weekend. The concerns included the lack of independence of the DCMH, the primacy of its view in multidisciplinary risk assessments, and the absence of a composite risk assessment and care plan.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of independence in service mental health care
Wider context from the report “i. The lack of independence of DCMH risks service users minimising and/or under reporting the risks they may pose to themselves for fear that information may be disclosed to the Chain of Command . If the true extent of the risk of ████████ is not known by DCMH, an effective risk management plan to mitigate the risk of ████████ cannot be formulated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Primacy of DCMH views in multidisciplinary risk assessment
Wider context from the report “ii. The primacy of the view of DCMH when considering the risk of ████████ in MDT/Case Conferences again means that the true risk of ████████ may not be accounted for , particularly where a service user is providing different information to DCMH and Welfare and/or where there is a disagreement between DCMH and Welfare as to the presenting level of risk . Adopting a process similar to a Multi-Agency Risk Management Meeting ("MARM") or Multi Agency Risk Assessment Conference ("MARAC") in a civilian context may assist: in a MARM or MARAC, the level of risk adopted is the highest level raised in the meeting/conference, without any agency having primacy. Therefore, the risk management plan subsequently formulated addresses the highest level of risk brought to the meeting.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Absence of a composite risk assessment and care plan
Wider context from the report “iii. Where there is no composite risk assessment and care plan document that draws together all the relevant information for a patient and identifies the plan in place at any given time , there is a risk that key information and risk factors are missed , which is less likely if there is a composite document in addition to the clinical records.
” 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 Apply AGAI 110 Vulnerability Risk Management within the Unit.
Verbatim wording from the response “Societal stigma regarding mental health issues has reduced in recent years but does endure. This is a recognised risk within service communities with regards to the management of vulnerability. Cpl Tostevin’s Unit has now adopted the Army General Administrative Instruction (AGAI) 110 – Vulnerability Risk Management (VRM)⁵, which acknowledges the ongoing challenges, stating:” Source location 2021-0407-Response-from-Ministry-of-Defence_Published
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 Use holistic composite Care Assessment Plans and VRMIS to consolidate risk information, update carers and notify them of changes.
Verbatim wording from the response “In line with AGAI 110, composite CAP documents based on a holistic assessment of risk are now in place within Cpl Tostevin’s Unit. The Case Conferences continue to employ a multi-disciplinary approach to managing personnel deemed to be at risk, with carers’ meetings being conducted fortnightly. Meeting attendees now feed into a collaborative tool to manage vulnerable personnel, which is hosted on the Vulnerability Risk Management Information System (VRMIS).” Source location 2021-0407-Response-from-Ministry-of-Defence_Published
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 support through an embedded independent psychiatric nurse.
Verbatim wording from the response “The Unit also receives enhanced support from an embedded, independent, psychiatric nurse- a key asset in promoting mental health and wellbeing. The Unit is also exploring options to increase DCMH endorsed clinical mental health support and dedicated psychologist support. Each squadron has its own General Practitioner supported by a full-time medic. The close relationship between the Chain of Command and medical/welfare practitioners continues to enable any stigma associated with mental health issues to be combated, while also ensuring mental health First Aid measures can be implemented and any referrals made in a timely manner to ensure our SP are effectively supported.” Source location 2021-0407-Response-from-Ministry-of-Defence_Published
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 Implement a joint DCMH–RNFPS working protocol for resolving disagreements and improving communication.
Verbatim wording from the response “Since the tragic passing of Cpl Tostevin, to ensure this process runs effectively in the Unit, a joint working protocol between DCMH and the Royal Navy Families and People Support (RNFPS) team was agreed and signed in March 2020. A copy of this protocol is provided at Enclosure 2. This outlines the actions to be taken in cases where disagreements occur between the two organisations, which promotes improved lines of communication accounts for all views to ensure the wellbeing of the individual is protected.” Source location 2021-0407-Response-from-Ministry-of-Defence_Published
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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 DCMH is independent of Service chains of command, so its structure does not create the identified lack-of-independence risk.
Verbatim wording from the response “DCMH operates as an independent organisation, which sits within Defence Primary Healthcare (DPHC), a Tri-Service organisation in UK Strategic Command. Although military DCMH staff² are drawn from the medical services of the Royal Navy (RN), Army and Royal Air Force (RAF), DCMH is independent of all three Service chains of command. Mental health services play a vital Occupational Health role in supporting the Unit and the holistic care of Service personnel. Therefore, a close relationship with an individual’s Chain of Command and DPHC is often a key to ensure the best possible outcome for personnel experiencing mental health issues.” Source location 2021-0407-Response-from-Ministry-of-Defence_Published
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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 Existing Chain of Command-led multidisciplinary processes and disagreement protocols provide holistic risk management without adopting a MARM or MARAC model.
Verbatim wording from the response “While each Service has its own policies and frameworks to manage its vulnerable personnel, every case across Defence is Chain of Command led and supported, as appropriate, by welfare agencies, pastoral support and healthcare professionals (including DCMH). Cpl Tostevin’s Unit applies the Army’s Vulnerability Risk Management (VRM) Framework, which states:” Source location 2021-0407-Response-from-Ministry-of-Defence_Published
Open published response
17 Nov 2021 Victoria HARRILD-JONES · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Failure to provide post-operative prophylactic anti-coagulation during home recovery after overseas inpatient secondary care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Victoria HARRILD-JONES · 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
Victoria Harrild-Jones died at home on 27 December 2019 after developing a pulmonary embolism following gastric bypass surgery, with peritonitis, reduced mobility and thrombosis identified in the account of her death. The principal concern was that she was not prescribed prophylactic anti-coagulation medication after discharge, unlike the treatment described as required for UK-based patients under NICE guidance, potentially resulting in care below the standard expected in the UK for military personnel and dependants treated overseas.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to provide post-operative prophylactic anti-coagulation during home recovery after overseas inpatient secondary care
Wider context from the report “At the time of her death Victoria had not been prescribed any prophylactic anti-coagulation medication for the period of her recovery at home.
Following her operation on the 19th December 2019 the court was told that whilst in hospital, Victoria was required to wear compression stockings and was given a daily dose of anti-coagulation medication in order to assist in the prevention of a venous thromboembolism from forming.
However, upon Victoria’s discharge on the 22nd December 2019 these measure were withdrawn by her treating clinician, the court being told that this is standard practice for all patients in Cyprus.
The court then heard, that for UK based patients, National Institute for Health Care Excellence guidance requires that a prophylactic dose of anti-coagulation medication should be given for a period of at least 2 weeks post-operatively, including periods of recovery spent at home.
As such, anti-coagulation medication would have been prescribed to Victoria post-operatively for at least a two-week period had her operation occurred in the UK.
I am therefore concerned that military personnel (and their dependents) who receive inpatient secondary care from local provider’s whilst deployed overseas, may be provided treatment following their discharge which is not compliant with NICE guidance and which falls below the standard expected in the UK.
” Open source report
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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 Bring the new Cyprus secondary healthcare contract into effect, requiring Defence GPs to confirm proposed care pathways meet NICE guidelines.
Verbatim wording from the response “There are mitigations in place to manage the risks associated with personnel receiving inpatient secondary care from local providers whilst deployed overseas. Within Cyprus, the secondary health care contract includes the requirement to follow UK guidelines (NICE; NHS England) for those procedures that are approved, unless they contravene Cypriot MoH guidelines. The contracted service provider in Cyprus has been the Ygia Polyclinic since 2012. A new contract, based on an enhanced statement of requirement, has recently been awarded to the American Medical Centre (AMC) in Nicosia, Cyprus, and will come into effect from 1 April 2022, providing specified in-patient and out-patient services to the entitled population. Within the new contract, Defence GPs will confirm that a proposed care pathway meets NICE guidelines.” Source location 2021-0386-Response-from-MoD_Published
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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 Existing policy, contractual requirements, GP review and professional liaison visits are considered sufficient mitigations for risks from approved overseas secondary care.
Verbatim wording from the response “There are mitigations in place to manage the risks associated with personnel receiving inpatient secondary care from local providers whilst deployed overseas. Within Cyprus, the secondary health care contract includes the requirement to follow UK guidelines (NICE; NHS England) for those procedures that are approved, unless they contravene Cypriot MoH guidelines. The contracted service provider in Cyprus has been the Ygia Polyclinic since 2012. A new contract, based on an enhanced statement of requirement, has recently been awarded to the American Medical Centre (AMC) in Nicosia, Cyprus, and will come into effect from 1 April 2022, providing specified in-patient and out-patient services to the entitled population. Within the new contract, Defence GPs will confirm that a proposed care pathway meets NICE guidelines.” Source location 2021-0386-Response-from-MoD_Published
Open published response
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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 NICE guidance does not routinely require more than seven days of LMWH after bariatric surgery, rather than the asserted two weeks.
Verbatim wording from the response “The UK national best practice to prevent VTE is embodied within the National Institute for Health and Care Excellence (NICE) Guideline on ‘Venous Thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism’. There is only one situation where LMWH prophylaxis greater than seven days from admission is routinely recommended by NICE, which is for major cancer surgery involving the abdomen (para 1.14.4) when evidence shows a reduction in VTE with prophylaxis if extended for 28 days.” Source location 2021-0386-Response-from-MoD_Published
Open published response
3 Aug 2021 Cpl Ryan Lovatt · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 2 Lack of a realistic, workable, widely understood and enforceable alcohol policy on Op Cabrit View source Failure to formalise, communicate and give prominence to the shark watch role View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Cpl Ryan Lovatt · 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
Cpl Ryan Lovatt died after falling accidentally and unwitnessed from his seventh-floor hotel balcony in Warsaw in the early hours of 1 August 2019. He had been drinking heavily, was intoxicated with alcohol, and had been pepper sprayed outside a club before being taken to his room. The principal concerns were whether the alcohol policy for Op Cabrit was realistic, workable and understood, and whether the “shark watch” safeguard was formalised and effective.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a realistic, workable, widely understood and enforceable alcohol policy on Op Cabrit
Wider context from the report “I am concerned about whether the existing alcohol policy is fit for purpose and whether there are systemic failures in respect of it. According to the Learning account, I understand the policy was reviewed as a result of this tragic incident and deemed to be appropriate.
I understand that Op Cabrit is unusual in that it is a formal operation but one that is within allied nations. I note from the Learning Account that there is an emphasis on normalising the deployment to make it appealing to soldiers to re-deploy for a second time. I also understand though that the facilities at the camp where Cpl Lovatt was based in Poland left a lot to be desired and morale was not high. There is what appears to be a fairly restrictive alcohol policy, the 2 can rule.
The deployment appears to sit somewhere between an operational tour and being normalised. The result of this appears to be a systemic problem with regard to understanding the policy and complying with it. It is possible that a restrictive alcohol policy and poor conditions in the base might lead to excessive/binge drinking when on a trip such as this one. Rather than tightening the policy, it is possible that less restrictive conditions at the base is part of the answer.
Whichever view is taken of the above, whether it is a 2 can rule, 4 can rule or more, an important safeguard is the requirement for a soldier, normally an NCO, to be nominated as shark watch and to remain sober and vigilant. It is a well known and common sense concept. It is not clear to me if there is a formalised policy. I anticipate the system may operate differently depending on the personnel and location. In this case, the system did not operate effectively as the person nominated as shark watch did not appear to know that he had been nominated. Others who gave evidence were unclear about the existence or requirements of such a system.
In short, my concern is that there is not a realistic, workable, or widely understood policy that is capable of being enforced with regard to alcohol on Op Cabrit and that, furthermore, the role of shark watch is not given greater prominence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to formalise, communicate and give prominence to the shark watch role
Wider context from the report “I am concerned about whether the existing alcohol policy is fit for purpose and whether there are systemic failures in respect of it. According to the Learning account, I understand the policy was reviewed as a result of this tragic incident and deemed to be appropriate.
I understand that Op Cabrit is unusual in that it is a formal operation but one that is within allied nations. I note from the Learning Account that there is an emphasis on normalising the deployment to make it appealing to soldiers to re-deploy for a second time. I also understand though that the facilities at the camp where Cpl Lovatt was based in Poland left a lot to be desired and morale was not high. There is what appears to be a fairly restrictive alcohol policy, the 2 can rule.
The deployment appears to sit somewhere between an operational tour and being normalised. The result of this appears to be a systemic problem with regard to understanding the policy and complying with it. It is possible that a restrictive alcohol policy and poor conditions in the base might lead to excessive/binge drinking when on a trip such as this one. Rather than tightening the policy, it is possible that less restrictive conditions at the base is part of the answer.
Whichever view is taken of the above, whether it is a 2 can rule, 4 can rule or more, an important safeguard is the requirement for a soldier, normally an NCO, to be nominated as shark watch and to remain sober and vigilant. It is a well known and common sense concept. It is not clear to me if there is a formalised policy. I anticipate the system may operate differently depending on the personnel and location. In this case, the system did not operate effectively as the person nominated as shark watch did not appear to know that he had been nominated . Others who gave evidence were unclear about the existence or requirements of such a system.
In short, my concern is that there is not a realistic, workable, or widely understood policy that is capable of being enforced with regard to alcohol on Op Cabrit and that, furthermore, the role of shark watch is not given greater prominence .
” Open source report
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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 daily Part 1 Orders requiring all ranks to read repeated alcohol and Sharkwatch requirements and duty-personnel actions.
Verbatim wording from the response “Part 1 Orders are issued daily and required to be read by all ranks. These orders contain regular repeats of all aspects of the Force Protection policy, including the prevailing restrictions on alcohol and the actions required of duty personnel, including those undertaking Sharkwatch. This is targeted at ensuring an instinctive understanding of the alcohol and Sharkwatch policy at all levels among the deployed force. An example of recent Part 1 Orders from Poland is at Enclosure 3.” Source location 2021-0373-Response-from-Ministry-of-Defence_Published
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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 Amend Sharkwatch orders to require the nominated person to keep the group together, ensure safe return, report deviations, sign the orders and retain them with the commander.
Verbatim wording from the response “This policy review also considered whether the existing Sharkwatch direction was sufficient. Sharkwatch is an established military protocol, which grew out of requirements in Northern Ireland and West Germany to prevent soldiers being taken advantage of by those who wished them harm (‘sharks’). A member of the group is nominated to remain sober, to keep watch in a supervisory role. It was outlined in the Force Protection policy that was extant at the time of Corporal Lovatt’s death, but there was no explicit direction that the nominated individual should acknowledge their responsibility. The Sharkwatch policy was amended on 13 Nov 19 to include written orders which include the requirement to keep the group together, to return everyone safely to their overnight location and to report any deviation from orders to the Chain of Command.” Source location 2021-0373-Response-from-Ministry-of-Defence_Published
Open published response
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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 Replace the universal two-can alcohol limit with impact-based criteria requiring moderation and unimpaired judgement.
Verbatim wording from the response “Nonetheless, following this incident there was a comprehensive review of the force protection policy on Op CABRIT. This review has replaced the 2-can rule with impact criteria, moving focus from the amount of alcohol consumed to the negative effects of consumption, in particular on the behaviour of personnel. This more nuanced direction states soldiers must “drink in moderation” ensuring they do not allow their judgement to become impaired or their behaviour to fall short of the Army’s values and standards. It is combined with an education programme regarding the consequences of excessive alcohol consumption. I believe removal of the universal 2-can limit ties in with your remark that a less restrictive alcohol policy may reduce temptation to engage in excessive drinking when off camp. The current alcohol policy is at Paras 19–25 of Enclosure 1.” Source location 2021-0373-Response-from-Ministry-of-Defence_Published
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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 amended Sharkwatch policy, including signed written orders and reporting duties, has effectively addressed concerns about the role’s understanding and prominence.
Verbatim wording from the response “This policy review also considered whether the existing Sharkwatch direction was sufficient. Sharkwatch is an established military protocol, which grew out of requirements in Northern Ireland and West Germany to prevent soldiers being taken advantage of by those who wished them harm (‘sharks’). A member of the group is nominated to remain sober, to keep watch in a supervisory role. It was outlined in the Force Protection policy that was extant at the time of Corporal Lovatt’s death, but there was no explicit direction that the nominated individual should acknowledge their responsibility. The Sharkwatch policy was amended on 13 Nov 19 to include written orders which include the requirement to keep the group together, to return everyone safely to their overnight location and to report any deviation from orders to the Chain of Command.” Source location 2021-0373-Response-from-Ministry-of-Defence_Published
Open published response
19 Nov 2020 PAUL HILLS · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 9 Failure to update mental health care plans View source Absence of an urgent assessment and review pathway for deteriorating mental health View source Insufficient local availability of mental health treatment View source Failure to update risk assessments when risk scores or behaviour change View source Failure of communication and sharing of relevant information between treatment services View source Failure to provide effective safety advice addressing imminent dangerous driving thoughts View source Failure to share relevant mental health risk information with family members View source Lack of risk assessment for virtual mental health appointments during service changes View source Failure to document disclosures relevant to mental health risk View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
PAUL HILLS · 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
Paul Hills was found deceased at home in his garage on 24 April 2020 after suspending himself from a rafter. He had a history of post-traumatic stress disorder, reported episodes and dry runs of self-harm, and was receiving treatment. Concerns included inadequate risk assessment and care-plan updates, failure to document or share escalating risk information, insufficient planning for remote treatment during the COVID-19 pandemic, and limitations affecting local treatment and communication.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to update mental health care plans
Wider context from the report “2. Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Absence of an urgent assessment and review pathway for deteriorating mental health
Wider context from the report “1. No risk assessment was completed on the issue of moving mental health appointments to virtual during the COVID-19 pandemic and how patients could be kept safe in the event of deterioration in his mental health. There was no plan in place for patients that required urgent assessment/review due to deterioration in their mental health.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Insufficient local availability of mental health treatment
Wider context from the report “6. Evidence was heard during the inquest that RAF Manston was being decommissioned and this impacted on the treatment available locally for Sgt Hills and impacted on communications with the DCMH and the sharing of relevant information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to update risk assessments when risk scores or behaviour change
Wider context from the report “2. Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure of communication and sharing of relevant information between treatment services
Wider context from the report “6. Evidence was heard during the inquest that RAF Manston was being decommissioned and this impacted on the treatment available locally for Sgt Hills and impacted on communications with the DCMH and the sharing of relevant information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective safety advice addressing imminent dangerous driving thoughts
Wider context from the report “5. Sgt Hills was advised not to drive with his wife and children in the car when he disclosed strong thoughts to drive head long into oncoming traffic. This advice would not have protected Sgt Hills or other road users.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant mental health risk information with family members
Wider context from the report “3. Risk issues were not shared with the family even though Sgt Hills was in lockdown with them and there were no discussions regarding sharing of information . He disclosed his dry runs of self-strangulation on 28th February and 16th April and his withdrawal/isolation from his family who had been very supportive of him. On 22nd April he disclosed he was looking for a rafter to harm himself from and there was an overreliance on his family as a protective factor in the absence of this knowledge being shared with them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment for virtual mental health appointments during service changes
Wider context from the report “1. No risk assessment was completed on the issue of moving mental health appointments to virtual during the COVID-19 pandemic and how patients could be kept safe in the event of deterioration in his mental health. There was no plan in place for patients that required urgent assessment/review due to deterioration in their mental health.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to document disclosures relevant to mental health risk
Wider context from the report “4. His risk assessment was not up-to-date and his disclosures during April were not documented .
” Open source report
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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 clinical record keeping to ensure care plans, risk assessments and clinical reasoning are documented clearly and electronically.
Verbatim wording from the response “Sgt Hills’ risk was assessed by treating clinicians in Department of Community Mental Health, London, and as a result he was offered a face-to-face appointment. Following discussion with Sgt Hills, who was concerned about attendance in person, a telephone appointment was agreed as an alternative. We agree that the factors his clinicians considered in proceeding with telephone consultations should have been documented more clearly. Steps have now been taken to ensure better record keeping. This is covered in more detail below, in the response to your matters of concern 2 and 4.” Source location 2020-0247-Response-from-MP-MOD-Redacted.pdf
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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 enhanced risk-management training for all Department of Community Mental Health clinical staff, including tools for recognising, assessing and managing mental-health risks.
Verbatim wording from the response “On the issue of risk management, Defence Primary Healthcare is introducing enhanced risk management training for all Department of Community Mental Health clinical staff. This will be delivered by a recognised national provider and will be completed for all mental health clinicians by the end of March 2021. The training will provide best-practice tools to recognise, assess and manage risks for mental health and related matters.” Source location 2020-0247-Response-from-MP-MOD-Redacted.pdf
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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 Strengthen senior-clinician oversight of record-keeping quality and regularly review clinicians whose performance falls below the required standard.
Verbatim wording from the response “More broadly, steps have been taken to ensure that Senior clinicians focus on the quality of record keeping and, should the performance of any treating clinician fall below the expected standard, that person’s performance will be reviewed regularly until the required quality is achieved. To support this, Defence Primary Healthcare is currently updating its guidance on the delivery of mental healthcare to ensure clinicians, Departments of Community Mental Health and Regions have the support they require and can be held to account for their adherence to clinical policy.” Source location 2020-0247-Response-from-MP-MOD-Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require clinicians to document evidence that patients instructed not to drive were advised to notify the DVLA, enabling monitoring throughout care.
Verbatim wording from the response “However, I recognise the significance of this concern and about the way this issue may have been approached - this would not have protected Sgt Hills or other road users. In future, Clinicians will be required to provide evidence where an individual has been instructed not to drive and to advise the DVLA, to ensure that this can be monitored throughout care.” Source location 2020-0247-Response-from-MP-MOD-Redacted.pdf
Open published response
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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 care plan was updated and risk levels were reviewed, contrary to the concern that neither had been updated as risk escalated.
Verbatim wording from the response “Sgt Hills’ care plan was updated on a number of occasions and his risk levels were being reviewed. However, the records of this case were not to the standard expected. Sgt Hills’ initial care plan, dated October 2019, formed the basis for treatment. Within a Department of Community Mental Health, subsequent updating of the care plan is part of the overall treatment record, which clinicians document on a review/assessment template. On this template, there is a section for recording any updates to the care plan, or to confirm the extant care plan, as well as assessment of risks, clinical reasonings and any prescribed medication.” Source location 2020-0247-Response-from-MP-MOD-Redacted.pdf
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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 site's planned decommissioning had no impact on patient care, communications or referral information because key staff remained in place.
Verbatim wording from the response “I note your concern, but I hope I can rectify any misunderstanding created at the Inquest about the planned closure of RAF Manston. Department of Community Mental Health clinicians were aware that the Defence Fire Training Development Centre Manston¹ was being decommissioned. Some confusion may have arisen about the gap between the MOD-wide announcement of the planned closure of the site and the planned decommissioning date itself. The decommissioning of the Centre did not begin until November 2020. Before and during April 2020 the Centre was still carrying out its assigned training tasks and all key staff remained in place. There was no impact on any patient care as a result of the planned decommissioning of the Manston base.” Source location 2020-0247-Response-from-MP-MOD-Redacted.pdf
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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 Existing processes enable emergency inpatient admission whenever a patient significantly deteriorates.
Verbatim wording from the response “As outlined above, there is a stepped approach to the provision of mental healthcare. The assessing clinician will consider the severity of a patient’s condition. This is largely a decision based on clinical assessment and observation. In a case where a patient is significantly deteriorating, MOD has processes in place to arrange, at any time, emergency admittance to an inpatient mental health unit. Service personnel are assessed, stabilised and treated in hospitals as close to their home or parent Unit as possible.” Source location 2020-0247-Response-from-MP-MOD-Redacted.pdf
Open published response
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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 Routine family engagement cannot occur where patients withhold permission, subject to risk management and patient-information disclosure guidelines.
Verbatim wording from the response “You have raised important points about communication with families around issues of risk, and we recognise the invaluable support provided by loved ones in often distressing circumstances. As you will appreciate, if a patient is receiving mental health support, there is no routine engagement with families as some patients might not want their family to know that they are receiving treatment. If the patient refuses permission for his or her clinician to contact their family, this will be considered as part of the risk management procedures, and in accordance with guidelines on the disclosure of patient information. I understand Sgt Hills’ consultant was in contact with his family, however, I do appreciate your concern, and this will be addressed further in the risk management training.” Source location 2020-0247-Response-from-MP-MOD-Redacted.pdf
Open published response
6 Dec 2019 Kamil Iddrisu and Youngson Nkhoma · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Failure to urgently test previously processed non-UK selection candidates for sickle cell trait View source Failure to screen non-UK selection candidates for sickle cell trait before selection View source Increased risk of death or collapse during military exercise for people with sickle cell trait View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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. The report was sent to Ministry of Defence; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to screen non-UK selection candidates for sickle cell trait before selection
Wider context from the report “1. Consideration should be given to all non UK selection candidates being screened for sickle cell trait before embarking on any selection process . A blood test can be undertaken to assess whether candidates have sickle cell trait.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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.
” Open source report
1 Nov 2019 Joshua Hoole · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 22 Failure to provide and communicate correct WBGT placement requirements View source Failure to provide and monitor adequate recurring training on key tasks and publications View source Insufficient medic training and competence to identify heat illness 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 Inconsistency between JSP539 and MATT2 on the required response to suspected heat illness View source Confusing JSP539 annex identification View source Lack of a system to provide individual risk information for activity risk assessments View source Failure of the heat illness reporting system to produce complete and accurate data View source Absence of generic activity risk assessments in MATT2 View source Failure of MATT2 to clarify the continuing need to use WBGT View source Inadequate commander training and understanding of JSP539 View source Lack of venue-specific WBGT placement policies View source Lack of a system to disseminate JSP539 information and verify commanders’ knowledge View source Failure to provide further WBGT-related training for gym staff View source Lack of acceptable WBGT guidance for GCC and RFT activities View source Lack of a system to ensure WBGT readings before training exercises View source Failure of JSP539 to define the medic’s role in passing on medical information View source Unavailability of the WBGT instructional video on MOD laptops View source Failure to train personnel required to produce activity risk assessments View source Failure to train commanding officers in risk assessment completion View source JSP539 remaining difficult to understand because of its length and complexity View source See 19 more concerns
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to provide and monitor adequate recurring training on key tasks and publications
Wider context from the report “14. Witnesses at the inquest stated they were unaware of publications and had not received adequate training on those publications they were aware of. There needs to be a clear system of training for key tasks and updated publications . There needs to be measures in place to ensure all commanders are provided with the necessary information and a mechanism for annual updates and monitoring of awareness and training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Confusing JSP539 annex identification
Wider context from the report “5. The current JSP539 has several annex “A’s” which could be confusing if commanders reference the wrong annex .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to provide individual risk information for activity risk assessments
Wider context from the report “6. Individual risk factors were an important part of understanding how a soldier would react to a situation and how best to mitigate any associated risk. At present there is no clear system in place to ensure those conducting activities have the necessary information about an individual to enable them to carry out an appropriate risk assessment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Absence of generic activity risk assessments in MATT2
Wider context from the report “13. MATT2 states that commanders should use a generic risk assessment as a starting point to risk assess a particular activity however there is no generic risk assessment within MATT2 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Inadequate commander training and understanding of JSP539
Wider context from the report “2. I heard evidence at the inquest that Commanders were unaware of the provision of JSP539 and how they should apply to an annual fitness test (AFT). Several said they have not been trained on the publication and those that had seen it confirmed they did not understand the full effects of it and had not been trained on it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of venue-specific WBGT placement policies
Wider context from the report “16. Each venue with a WBGT needs to have a clear policy for its placement depending on the time of year and day .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to disseminate JSP539 information and verify commanders’ knowledge
Wider context from the report “• Commanding officers were unaware of the JSP539 and there was no clear system in place either to disseminate information or to check those commanding had the requisite knowledge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to provide further WBGT-related training for gym staff
Wider context from the report “18. No further training has been provided for gym staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to ensure WBGT readings before training exercises
Wider context from the report “• There was no system in place to ensure WBGT readings were taken before training exercises .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure of JSP539 to define the medic’s role in passing on medical information
Wider context from the report “7. The current JSP539 does not set out explicitly that it is the role of the medic on an activity to pass on medical information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Unavailability of the WBGT instructional video on MOD laptops
Wider context from the report “17. The YouTube video does not play on MOD laptops .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to train personnel required to produce activity risk assessments
Wider context from the report “19. The senior commanders at the inquest confirmed they had not received training on the production of risk assessments for the activities they were conducting. There needs to be a robust approach to training and management of risk assessments ensuring those who are required to complete them have the necessary skills and training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to train commanding officers in risk assessment completion
Wider context from the report “• Commanding officers had not been trained on completing risk assessments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation JSP539 remaining difficult to understand because of its length and complexity
Wider context from the report “3. Evidence at the inquest confirmed that the version of JSP539 in place at the time was difficult to read and understand. The latest version remains long and complex and difficult to understand .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Brief commanding officers on JSP 539 through training, conferences and written communications, while inspecting units’ use of current policy.
Verbatim wording from the response “Having recently spent time with the families of the three soldiers who died in Brecon in 2013, the Commander Field Army has been rigorous in addressing the failure to learn lessons from this tragic event. Awareness of Joint Service Publication 539 - Heat Illness and Cold Injury: Prevention and Management (JSP 539), by commanders has improved since 2013 and since Cpl Hoole’s death, but we continue to do more. All Commanding Officers (COs) are briefed on JSP 539 during pre-employment training and, to further raise its profile, actions are being taken to reinforce the importance of its content (See para 1a). A significant amount of work has recently been completed to address the training shortfall in the matter of risk assessments.” Source location 2019-0458-Response-by-MOD
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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 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 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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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out risk-assessment training through trained instructors, mass training and a continuing programme across the Army.
Verbatim wording from the response “You highlighted your concerns regarding Risk Assessments following the deaths in Brecon and this shortfall was readily apparent in the circumstances surrounding Cpl Hoole’s death. The Army has now addressed this matter and commissioned a comprehensive Training Needs Analysis. The report on Safety Risk Management was published in October 2019 and training for the Army will be rolled out in 3 phases:” 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 Add the same explicit medic communication instruction to the amended JSP 539.
Verbatim wording from the response “The recently updated MATT 2 and AGAI Vol 1 Ch 7 now include direction that medics are to communicate medical details of incidents to the Officer in Charge of physical training events. JSP 539 will also include this explicit instruction in its new amended iteration.” 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 Use the Heat Illness and Cold Injury Field Guide as a short reference guide for commanders.
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
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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 Review the Unit Fitness Training Officer course and Physical Development Audit to increase focus on JSP 539 and WBGT readings.
Verbatim wording from the response “It is the instructions contained in MATT 2 and AGAI Vol 1 Ch 7 that provide commanders on the ground with the necessary information and guidance on how to safely conduct an AFT. JSP 539 is the top level, overarching, publication and MATT 2 and AGAI Vol 1 Ch 7 are complementary single service policy documents that provide additional information to commanders. MATT 2 and AGAI Vol 1 Ch 7 make specific references to direction and guidance contained in JSP 539. In order to increase awareness of JSP 539, the Army is conducting a review of the Unit Fitness Training Officer course (training) and the Physical Development Audit (assurance) to ensure that both include an increased focus on JSP 539 and WBGT Monitor readings. This review will be complete by 30 March 2020.” Source location 2019-0458-Response-by-MOD
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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 Add an individual-factor checklist and heat-illness risk-assessment direction to the new Army heat-illness prevention order.
Verbatim wording from the response “JSP 539 includes guidance on the individual factors to be considered in relation to heat. The new ACSO 3222 Army Heat Illness Prevention, will provide additional direction specific to Army requirements. This will include a checklist of individual factors for use by commanders prior to the activity, and specific reference to heat illness risk assessments (Annex C to ACSO 3222).” 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 Amend MATT 2 and AGAI guidance to require generic risk assessments for physical testing and assessment activities, tailored on the day.
Verbatim wording from the response “MATT 2 and AGAI Vol 1 Ch 7 have been amended to give clear direction that units are to produce generic risk assessments for all physical testing and assessment activity. Generic Risk Assessments will be used as part of the forward planning of the activity. However, on the day of the activity, the Risk Assessment must be reviewed and amended as appropriate to the specific site and conditions.” 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 Amend the Physical Development Audit to check generic risk assessments and monitor unit compliance.
Verbatim wording from the response “The Physical Development audit question set will be amended by 30 March 2020 to include a specific check on generic risk assessments, and units will be monitored for compliance.” 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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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Unit Fitness Training Officer course to include relevant publications and provide required training.
Verbatim wording from the response “Headquarters Royal Army Physical Training Corps, as the Training Requirements Authority is conducting a review of the content of the Unit Fitness Training Officer course. This review will ensure that all relevant publications are included in the” Source location 2019-0458-Response-by-MOD
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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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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
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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 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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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require medics to communicate incident medical details to officers in charge of physical-training events through amended guidance.
Verbatim wording from the response “The recently updated MATT 2 and AGAI Vol 1 Ch 7 now include direction that medics are to communicate medical details of incidents to the Officer in Charge of physical training events. JSP 539 will also include this explicit instruction in its new amended iteration.” Source location 2019-0458-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 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
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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 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
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18 Jul 2018 Matthew Karl Hatfield and Darren Paul Neilson · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Failure to maintain up-to-date knowledge of tank status on the range View source Lack of soldier clarity about Prove The Gun drill timing and terminology View source Failure of risk assessments to actively consider drills and identify hazards during manufacture View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Matthew Karl Hatfield and Darren Paul Neilson · 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
Matthew Karl Hatfield and Darren Paul Neilson died after a Challenger 2 tank fired while its BVA assembly was absent, causing a breech explosion, intense fire and blast-related injuries. The principal concerns included unclear use and meaning of the Prove The Gun drill, inadequate communication about the condition of tanks and the absence of written procedures for checking, removing and storing the BVA assembly. The report also identified insufficient consideration of the hazard during the gun’s design and manufacture, inadequate communication about the opportunistic experience shoot, and routinely unstowed charges that caused a secondary explosion.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain up-to-date knowledge of tank status on the range
Wider context from the report “2. One of the contributing factors to this tragedy was that the RCO, the person in charge of the live firing exercise, did not know the state of the tanks on the range and therefore allocated a stripped down tank for a live firing exercise. I remain concerned that it is vital that the person in charge of such exercises has up to date knowledge about the status of the tanks on the range . The MOD should look at what communication can be put in place to ensure the RCO is in fact in charge and has all the correct information to make decisions during the exercise.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of soldier clarity about Prove The Gun drill timing and terminology
Wider context from the report “1. I remain concerned that soldiers are not clear about when to use the Prove The Gun drill and the meaning of the word “work” in the drill . This was supported by the evidence of ████████ who stated there was still a lack of clarity . The MOD should ensure that soldiers are clear about the meaning of the word work in the drill and when the drill should be undertaken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure of risk assessments to actively consider drills and identify hazards during manufacture
Wider context from the report “3. ████████ from the HSE confirmed that had applied advanced or developed risk assessment techniques when undertaken then it would have been identified in the design and manufacture of the gun that it could fire without the BVA assembly present when undertaking the TVEDU red drill. BAE and the MOD should look at their process to ensure that their risk assessments are suitable and importantly that drills are actively considered when assessing risk and identifying hazards during manufacture .
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Land Systems Safety Cases with Front Line Commands and other relevant parties using proportionate risk-assessment methodologies and documented rationale.
Verbatim wording from the response “c. The need to review all Land Systems Safety Cases in conjunction with the Front Line Command and other interested parties to ensure that we are using the appropriate risk assessment methodology, proportionate to the level of the risk and further ensuring that this is documented with the supporting rationale.” Source location 2018-0231-Response-by-Ministry-of-Defence
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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 Implement revised AESPs clarifying when to prove the gun and requiring specific checks for the BVA, obturator and shim.
Verbatim wording from the response “The SEMP reviewed the procedures in the Army Equipment Support Publications (“AESPs”) ‘2350-P-102-201 – Tank, Combat, 120mm Gun Challenger 2 – Operating Information’ and ‘2350-P-102-601 – Tank, Combat, 120mm Gun Challenger 2 - Maintenance Schedule’. The SEMP concluded that had the extant procedures detailed in the AESPs been followed, the absence of the obturator assembly (consisting of the Bolt Vent Axial, thrust housing and shim) would have been identified. However, it also concluded that the accident could be repeatable and there were areas where procedures could be adjusted to reduce the risk of a re-occurrence of the accident. The SEMP directed that:” Source location 2018-0231-Response-by-Ministry-of-Defence
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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 Train all CR2 crews in the revised drills and procedures, incorporating the prove-the-gun drill into Weapons Handling Tests and assuring training through sampled retesting.
Verbatim wording from the response “The panel of gunnery SMEs recommended specific adjustments to the AESPs. These recommendations were presented to the SEMP, examined in detail and then endorsed. The changes have been fully implemented in to the current AESPs and all documents which support the delivery of training. Prior to implementation, the AFVTTS School’s Instructors tested the new drills and procedures. The new procedures were then cascaded down to Regimental” Source location 2018-0231-Response-by-Ministry-of-Defence
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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 Commission and complete FMECA, physical-safety-mechanism feasibility, and human-factors analyses for the CR2 main armament.
Verbatim wording from the response “As discussed previously, the SEMP directed, as part of their recommendations, that BAES be tasked by DE&S to explore the viability of a physical or electronic safety mechanism to prevent the gun being fired when the obturator assembly was not fitted. This task was placed on BAES in August 2017 and the BAES response was received by DE&S on the 26 June 2018. BAES were directed to:” Source location 2018-0231-Response-by-Ministry-of-Defence
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 Crew responsibility, training, revised drills and repeated component checks make the risk of firing without safety-critical components acceptably low.
Verbatim wording from the response “The Army judges that any potential risk presented by the RCO not being aware of the state of tanks on the range is ALARP. As indicated above the revised drills and procedures ensure that there is no scenario in which a crew could proceed to fire the main gun without first having completed the ‘prove the gun’ drill which mandates a specific check for the presence of the BVA, obturator and shim (Paragraph 6.19). Even if the ‘prove the gun’ drill was not adequately completed the presence of the BVA, obturator and shim would be checked again upon ‘going to action’ and if necessary again upon receiving a ‘TVEDU – Red Indication or No Display’ (an inevitable consequence if the BVA is missing).” Source location 2018-0231-Response-by-Ministry-of-Defence
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 Requiring the RCO to keep contemporaneous tank-status records or maintain a centrally managed system would be impractical and distract from range safety duties.
Verbatim wording from the response “It is essential that the RCO is focused on delivering a safe live firing exercise. Any requirements for the RCO to keep contemporaneous records on the state of the tanks would detract from his focus on the safety of the range as a whole.” Source location 2018-0231-Response-by-Ministry-of-Defence
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 revised drills and procedures provide clarity about when the “prove the gun” drill must be completed, so no lack of clarity remains.
Verbatim wording from the response “The SEMP and the panel of SME’s convened at the AFVTTs Gunnery Wing consider that the changes made to the AESPs have reduced the risk to a level which is as low as reasonably practicable (“ALARP”). All CR2 crews are appropriately trained, there is no lack of clarity about when drill must be completed, the delivery of that training and the crew’s understanding of that training is appropriately assured and any risk of reoccurrence is ALARP.” Source location 2018-0231-Response-by-Ministry-of-Defence
Open published response
18 Jul 2018 Matthew Karl Hatfield and Darren Paul Neilson · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Failure of the person in charge of live firing exercises to maintain up-to-date knowledge of tank status on the range View source Unsuitable risk assessments during gun design and manufacture View source Failure to actively consider drills when assessing risk and identifying hazards during manufacture View source Lack of clarity among soldiers about when to use the Prove The Gun drill and the meaning of “work” in the drill View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Matthew Karl Hatfield and Darren Paul Neilson · 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
Cpls Matthew Karl Hatfield and Darren Paul Neilson died after a Challenger 2 tank fired while its BVA assembly was absent, causing hot pressurised gases to enter the turret, the breech block to explode and a subsequent fire. The substantive concerns included unclear use and meaning of the Prove The Gun drill, inadequate information about tank status available to the Range Conducting Officer, and insufficient risk assessment of the gun’s ability to fire without the BVA assembly.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure of the person in charge of live firing exercises to maintain up-to-date knowledge of tank status on the range
Wider context from the report “2. One of the contributing factors to this tragedy was that the RCO, the person in charge of the live firing exercise, did not know the state of the tanks on the range and therefore allocated a stripped down tank for a live firing exercise. I remain concerned that it is vital that the person in charge of such exercises has up to date knowledge about the status of the tanks on the range . The MOD should look at what communication can be put in place to ensure the RCO is in fact in charge and has all the correct information to make decisions during the exercise.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Unsuitable risk assessments during gun design and manufacture
Wider context from the report “3. ████████ from the HSE confirmed that had applied advanced or developed risk assessment techniques when undertaken then it would have been identified in the design and manufacture of the gun that it could fire without the BVA assembly present when undertaking the TVEDU red drill. BAE and the MOD should look at their process to ensure that their risk assessments are suitable and importantly that drills are actively considered when assessing risk and identifying hazards during manufacture.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to actively consider drills when assessing risk and identifying hazards during manufacture
Wider context from the report “3. ████████ from the HSE confirmed that had applied advanced or developed risk assessment techniques when undertaken then it would have been identified in the design and manufacture of the gun that it could fire without the BVA assembly present when undertaking the TVEDU red drill. BAE and the MOD should look at their process to ensure that their risk assessments are suitable and importantly that drills are actively considered when assessing risk and identifying hazards during manufacture .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity among soldiers about when to use the Prove The Gun drill and the meaning of “work” in the drill
Wider context from the report “1. I remain concerned that soldiers are not clear about when to use the Prove The Gun drill and the meaning of the word “work” in the drill . This was supported by the evidence of ████████ who stated there was still a lack of clarity . The MOD should ensure that soldiers are clear about the meaning of the word work in the drill and when the drill should be undertaken.
” Open source report
24 Jul 2017 Ben Alan Jukes · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 3 Failure of army drug-testing to detect illicit drug use View source Failure of drug testing to remain random and unannounced View source Supply of heroin to homeless drug users View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ben Alan Jukes · 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
Ben Alan Jukes was an army captain serving in the Royal Corps of Signals; the supplied text does not state the circumstances or date of his death. The report identified concerns that army drug testing failed to detect his regular heroin and cocaine use, that he was forewarned of at least one test and evaded it, and that he supplied heroin to homeless drug users in Manchester city centre.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure of army drug-testing to detect illicit drug use
Wider context from the report “1. Whatever drug-testing regime may have been operated by the army during the five year period failed to detect Captain Jukes' regular use of heroin and cocaine . More regular testing by the army in that period would have increased the likelihood of detection.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure of drug testing to remain random and unannounced
Wider context from the report “3. It appears that on at least one occasion as set out above Captain Jukes was forewarned of a drug test.
4. Thus forewarned, Captain Jukes was easily able to evade the drug test which would as a near certainty have exposed him as a user of heroin and cocaine.
5. Unless drug testing is random and unannounced it will fail to detect illicit drug use among servicemen and women . Failure to detect illicit drug use increases the likelihood of further deaths as a result of the same .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Supply of heroin to homeless drug users
Wider context from the report “2. Captain Jukes' supply of heroin to homeless drug users in Manchester City centre exacerbated an already high risk of death among that group . More regular testing by the army in that period would have increased the likelihood of detection.
” 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 Reiterate the need for absolute discretion to units when notifying them of compulsory drug-testing visits.
Verbatim wording from the response “The initial notification of the visit will be made through the Adjutant, who is expected to notify the Commanding Officer. Prior notification is necessary to enable this core element of the unit command structure to plan the support required from the unit to facilitate the testing and to make contingencies for the disruption of unit activity that will occur as a result of testing. It will also enable the Adjutant to make an assessment of the number of personnel expected to be in barracks and thus available for testing at the time of the scheduled CDT visit. In doing so, the Commanding Officer and his immediate team will manage the information with the utmost discretion to avoid pre-warning anyone not required to know in advance. In future, the need for absolute discretion will be reiterated to units as part of their initial notification.” Source location 2017-0335-Response-by-MOD
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 Education and deterrence through the existing drug misuse strategy are assessed as effective despite testing not detecting every instance of misuse.
Verbatim wording from the response “The Army’s drug misuse strategy was revised in November 2016. It is based on three pillars: prevention through education, deterrence through testing, and regulation. Education begins from initial entry into military service, whether it be as an officer or a soldier. It is made quite clear through education to all Service Personnel that the misuse of controlled drugs is incompatible with military service. It is also made clear during this education that Service Personnel have a personal responsibility to adhere to these values and standards.” Source location 2017-0335-Response-by-MOD
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 Frequent testing sufficient to ensure detection of all drug misuse is impracticable because traces may leave the body before testing.
Verbatim wording from the response “It is further acknowledged that CDT can only act as a deterrent – it cannot detect misuse at a time after the traces of misuse have left the body and are no longer detectable. It is therefore impracticable for the Army to test each soldier and officer frequently enough to ensure that all drugs misuse is always detected. Nonetheless, the combined effect of education and deterrence are assessed to have effect. The 2015/16 Crime Survey of England and Wales reports drug misuse across society to be at 8.4% or 1 in 12. While any misuse in the Army is unacceptable and strenuous efforts to reduce it continue, the level of misuse in the Army is reported at 0.7 – 0.9%.” Source location 2017-0335-Response-by-MOD
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 Advance notification of testing is necessary to plan operational support and manage disruption, although information is to be handled discreetly.
Verbatim wording from the response “CDT visits are scheduled by the CDT team with unit notification usually made with as little as 24 hours’ notice. This period of notice will only be varied in exceptional circumstances, such as when security clearances for Northern Ireland are required or where there is a specific intelligence led need.” Source location 2017-0335-Response-by-MOD
Open published response
8 Sep 2015 David Efemena · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 4 Lack of an AED at fieldcraft training activities View source Unclear communication-check requirements in fieldcraft training instructions View source Lack of an AED-trained first aider at fieldcraft training activities View source Failure to establish and test effective communications between cadets and supervising staff before night-time separation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
David Efemena · 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
David Efemena became unresponsive while sleeping outdoors during an Air Training Corps fieldcraft exercise on 23 March 2014 and was pronounced deceased in hospital at 09:09 after resuscitation attempts. The report raised concerns about the absence of an AED and AED-trained first aider, inadequate communication checks, the distance between cadets and adult staff, lack of overnight supervision, and insufficient staffing.
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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of an AED at fieldcraft training activities
Wider context from the report “1. The first aid equipment available at the training site did not include a defibrillator (AED). The location of David at the time of his collapse was in the woodland area of the training estate. The paramedics took 10 minutes to travel from the ambulance station to the Bramley Training Estate. Upon arrival at the Training Estate it took them 8 minutes to reach David.
This type of fieldcraft activity is likely to involve some level of physical activity and some inherent risk, as a result of the terrain. Access by emergency services is likely to be challenging, as was experienced in this case. The consultant cardiologist who gave evidence at the Inquest, ████████ confirmed that in general terms the sooner an AED is used in resuscitation is the better prospect of a successful outcome. I note that the heart start training includes an optional session on AED but that this is not offered to squadrons within London. I would ask that this decision is reconsidered. The lack of an AED and AED trained first aider at this type of cadet activity, poses a risk to future cadets.
2. There were no communication checks between the adult staff and cadets when the two groups settled for sleep. There was radio contact after nightfall on the 22nd March 2014 but staff were located very near to the cadets at this time. There was no check to ensure that the communication was effective between the two groups in their final resting positions. We now know that the radios available to the cadets would not work at the distance where the staff were based. The new policy in place dealing with communication checks- Air Cadet Fieldcraft Training Instruction Number 7 -Improvised Camping in a Field Environment, remains unclear in relation to communication checks.
Paragraph 12, dealing with emergency procedures, provides that “direct and reliable communications are to be established between cadets and supervising staff and this is to be tested before nightfall”. A footnote states that nightfall will vary according to the time of the year and prevailing weather conditions.
The concern is that this particular direction was complied with in David Efemena’s case. There was radio contact before nightfall. There was however no effective communication between the cadets and the supervising staff during the night. Instructors therefore should be directed to ensure that effective communications exist between cadets and supervising staff before the 2 groups retire at night. It is suggested that this should be explicit within the instruction.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Unclear communication-check requirements in fieldcraft training instructions
Wider context from the report “1. The first aid equipment available at the training site did not include a defibrillator (AED). The location of David at the time of his collapse was in the woodland area of the training estate. The paramedics took 10 minutes to travel from the ambulance station to the Bramley Training Estate. Upon arrival at the Training Estate it took them 8 minutes to reach David.
This type of fieldcraft activity is likely to involve some level of physical activity and some inherent risk, as a result of the terrain. Access by emergency services is likely to be challenging, as was experienced in this case. The consultant cardiologist who gave evidence at the Inquest, ████████ confirmed that in general terms the sooner an AED is used in resuscitation is the better prospect of a successful outcome. I note that the heart start training includes an optional session on AED but that this is not offered to squadrons within London. I would ask that this decision is reconsidered. The lack of an AED and AED trained first aider at this type of cadet activity, poses a risk to future cadets.
2. There were no communication checks between the adult staff and cadets when the two groups settled for sleep. There was radio contact after nightfall on the 22nd March 2014 but staff were located very near to the cadets at this time. There was no check to ensure that the communication was effective between the two groups in their final resting positions. We now know that the radios available to the cadets would not work at the distance where the staff were based. The new policy in place dealing with communication checks- Air Cadet Fieldcraft Training Instruction Number 7 -Improvised Camping in a Field Environment, remains unclear in relation to communication checks.
Paragraph 12, dealing with emergency procedures, provides that “direct and reliable communications are to be established between cadets and supervising staff and this is to be tested before nightfall”. A footnote states that nightfall will vary according to the time of the year and prevailing weather conditions.
The concern is that this particular direction was complied with in David Efemena’s case. There was radio contact before nightfall. There was however no effective communication between the cadets and the supervising staff during the night. Instructors therefore should be directed to ensure that effective communications exist between cadets and supervising staff before the 2 groups retire at night. It is suggested that this should be explicit within the instruction.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of an AED-trained first aider at fieldcraft training activities
Wider context from the report “1. The first aid equipment available at the training site did not include a defibrillator (AED). The location of David at the time of his collapse was in the woodland area of the training estate. The paramedics took 10 minutes to travel from the ambulance station to the Bramley Training Estate. Upon arrival at the Training Estate it took them 8 minutes to reach David.
This type of fieldcraft activity is likely to involve some level of physical activity and some inherent risk, as a result of the terrain. Access by emergency services is likely to be challenging, as was experienced in this case. The consultant cardiologist who gave evidence at the Inquest, ████████ confirmed that in general terms the sooner an AED is used in resuscitation is the better prospect of a successful outcome. I note that the heart start training includes an optional session on AED but that this is not offered to squadrons within London. I would ask that this decision is reconsidered. The lack of an AED and AED trained first aider at this type of cadet activity, poses a risk to future cadets.
2. There were no communication checks between the adult staff and cadets when the two groups settled for sleep. There was radio contact after nightfall on the 22nd March 2014 but staff were located very near to the cadets at this time. There was no check to ensure that the communication was effective between the two groups in their final resting positions. We now know that the radios available to the cadets would not work at the distance where the staff were based. The new policy in place dealing with communication checks- Air Cadet Fieldcraft Training Instruction Number 7 -Improvised Camping in a Field Environment, remains unclear in relation to communication checks.
Paragraph 12, dealing with emergency procedures, provides that “direct and reliable communications are to be established between cadets and supervising staff and this is to be tested before nightfall”. A footnote states that nightfall will vary according to the time of the year and prevailing weather conditions.
The concern is that this particular direction was complied with in David Efemena’s case. There was radio contact before nightfall. There was however no effective communication between the cadets and the supervising staff during the night. Instructors therefore should be directed to ensure that effective communications exist between cadets and supervising staff before the 2 groups retire at night. It is suggested that this should be explicit within the instruction.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to establish and test effective communications between cadets and supervising staff before night-time separation
Wider context from the report “1. The first aid equipment available at the training site did not include a defibrillator (AED). The location of David at the time of his collapse was in the woodland area of the training estate. The paramedics took 10 minutes to travel from the ambulance station to the Bramley Training Estate. Upon arrival at the Training Estate it took them 8 minutes to reach David.
This type of fieldcraft activity is likely to involve some level of physical activity and some inherent risk, as a result of the terrain. Access by emergency services is likely to be challenging, as was experienced in this case. The consultant cardiologist who gave evidence at the Inquest, ████████ confirmed that in general terms the sooner an AED is used in resuscitation is the better prospect of a successful outcome. I note that the heart start training includes an optional session on AED but that this is not offered to squadrons within London. I would ask that this decision is reconsidered. The lack of an AED and AED trained first aider at this type of cadet activity, poses a risk to future cadets.
2. There were no communication checks between the adult staff and cadets when the two groups settled for sleep. There was radio contact after nightfall on the 22nd March 2014 but staff were located very near to the cadets at this time. There was no check to ensure that the communication was effective between the two groups in their final resting positions. We now know that the radios available to the cadets would not work at the distance where the staff were based. The new policy in place dealing with communication checks- Air Cadet Fieldcraft Training Instruction Number 7 -Improvised Camping in a Field Environment, remains unclear in relation to communication checks.
Paragraph 12, dealing with emergency procedures, provides that “direct and reliable communications are to be established between cadets and supervising staff and this is to be tested before nightfall”. A footnote states that nightfall will vary according to the time of the year and prevailing weather conditions.
The concern is that this particular direction was complied with in David Efemena’s case. There was radio contact before nightfall. There was however no effective communication between the cadets and the supervising staff during the night. Instructors therefore should be directed to ensure that effective communications exist between cadets and supervising staff before the 2 groups retire at night. It is suggested that this should be explicit within the instruction.
” Open source report
20 Jul 2015 Craig Roberts and 2 others · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 19 Lack of experienced medical input into the exercise medical plan View source Failure to communicate daytime WBGT readings to exercise commanders View source Disjointed reporting of heat-illness cases View source Failure to verify requisite knowledge and training of exercise commanders View source Failure to instruct commanders to adhere to JSP539 during specialist exercises View source Failure to account for differing reservist preparation before test week View source Lack of risk-assessment training for exercise risk-assessment and delivery staff View source Lack of prior liaison with NHS and mountain rescue for exercise casualties View source Lack of a clear system for disseminating safety information across regiments View source Lack of clear heat-illness detection guidance for specialist exercises View source Failure to independently prepare the exercise risk assessment View source Failure to address a known unfit-for-purpose tracker system View source Lack of a clear pathway for communicating safety lessons View source Lack of JSP539 training for senior commanders View source Failure to implement lessons from previous heat-illness and tracking events View source Failure of the tracker system to identify static or slow-moving soldiers View source Failure of exercise staff to understand JSP539 climatic guidance and heat-illness implications View source Failure of senior commanders to identify and mitigate tracker-system failure View source Inaccurate heat-illness data View source See 16 more concerns
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 this recipient says it has done, is doing, or plans to do in response to the concern raised. 15
Action
Operate interim tracker safeguards, including visual monitoring, five-minute refreshes, checkpoint escalation, rapid response, messaging, and beacon checks.
Stated completedThe respondent said that this action was complete when they made their response on 20 July 2015. View source
Action
Train personnel in risk assessment and implement the revised Training Governance and Assurance Policy across subordinate units.
Stated plannedThe respondent said that this action was planned when they made their response on 20 July 2015. View source
Action
Conduct a Service Inquiry into the incident and wider endurance-training safety lessons across Defence.
Stated plannedThe respondent said that this action was planned when they made their response on 20 July 2015. View source
Action
Hold a delivery-authority and directing-staff meeting to capture tracker requirements and address them or establish mitigations before the next selection exercise.
Stated plannedThe respondent said that this action was planned when they made their response on 20 July 2015. View source
Action
Upgrade the tracker system to handle continuous contact with large numbers of beacons before the end of the calendar year.
Stated plannedThe respondent said that this action was planned when they made their response on 20 July 2015. View source
Action
Measure and continuously monitor WBGT conditions at exercise locations, record changes, and notify checkpoints of required control measures.
Stated completedThe respondent said that this action was complete when they made their response on 20 July 2015. View source
Action
Load Reservists’ medical information into DMICP so Regular and Reserve climatic injuries appear in Defence Statistics health audits.
Stated in progressThe respondent said that this action was in progress 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 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 completedThe respondent said that this action was complete when they made their response on 20 July 2015. View source
Action
Improve heat-illness reporting through the working group and require prompt, accurate climatic-injury reporting in the exercise Medical Plan.
Stated in progressThe respondent said that this action was in progress when they made their response on 20 July 2015. View source
Action
Provide Reserve Units with instructor-led, controlled-pace marches before the more demanding regular-unit build-up marches.
Stated completedThe respondent said that this action was complete when they made their response on 20 July 2015. View source
Action
Reinforce the formal lessons-learning process through the Training Governance and Assurance Policy review and biannual training reviews.
Stated plannedThe respondent said that this action was planned when they made their response on 20 July 2015. View source
Action
Liaise with local police, Mountain Rescue, search and rescue, and hospitals before exercises, and rehearse responses to medical emergencies.
Stated 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 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 completedThe respondent said that this action was complete when they made their response on 20 July 2015. View source See 12 more actions
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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. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of experienced medical input into the exercise medical plan
Wider context from the report “(12) There was no involvement of a doctor experienced in heat illness detection and treatment when devising the medical plan for this exercise ; the medical plan was prepared by a junior combat medical technician .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to verify requisite knowledge and training of exercise commanders
Wider context from the report “(4) Senior commanders had received no training before this tragedy on JSP539. There was no clear system for disseminating information to different regiments and no means to check those commanding this type of exercise had the requisite knowledge and training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to account for differing reservist preparation before test week
Wider context from the report “(7) Senior commanders were unaware that the reservist units had a different build up to test week . The reservists had a military skills week the week before test week whereas the signals regiment had build up marches. None of the signals regiment students suffered heat illness.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of risk-assessment training for exercise risk-assessment and delivery staff
Wider context from the report “(5) Senior commanders were unaware that the staff who completed the risk assessment for this exercise and who conducted the exercise had not been trained in the preparation of risk assessments . The risk assessment used simply adopted a risk assessment that had been prepared by the lead regular unit.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of prior liaison with NHS and mountain rescue for exercise casualties
Wider context from the report “(13) There was no prior liaison with the NHS and Mountain rescue before this exercise about what their involvement might be in the case of any injuries or illness .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear system for disseminating safety information across regiments
Wider context from the report “(4) Senior commanders had received no training before this tragedy on JSP539. There was no clear system for disseminating information to different regiments and no means to check those commanding this type of exercise had the requisite knowledge and training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to independently prepare the exercise risk assessment
Wider context from the report “(5) Senior commanders were unaware that the staff who completed the risk assessment for this exercise and who conducted the exercise had not been trained in the preparation of risk assessments. The risk assessment used simply adopted a risk assessment that had been prepared by the lead regular unit .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to address a known unfit-for-purpose tracker system
Wider context from the report “(9) The tracker system used at the time was known to be unfit for purpose in that the slow man/static function did not work effectively. No commander at any level addressed this deficiency in any directions to staff or further risk assessments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear pathway for communicating safety lessons
Wider context from the report “(10) A previous fatality, Soldier G see LAIT report October 2012, had identified that treatment for casualties should be within the “golden hour”. In addition following Private Poole’s death in 2009 it was identified that the tracker was not fit for purpose and standard operating procedures were issues dated January 2011. None of these recommendations were implemented by those involved in this exercise. I am concerned that lessons had not been learnt from these previous events. There appears to be no clear pathway for communicating this sort of information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Lack of JSP539 training for senior commanders
Wider context from the report “(4) Senior commanders had received no training before this tragedy on JSP539 . There was no clear system for disseminating information to different regiments and no means to check those commanding this type of exercise had the requisite knowledge and training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure to implement lessons from previous heat-illness and tracking events
Wider context from the report “(10) A previous fatality, Soldier G see LAIT report October 2012, had identified that treatment for casualties should be within the “golden hour”. In addition following Private Poole’s death in 2009 it was identified that the tracker was not fit for purpose and standard operating procedures were issues dated January 2011. None of these recommendations were implemented by those involved in this exercise . I am concerned that lessons had not been learnt from these previous events . There appears to be no clear pathway for communicating this sort of information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure of the tracker system to identify static or slow-moving soldiers
Wider context from the report “(1) A new tracker system has been introduced recently. The new system’s slow man/static function does not work . It is therefore still the case that those running the exercise have no means to identify static or slow moving soldiers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Failure of senior commanders to identify and mitigate tracker-system failure
Wider context from the report “(2) Those in a senior commanding position were unaware that the new tracker system’s slow man/static function did not work until the inquest – this came to light as I asked for a demonstration of the new system which was undertaken on the Malvern’s on Sunday 21 June 2015. I was informed the slow man/static function did not work. I heard no evidence that any steps have been taken to address this problem and no interim measures have been put in place to mitigate the risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Defence; that does not assign responsibility.
PFD Monitor interpretation Inaccurate heat-illness data
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.
” 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 Operate interim tracker safeguards, including visual monitoring, five-minute refreshes, checkpoint escalation, rapid response, messaging, and beacon checks.
Verbatim wording from the response “In addition there are issues with the system's ability to cope with the volume of data it receives when in continuous contact with a large number of beacons, as this was not how it was designed. This will be rectified in an upgrade scheduled to take place before the end of this calendar year. In order to overcome the issues with interpretation of the slow man/static function in the intervening period, the following mitigation measures have been put in place:” Source location 2015-0228-Response-by-MOD
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 Train personnel in risk assessment and implement the revised Training Governance and Assurance Policy across subordinate units.
Verbatim wording from the response “Training in the conduct of Risk Assessments was addressed in the immediate aftermath of the incident in 2013 and following the improvement notice issued by the HSE. In addition to this, work is being conducted to review how the organisation can improve training in this area and HQ specialist military units is reviewing and rewriting its Training Governance and Assurance Policy which will lead to further changes in the policy and procedures of subordinate units. The revised Training Governance and Assurance Policy was completed in August and changes by the subordinate units will be in place before the end of the calendar year, prior to the next iteration of the exercise.” Source location 2015-0228-Response-by-MOD
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 Conduct a Service Inquiry into the incident and wider endurance-training safety lessons across Defence.
Verbatim wording from the response “We continue to work with the Health and Safety Executive to take forward their recommendations and seek their advice on implementing improved processes. I have directed that two further inquiries be conducted by the Ministry of Defence. Firstly, a Service Inquiry will look at the events of 13 July 2013 to try and ensure that all safety-related lessons, including those identified in your Regulation 28 report, are learnt for endurance training across the whole of Defence. This will be conducted by a Service Inquiry Panel, convened by the Director General Defence Safety Authority, which will provide an independent, thorough and objective review outside of the chain of command. In order to ensure all relevant issues are captured and considered by the Service Inquiry, I have also written to the Director of Specialist Military Units,” Source location 2015-0228-Response-by-MOD
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 Hold a delivery-authority and directing-staff meeting to capture tracker requirements and address them or establish mitigations before the next selection exercise.
Verbatim wording from the response “Upgrades outlined under Point 1 should address remaining concerns, however to ensure all matters raised during the inquest and in the various investigations are being addressed, a meeting will take place in October between the delivery authorities (Defence Equipment and Support) and the Directing Staff. The timing of this meeting will ensure all requirements are captured and either addressed or alternative mitigations put in place before the next planned selection exercise.” Source location 2015-0228-Response-by-MOD
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 Upgrade the tracker system to handle continuous contact with large numbers of beacons before the end of the calendar year.
Verbatim wording from the response “In addition there are issues with the system's ability to cope with the volume of data it receives when in continuous contact with a large number of beacons, as this was not how it was designed. This will be rectified in an upgrade scheduled to take place before the end of this calendar year. In order to overcome the issues with interpretation of the slow man/static function in the intervening period, the following mitigation measures have been put in place:” Source location 2015-0228-Response-by-MOD
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 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
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 Load Reservists’ medical information into DMICP so Regular and Reserve climatic injuries appear in Defence Statistics health audits.
Verbatim wording from the response “At the time of the incident there was no mechanism to record Reserve medical information on the Defence Medical Information Capability Programme (DMICP). There was a system for Medical Reporting of cases of heat illness but this relied on the use of paper forms which may have contributed to failings in their recording. Their medical information relating to Reservists is now being loaded on to DMICP, thus statistics relating to climatic injuries sustained by both Regular and Reserve personnel will show up in health audits by Defence Statistics. This has been reflected in the exercise Medical Plan.” Source location 2015-0228-Response-by-MOD
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require formal Director-level waivers and documented mitigation when exercises operate outside JSP 539 parameters.
Verbatim wording from the response “Commanders of Specialist Military Units are all now briefed on JSP 539 as part of their pre-appointment training. All specialist units will now receive appropriate training packages on JSP 539, heat illness and its treatment. If a requirement to operate outside the parameters of JSP 539 is identified by the Directing Staff, then a formal waiver must be issued by Director Specialist Military Units. This approval requires an explanation of the measures in place to justify such a deviation as well as the operational necessity for them.” Source location 2015-0228-Response-by-MOD
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 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
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 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
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 Reserve Units with instructor-led, controlled-pace marches before the more demanding regular-unit build-up marches.
Verbatim wording from the response “In consultation with the HSE the preparatory training undertaken by Reserve Units was reviewed following the incident. Following this Reserves were included in the build up marches undertaken by Regulars in the week preceding the exercise. A further review was undertaken at the end of June 2015 which concluded that this had failed to fully mitigate the risk. A further change was made prior to the most recent exercise with Reserves now undertaking instructor-led marches (at controlled pace) before moving on to the more demanding build up marches undertaken by Regulars.” Source location 2015-0228-Response-by-MOD
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 Reinforce the formal lessons-learning process through the Training Governance and Assurance Policy review and biannual training reviews.
Verbatim wording from the response “There is a formal process in place for the capturing of lessons learnt/identified (Land Forces Standing Order (LFSO) 1118 – Learning Lessons in the Land Environment). Lessons are managed through the Defence Lessons Implementation and Management System (DLIMS) process which provides for a comprehensive way in which to consider that appropriate lessons are learnt, and that all appropriate steps are taken to prevent or minimise a recurrence. There is a clear and well established process, which is now being reinforced through the Training and Governance Policy review referred to under” Source location 2015-0228-Response-by-MOD
Open published response
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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 Liaise with local police, Mountain Rescue, search and rescue, and hospitals before exercises, and rehearse responses to medical emergencies.
Verbatim wording from the response “Local Commanders now liaise with local Police and Mountain Rescue prior to the start of every exercise. In addition, communications are established with the closest Search and Rescue location to confirm the communications plan and Medical Staff are required to liaise with local hospitals. The Medical Officers that rehearse and virtual exercises be undertaken to consider the response, including likely timelines, to medical emergencies.” Source location 2015-0228-Response-by-MOD
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide JSP 539, heat-illness, and treatment training to commanders and specialist units, with Directing Staff training and student procedural declarations.
Verbatim wording from the response “Commanders of Specialist Military Units are all now briefed on JSP 539 as part of their pre-appointment training. All specialist units will now receive appropriate training packages on JSP 539, heat illness and its treatment. If a requirement to operate outside the parameters of JSP 539 is identified by the Directing Staff, then a formal waiver must be issued by Director Specialist Military Units. This approval requires an explanation of the measures in place to justify such a deviation as well as the operational necessity for them.” Source location 2015-0228-Response-by-MOD
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 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
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 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
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 complexity of procuring the replacement tracker delayed implementation, although interim mitigation should have been provided during the capability gap.
Verbatim wording from the response “In the case of the issues with the tracker in use at the time of Marine Poole’s death; work was undertaken to enhance its capability and improvements were introduced in December 2010. It was subsequently identified that there was a need to replace the system and this led to revised set of ‘User Requirements’ which included statements taken from the Lessons Identified. The time it took to implement the new system was not a result of a failure to identify the lessons, but a result of the complexity of procuring such a piece of equipment. I accept that further mitigation should have been put in place to address the gap in capability while the systems were being upgraded and replaced, these issues have now been addressed through the improvements in training and the conduct of risk assessments and improved awareness throughout the command chain of the capabilities of the system.” Source location 2015-0228-Response-by-MOD
Open published response
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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 A formal, established process already captures and manages lessons learned, with the Training Governance and Assurance Policy review reinforcing it.
Verbatim wording from the response “There is a formal process in place for the capturing of lessons learnt/identified (Land Forces Standing Order (LFSO) 1118 – Learning Lessons in the Land Environment). Lessons are managed through the Defence Lessons Implementation and Management System (DLIMS) process which provides for a comprehensive way in which to consider that appropriate lessons are learnt, and that all appropriate steps are taken to prevent or minimise a recurrence. There is a clear and well established process, which is now being reinforced through the Training and Governance Policy review referred to under” Source location 2015-0228-Response-by-MOD
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations