10 Jul 2015 Cameron William LAING · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 4 Incomplete training in trailer coupling and uncoupling procedures View source Failure to deliver training on alternative extraction manoeuvres not included in the Army Equipment Support Publication View source Failure to teach or recognise alternative trailer-extraction manoeuvres View source Lack of understanding of emergency trailer-brake operation View source See 1 more concern
Responses linked to these concerns
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Cameron William LAING · 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
Cameron William Laing, a soldier, was crushed between a military lorry and a 4-tonne trailer while attempting to reattach the trailer at Bracken Tor on 29 April 2014. The report raised concerns that soldiers did not understand how reconnecting the air line could release the trailer’s emergency brake, that alternative recovery methods were not taught, and that relevant training was not provided.
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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 Incomplete training in trailer coupling and uncoupling procedures
Wider context from the report “1. It was clear from the evidence, and reflected in the Juror' findings, that the Soldiers in Cameron's Packet were not aware that when the emergency brake locked on, upon depletion of air tanks on a kings Trailer, reconnection of the air (red line) would release the brakes once operating pressure was achieved. Thus would cause the trailer to move out of control if the hand brake was not applied.
None of the witnesses who were trained to varying degrees understood this or the mechanism of brake action which was admittedly complicated. The Packet Commander was not fully trained in coupling and un-coupling procedures and relied on the Soldiers in her unit to advise her.
This lack of understanding led to the accident that caused Cameron’s death.
” 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 deliver training on alternative extraction manoeuvres not included in the Army Equipment Support Publication
Wider context from the report “3. I am concerned that in WO1 Orpe's Table of Responses by the Ministry of Defence to the Land Accident Investigation Team report p8, paragraph 27, the Ministry of Defence Logistic training team take the view that such training of alternative manoeuvres cannot be delivered as they “do not appear in the Army Equipment Support Publication “ .
This does not appear to be a rational approach to the evident need for Soldiers to be given alternative methods of extracting themselves/vehicles from difficult situations, which in this case resulted in Cameron’s death.
” 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 teach or recognise alternative trailer-extraction manoeuvres
Wider context from the report “2. We received evidence from the Vehicle Examiner that an alternative method of extracting the trailer from the confined area at Bracken Tor Hostel would have been able to pull the trailer backwards via a DROPS vehicle, which had the necessary towing attachments, from behind or “nose manoeuvre” the trailer. Neither of these possibilities (which would have avoided manual handling and vulnerability to being trapped between the trailer and the DROPS) were taught to the Soldiers or recognised by them to be a solution to recovery of the trailer .
” 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 emergency trailer-brake operation
Wider context from the report “1. It was clear from the evidence, and reflected in the Juror' findings, that the Soldiers in Cameron's Packet were not aware that when the emergency brake locked on, upon depletion of air tanks on a kings Trailer, reconnection of the air (red line) would release the brakes once operating pressure was achieved . Thus would cause the trailer to move out of control if the hand brake was not applied.
None of the witnesses who were trained to varying degrees understood this or the mechanism of brake action which was admittedly complicated . The Packet Commander was not fully trained in coupling and un-coupling procedures and relied on the Soldiers in her unit to advise her.
This lack of understanding led to the accident that caused Cameron’s death.
” 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 DROPS operator training for towing KINGS trailers and support it with step-by-step coupling and uncoupling video guidance.
Verbatim wording from the response “However, the training package for DROPS operators qualified to tow the KINGS trailer was improved in order to reinforce the extant training objectives and is now supported by a video which details acceptable procedures step-by-step, covering all aspects of coupling and uncoupling the trailer, including the airlines, chocks and shunt” Source location 2015-0268-Response-by-MOD
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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 Review the training package and determine that additional recovery manoeuvres should not be taught to vehicle operators.
Verbatim wording from the response “After the accident the training package was reviewed by the Training Requirements Authority and it was determined that additional manoeuvres should not be taught to operators. The advanced techniques described by the Vehicle Examiner at the inquest are only to be conducted by the specialist mechanical engineers of the Royal Electrical and Mechanical Engineers (REME). It is not feasible or necessary for every vehicle operator to be trained to such a specialist capability. The approach used within the Army for recovery, as laid down in the All Arms Equipment Recovery Manual (AAERM) and taught to all operators, is that recovery by driver/operators is restricted to the capabilities of the recovery equipment held by the unit and as part of the vehicle’s Complete Equipment Schedule.” Source location 2015-0268-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 Specialist recovery techniques and assistance are assigned to Royal Electrical and Mechanical Engineers personnel rather than ordinary vehicle operators.
Verbatim wording from the response “After the accident the training package was reviewed by the Training Requirements Authority and it was determined that additional manoeuvres should not be taught to operators. The advanced techniques described by the Vehicle Examiner at the inquest are only to be conducted by the specialist mechanical engineers of the Royal Electrical and Mechanical Engineers (REME). It is not feasible or necessary for every vehicle operator to be trained to such a specialist capability. The approach used within the Army for recovery, as laid down in the All Arms Equipment Recovery Manual (AAERM) and taught to all operators, is that recovery by driver/operators is restricted to the capabilities of the recovery equipment held by the unit and as part of the vehicle’s Complete Equipment Schedule.” Source location 2015-0268-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 Existing recovery arrangements restrict driver/operator recovery to available unit equipment, so additional manoeuvres need not be taught to vehicle operators.
Verbatim wording from the response “After the accident the training package was reviewed by the Training Requirements Authority and it was determined that additional manoeuvres should not be taught to operators. The advanced techniques described by the Vehicle Examiner at the inquest are only to be conducted by the specialist mechanical engineers of the Royal Electrical and Mechanical Engineers (REME). It is not feasible or necessary for every vehicle operator to be trained to such a specialist capability. The approach used within the Army for recovery, as laid down in the All Arms Equipment Recovery Manual (AAERM) and taught to all operators, is that recovery by driver/operators is restricted to the capabilities of the recovery equipment held by the unit and as part of the vehicle’s Complete Equipment Schedule.” Source location 2015-0268-Response-by-MOD
Open published response
1 Jun 2015 Sgt Mark Colin Foley · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 3 Failure of vehicle commanders to wear safety harnesses View source Insufficient driver experience in controlling vehicles during difficulties View source Failure of senior officers to enforce safety harness standing orders 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
Sgt Mark Colin Foley · 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
Sgt Mark Colin Foley died on 4 June 2014 after being ejected from a Land Rover that left the road and rolled over him. The substantive concerns were insufficient driver experience and a practice of vehicle commanders not wearing safety harnesses, together with failure by senior officers to enforce standing orders requiring their use.
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 vehicle commanders to wear safety harnesses
Wider context from the report “2. Although standing orders had been in place following a previous similar accident there was a practice among commanders of vehicles not to wear safety harnesses and failure to enforce such standing orders by senior officers.
” 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 driver experience in controlling vehicles during difficulties
Wider context from the report “1. Although the Army has taken action following a land accident prevention and investigation team report I was concerned although ████████ was qualified to drive the vehicle he had insufficient experience in encountering difficulties in controlling the vehicle .
” 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 officers to enforce safety harness standing orders
Wider context from the report “2. Although standing orders had been in place following a previous similar accident there was a practice among commanders of vehicles not to wear safety harnesses and failure to enforce such standing orders by senior officers .
” 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 Develop an online defensive-driver training package covering road awareness, vehicle control, driving styles and vehicle technology.
Verbatim wording from the response “We are currently looking at a potential requirement to create an online defensive driver training package to improve safety through inclusion of road awareness, vehicle control, driving styles and vehicle technology.” Source location 2015-0204-Response-by-Ministry-of-Defence
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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 Review the feasibility of additional inexperienced-driver training for vehicle loss-of-control scenarios.
Verbatim wording from the response “With regard to driver training, defensive driving is an integral element of all our vehicle instructor, commander and driver training. We have reviewed the feasibility of providing additional training for inexperienced drivers in case of the loss of control of vehicles, and concluded that it would be exceptionally difficult to replicate such circumstances without introducing a high degree of risk to those within the vehicle.” Source location 2015-0204-Response-by-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 safety directions to commanding officers of units equipped with wheeled armoured vehicles.
Verbatim wording from the response “As you are aware, on conclusion of the Land Accident Investigation Team investigation into Sgt Foley’s death, a letter was sent to the Commanding Officers of all units equipped with wheeled armoured vehicles highlighting a range of safety concerns and directing the adoption of a number of measures to improve safe operation. Evidence from training suggests that this direction is being followed by both the chain of command and the user, with a negligible number of related incidents reported. Linked to these changes in course content (including placing greater emphasis on the training of commanders) and training delivery, I am assured that the chain of command is meeting its responsibilities for the safe and effective operation of wheeled armoured vehicles.” Source location 2015-0204-Response-by-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 Reinforce safety-harness requirements through commander instruction, revised driver and commander training, and annual mandated currency training.
Verbatim wording from the response “As you have recognised, the policy for the wearing of seatbelts and safety harnesses is clearly set out in Armoured Vehicle Standing Orders, which are to be complied with by all crew members, regardless of rank. Commanders of wheeled armoured vehicles are now taught that they are responsible for ensuring that members of their crew wear safety harnesses at all times unless directed otherwise in relation to a specific tactical situation. Commanders are taught to reassess this as soon as the tactical situation” Source location 2015-0204-Response-by-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 Existing safety-harness policy and commander training were treated as sufficient to reinforce compliance, subject to tactical exceptions and reassessment.
Verbatim wording from the response “As you have recognised, the policy for the wearing of seatbelts and safety harnesses is clearly set out in Armoured Vehicle Standing Orders, which are to be complied with by all crew members, regardless of rank. Commanders of wheeled armoured vehicles are now taught that they are responsible for ensuring that members of their crew wear safety harnesses at all times unless directed otherwise in relation to a specific tactical situation. Commanders are taught to reassess this as soon as the tactical situation” Source location 2015-0204-Response-by-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 Additional training to replicate vehicle loss-of-control situations was not pursued because doing so would create a high degree of risk to vehicle occupants.
Verbatim wording from the response “With regard to driver training, defensive driving is an integral element of all our vehicle instructor, commander and driver training. We have reviewed the feasibility of providing additional training for inexperienced drivers in case of the loss of control of vehicles, and concluded that it would be exceptionally difficult to replicate such circumstances without introducing a high degree of risk to those within the vehicle.” Source location 2015-0204-Response-by-Ministry-of-Defence
Open published response
12 May 2015 Paul Mc Guigan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 16 Unavailability of enhanced criminal-record disclosures for overseas armed private security employment View source Lack of recording of pre-conviction disclosures View source Lack of understanding of overseas armed close protection work View source Lack of guidance and transfer arrangements for MAPPA-triggering offenders View source Lack of computer categorisation for close protection occupations View source Lack of clear procedure and funding responsibility for independent forensic psychiatric reports View source Lack of training for officers and civilian employees on disclosure procedures View source Failure to understand and operate the Notifiable Occupation Scheme View source Failure to consider disclosure to employers View source Inadequate and infrequent formal supervision of newly qualified offender managers View source Lack of a national system and contact point for obtaining military information View source Failure to record discussions among key professionals View source Failure of agencies to check and share available information before multi-agency meetings View source Incomplete and unclear procedure for the Common Law Police Disclosure Scheme View source Misunderstanding of residence conditions for offender monitoring View source Lack of recording of offenders' bail conditions View source See 13 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
Paul Mc Guigan · 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 Mc Guigan was shot and unlawfully killed by a close protection work colleague on 9 August 2009 while both were working as armed private security contractors in Baghdad. The report identified missed opportunities and failings in managing the offender’s escalating offending behaviour and risk, and stated that G4S had not adequately vetted him before deployment. Concerns also included failures in information sharing, recording bail conditions, police disclosure processes, and the supervision and risk assessment of offenders.
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 Unavailability of enhanced criminal-record disclosures for overseas armed private security employment
Wider context from the report “I also have a concern that an employer on a private security contract at home has regulated by the SIA and a private security employed overseas [unregulated save for voluntary schemes such as International Code of Conduct for Private Security Service Providers 2010 [ICoC] and accredited certification to the standard ANSI/ SSlS PSC. 1-2012] is not entitled or able to obtain an enhanced CRB and would only ever receive a Standard disclosure on a pre employment check.
It concerns me in particular that in respect of employing on individual on an armed contract then consideration should be given to enabling Private Security Companies a route to obtaining an enhanced disclosure.
” 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 recording of pre-conviction disclosures
Wider context from the report “It is clear that within GMP there was no recording anywhere as to when / if any pre convictions disclosures were made . It is important that there is a system of recording in this scenario and also to whom the disclosure is made. At present no-one can provide any information as to the number of detail of pre-conviction disclosures. In addition this means that officers who may be dealing with someone who has been arrested have no way of knowing if such a pre-conviction disclosure has ever been made.
” 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 overseas armed close protection work
Wider context from the report “In addition I have a concern that there is a complete lack of understanding by the Police and Probation / NOMS as to what close protection work overseas involves and in particular when this involves work on armed contracts .
” 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 guidance and transfer arrangements for MAPPA-triggering offenders
Wider context from the report “It concerns me to ensure that there is clear guidance given by NOMS to the private community rehabilitation companies [e.g. in Manchester Purple Futures] as to assessment of risk and for offenders who then do trigger MAPPA concerns that should be being supervised or assessed for eligibility under MAPPA to be transferred to be supervised by the National Probation 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 Lack of computer categorisation for close protection occupations
Wider context from the report “In respect of the GMP computer system and in respect of occupations that are regulated and require licensing by the SIA, there is no categorisation on the computer for “CLOSE PROTECTION” . Indeed the Court heard that there was some confusion and lack of understanding from many people as to what this occupation actually meant. Close protection work is a separate category of employment within the UK that the SIA regulates and the police system should reflect the occupations subject to regulation. It is important that the police and NOMS have a clear understanding as to what close protection work is to inform risk and 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 Lack of clear procedure and funding responsibility for independent forensic psychiatric reports
Wider context from the report “It concerns me that there is not a clear practice and procedure operating within the Court or probation system, including funding responsibility, for obtaining an Independent Forensic Psychiatric Report , particularly in circumstances where a defendant is remanded on bail in the community.
” 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 training for officers and civilian employees on disclosure procedures
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees . The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” 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 understand and operate the Notifiable Occupation Scheme
Wider context from the report “In my judgment there was a complete misunderstanding by GMP in respect of the operation of the Notifiable Occupation Scheme HOC 6/2006 .
Of immense concern also the complete failure for a period of approximately 18 months to make any post conviction notifications under the Notifiable Occupation Scheme , which was it transpired, formally withdrawn by the Home Secretary Theresa May MP in March 2015.
I heard and received evidence from the SIA that they were not aware that a regulatory gap existed in respect of the Police’s understanding of the scheme and notifications to themselves . The evidence I heard suggests that such a gap exists at GMP and has done so for in excess of 18 months.
” 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 consider disclosure to employers
Wider context from the report “In respect of the period of time when Post conviction disclosures were made [before this “back office” function ceased 18 months ago] these were only ever disclosures made to the Regulatory body and consideration never appears to have been given within GMP to disclosure to employers . Given the lack of understanding as to whom some regulatory bodies have responsibility for, this is important.
” 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 and infrequent formal supervision of newly qualified offender managers
Wider context from the report “I heard evidence that the Offender Manager was newly qualified and her formal supervision was inadequate and infrequent . This concerns me. It is important that newly qualified offender managers receive appropriate formal supervision .
” 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 national system and contact point for obtaining military information
Wider context from the report “My concern is to ensure that there is a system, protocol and point of contact for every offender manager nationally [including the private rehabilitation companies now operating as offender managers] that is well known as to who to contact to within the Ministry of Defence to obtain military 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 record discussions among key professionals
Wider context from the report “In addition I heard evidence and it concerns me that in advance of the Multi Agency meeting convened due to concerns as to the Offenders risk, key professionals had had discussions, telephone calls and meetings and I was concerned by the failure to record and document these important discussions , to ensure clarity, understanding and consistency. It is important when key professionals have discussions that these are documented 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 agencies to check and share available information before multi-agency meetings
Wider context from the report “It is important irrespective of who is the lead agency at a Multi Agency Meeting that each agency invited to attend checks information held on systems and records to which they have access and provides all this information to a multi agency meeting to ensure that a full and informed assessment of risk takes place and the fullest possible informed information sharing.
” 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 Incomplete and unclear procedure for the Common Law Police Disclosure Scheme
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees. The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” 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 Misunderstanding of residence conditions for offender monitoring
Wider context from the report “I also heard evidence that a GMP officer believed that Bail with a condition of residence was different to “bail live and sleep each night”. It is of concern that there is a misunderstanding within GMP as to what a condition of residence means and how this relates to the monitoring of offenders .
” 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 recording of offenders' bail conditions
Wider context from the report “I heard evidence that in respect of GMP systems and processes there was nowhere on the GMP computer system where bail conditions are recorded , although this used to be possible. It is of concern that there is no system of recording on the GMP computer of offenders bail conditions so that this information can be known by officers and appropriately shared.
” Open source report
28 Apr 2015 Colour Sergeant Martyn HORTON and 3 others · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 6 Failure to provide a maintenance-section cross-reference to front spring hanger torque settings View source Failure to apply height restrictions to remote weapon system gunners View source Lack of capability to achieve specified vehicle tyre pressures View source Inadequate operational effectiveness of Ridgeback lighting View source Failure to review the whole suspension system for the additional operational load of UK specification vehicles View source Failure to capture recurring component bolt retightening as an issue warranting investigation View source See 3 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
Colour Sergeant Martyn HORTON and 3 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
On 23 June 2010, four service personnel died by drowning after their Ridgeback vehicle collided with a parked Afghan National Police vehicle, left the road and overturned in a canal in Afghanistan. The report raised concerns about the Ridgeback and related vehicle fleet, including suspension fitness, driver and gunner height restrictions, lighting effectiveness, tyre-pressure equipment, maintenance documentation, emergency lighting and recognition of recurring component failures.
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 provide a maintenance-section cross-reference to front spring hanger torque settings
Wider context from the report “(V) AESP Torque references. During the course of the evidence I heard that the maintenance of the Ridgeback vehicle was governed by AESP documentation. I was told by Craftsman ████████ that regularly at MOB Price during Herrick 12 whilst maintaining these vehicles that he was unaware of the correct torque settings in relation to the front spring hanger assembly bolts and would ensure in the circumstances that the bolts, to quote him, were “fucking tight”. There were however torque settings on these settings appear to have been confined in the repair section of the AESP documentation in Section 5 as opposed to the maintenance section in Section 6. I fully accepted the evidence I heard that the AESP documentation is voluminous but I am concerned and believe that it would be of assistance to REME personnel and those responsible for the maintenance of the vehicles that consideration be given to ensuring mention of a cross reference pointing in Section 6 at the relevant section to where the torque settings can be found in Section 5 rather than repeating the verbatim torque settings again. I would ask that you give consideration to this so as to ensure correction maintenance procedures are carried 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 Failure to apply height restrictions to remote weapon system gunners
Wider context from the report “(II) Height restrictions. During the course of hearing evidence, I heard that there were height restrictions relative to the driver of Ridgeback vehicles as well as the designated Commander of the vehicle. Ordinarily both the driver and Commander sit in the two front seats of the vehicle. The vehicle involved in this particular incident was a remote weapon system variant Ridgeback and unlike other variants, the right hand seat is occupied by the remote weapon gunner and the Commander is moved to a position sitting at right angles to the driver who of course is occupying the left hand front seat. Depending on operational assessment, I am concerned that if there is a height restriction for a driver and Commander that if a gunner is required to occupy the front right hand seat, as is the case in the remote weapon system variant, that a height restriction ought to apply to the gunner as well. In this particular tragic incident I found no evidence that the height of Private Alexander Isaac contributed to his inability to escape from the stricken Ridgeback once it had entered the canal as he was able to remove his helmet and body armour and in fact was one of the first bodies to have been recovered through the top hatch.
” 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 capability to achieve specified vehicle tyre pressures
Wider context from the report “(IV) Tyre pressures. The Ridgeback in question following recovery was found to have under inflated rear tyres some 13% less than the recommended PSI which I believe is 110. During the course of the evidence I heard the REME maintenance crew at MOB Price did not have equipment to inflate tyres to that pressure and the on board compressor again did not have the necessary capability to inflate tyres over and above 100 PSI. I was told that if the required tyre pressure was to be achieved that the only equipment available was at Camp Bastion and of course the vehicles were not regularly, when on operational service in Afghanistan, travelling to Camp Bastion. I would ask that you review this concern. Tyre pressures are important. Both under inflated and over inflated tyres can materially affect the handling of the vehicles and if there is a specification for a certain tyre pressure then those operating or maintaining the vehicle ought to have the ability to ensure the correct tyre pressure is achievable. Again this potentially is applicable across the Cougar family fleet.
” 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 operational effectiveness of Ridgeback lighting
Wider context from the report “(III) Lighting. At the end of the day a Commander of a vehicle has overall control and a driver is required to use his or her skill and judgement relative to road conditions and the vehicle capabilities to drive at an appropriate speed taking into account speed limits. When responding to an emergency such as the QRF (Quick Reaction Force) role as is the case when UK civilian emergency response vehicles are responding to a legitimate emergency, speed limits may not ordinarily be adhered to and I very much take the view that it should be a matter of military judgement taken by those who have situational awareness at the time. The evidence I heard was that operationally drivers could realistically only see using white light approximately 10-15 metres in front of the vehicle. There was an issue with the Ridgeback involved in this incident in that for some reason the main head lights had a lower specification bulb fitted 75/70 watts as opposed to the specified 100/80 watt bulb. The Ridgeback is also fitted with 70 watt fog lamps and set of 70 watt additional lights which were moved following the incident to the outside of the bar armour. The main lights however still lie behind the bar armour and that must impede their effectiveness. I would like you however to review the effectiveness of Ridgeback lighting and arguably as it is part of the Cougar fleet, the lighting of the Mastiff and Wolfhound also as they are similar vehicles with the addition of an additional axle, as regards operational effectiveness especially if such vehicles are intended to be used in a QRF role or when operational requirements dictate a need to travel at speed. An operational limit of only 10-15 metres in front of the vehicle is in my view restrictive and significantly restricts the safe speed of the vehicle allowing for reaction and stoppage time. ████████ (retired) attempted as part of the LAIT investigation to carry out tests on Salisbury Plain, although I do have some concerns in relation to the accuracy and usefulness of the data obtained from those tests.
” 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 review the whole suspension system for the additional operational load of UK specification vehicles
Wider context from the report “(I) Suspension issues. During the course of the Inquest I heard how Ridgeback had been introduced into UK operational service as part of an urgent operational requirement to provide greater protection to UK service personnel on operation in Afghanistan due to the ever increasing threat that had been developing from improvised explosive devices. I heard how the original shell vehicle provided by the US manufacturer was modified to UK specifications by UK Government contractors and I heard that the resultant additional weight appears to have in particular resulted in an unusually large number of failures to the front spring hanger assembly, mounting bracket as well as leaf spring failures with four of those failures. Morgan Advanced Materials have been contracted to remedy the problem and I understand that additional information following the involvement of ████████ and members of the team of 710 Naval Squadron will be helpful in trying to find a solution. I have been provided with a timetable in respect of which various steps will be covered leading to a solution being found and rolled out which will exceed the usual 56 day time period to respond to a Regulation 28 Report. As part of my Regulation 28 duty I would like to monitor the resolution of the issue relative to the failures in the front suspension area and I am sure that the families of the four who died on 23 June 2010, even though that the failure to that particular vehicle (Spring hanger bolt failure) did not cause or contribute to their deaths, would also like to be appraised of developments insofar as sensitive material is not disclosed. I am however still concerned that the focus appears to be solely on the front suspension where the vast majority of the failures occurred. I would therefore ask for confirmation that given the modifications affected the overall operational load of the vehicle that the whole suspension system is reviewed with a view that ultimately it is fit for purpose having regard to the additional operational load that UK specification vehicles are required to deal with as compared to its American counterparts. In this respect I have suggested quarterly updates as a way forward. For the avoidance of any doubt although the inquest focussed on the Ridgeback, I am aware from the same Cougar family that the problem affected Wolfhound and Mastiff as well which of course the UK Government purchased as well.
” 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 capture recurring component bolt retightening as an issue warranting investigation
Wider context from the report “(VII) Component failure awareness. It was clear in 2010 that failures associated with the front suspension and spring hanger assembly in the Cougar fleet were starting to develop and following an incident involving a Ridgeback vehicle in Bovingdon in 2012, Qinetiq were instructed to analyse these failures. During the course of the evidence I heard from those that were maintaining these vehicles back in 2010 that the bolts on the front spring hanger assembly were in need of regular tightening and the vehicle was subject to 21 day inspection checks. The joint opinion of ████████ and members of the team at 1710 Naval Squadron was that it should not be necessary to repeatedly have to tighten the bolts relative to a component such as the spring hanger assembly. The need for the retightening of bolts was in their view indicative of a component issue and I would ask that you review from a learning point as regards raising the awareness of Craftsmen and Technicians and not just in relation to Ridgeback or Mastiff but in relation to any component across the services, that if an issue arises requiring regular or unusually frequent tightening of component bolts that matter ought to be highlighted as a concern warranting proportionate investigation relative to other similar pieces of equipment experiencing the same issue , such as was the case here with the Cougar fleet of vehicles. The retightening of bolts on a regular basis was something that was not captured as an issue in itself.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Ridgback height-policy wording and issue clarified guidance based on seating position rather than crew role.
Verbatim wording from the response “Following the conclusion of combat operations in Afghanistan, the Army Capability Directorate for Combat has amended the height policy for vehicle crewmen across the range of in-service platforms to maximise safety for those operating the vehicles. The new policy emphasises the chain of command’s responsibility to select and train personnel able to safely and effectively carry out the tasks required of them. Commanders on operations are still able to re-impose specific height restrictions on crew members should operational circumstances or the enemy threat require it. In response to your concerns the Army Capability Directorate for Combat will further review the wording of current policy on height restrictions for Ridgback and will ensure this is based on seating position, rather than the individual’s role as part of the crew.” Source location 2015-0164-Response-by-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 torque-reference cross-referencing across Cougar-based vehicle publications and issue major findings in a safety notice before publication.
Verbatim wording from the response “We are reviewing documentation to check for cross-referencing as you recommend. This review will encompass all of the publications for the 21 different in-service Cougar-based vehicle variants. The AESPs for the Cougar-based vehicle fleets are subject to a major update release every six months. The next is due 31 August 2015; the review work is due to be completed ahead of this date and any major findings will be issued in a Safety Notice prior to the formal publication.” Source location 2015-0164-Response-by-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 Amend vehicle-crew height policy across in-service platforms to emphasise command responsibility for selecting and training suitable personnel.
Verbatim wording from the response “Following the conclusion of combat operations in Afghanistan, the Army Capability Directorate for Combat has amended the height policy for vehicle crewmen across the range of in-service platforms to maximise safety for those operating the vehicles. The new policy emphasises the chain of command’s responsibility to select and train personnel able to safely and effectively carry out the tasks required of them. Commanders on operations are still able to re-impose specific height restrictions on crew members should operational circumstances or the enemy threat require it. In response to your concerns the Army Capability Directorate for Combat will further review the wording of current policy on height restrictions for Ridgback and will ensure this is based on seating position, rather than the individual’s role as part of the crew.” Source location 2015-0164-Response-by-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 Complete Vehicle Emergency Lighting System modifications across the Cougar fleet, including RODET trainers, and restrict active-fleet use without the modification.
Verbatim wording from the response “The Vehicle Emergency Lighting System (VELS) modification is on-going. The VELS kits were originally released to the Army and other users in June 2013; as at 02 June 2015 the percentage of the Cougar fleet that has been modified is as follows, with the percentage of the active fleet (vehicles actually being used by the Army and not in storage) shown in brackets: Ridgback 74% (85%), Mastiff 72% (77%), Wolfhound 49% (61%). Based on the time taken to complete modifications to date, the Army are expected to complete modifications on the active fleet² by 30 June 2016 and will not be able to use active fleet vehicles after this date unless VELS is fitted, with the whole of the fleet expected to be completed no later than the end of 2016.” Source location 2015-0164-Response-by-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 suspension data to determine the Cougar fleet maintenance schedule and issue a safety notice with findings.
Verbatim wording from the response “In response to your concerns we are conducting a review of the whole vehicle suspension system with consideration also being given to the rest of the Cougar fleet of vehicles (Mastiff and Wolfhound). This includes:” Source location 2015-0164-Response-by-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 Ridgback suspension system and options for implementation, then make recommendations to Army Headquarters.
Verbatim wording from the response “4. A full vehicle review of the Ridgback vehicle to determine the most effective suspension system and options for implementation. This is a more complex piece of work with a direct read-across from Ridgback to Mastiff and Wolfhound and will involve extensive physical prototyping and trialling before design and testing of the safety and operational” Source location 2015-0164-Response-by-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 Assess the performance of the upgraded vehicle lighting against the existing system from crew positions.
Verbatim wording from the response “In response to your concerns, Morgan Advanced Materials will provide an upgraded, legislatively compliant lighting system across the Cougar fleet of vehicles. Establishing what this means, and checking compliance with the Road Vehicle Lighting Regulations 1989, will be different for each vehicle. As well as checking legislative compliance we will conduct a subjective assessment of the performance of the lights in comparison with the old system from the position of the crewmen. The final design review is planned for July 2015. The production of circa 750 modification kits of a bespoke design will take 5 months after the final design review has formally signed-off the modification; therefore modification kits are expected by 30 November 2015 and implementation will be complete by 31 December 2016.” Source location 2015-0164-Response-by-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 Investigate options for providing on-vehicle or carried capability to inflate Cougar tyres to 110 PSI.
Verbatim wording from the response “As your report identified, there is presently no on-board means (either in terms of vehicle capabilities or by those of use of carried tools) to inflate the tyres to the required pressure. The requirement to check and adjust where necessary, tyre pressures is a daily task defined in the relevant Army Equipment Support Publication (AESP). The MOD is currently investigating means to provide the capability of inflating tyres to 110 PSI from systems contained or carried on the vehicle; this work is being conducted in parallel with work to provide a similar capability for the Jackal and Coyote fleets, consisting of circa 700 vehicles. We expect to have identified options to provide this capability by 30 September 2015.” Source location 2015-0164-Response-by-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 component-failure-awareness training and direct inclusion of lessons on fault reporting and experienced diagnosis.
Verbatim wording from the response “A review of current training in respect of component failure awareness has been completed. This has resulted in direction to include additional lessons to reinforce the reasons and timeframe for raising fault reports, and the importance of experienced tradespersons diagnosing and reporting equipment failure to effective equipment support.” Source location 2015-0164-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 Army Light Aid Detachments have sufficient capability to maintain deployed vehicle tyres at the required pressure without returning to a main operating base.
Verbatim wording from the response “As your report identified, there is presently no on-board means (either in terms of vehicle capabilities or by those of use of carried tools) to inflate the tyres to the required pressure. The requirement to check and adjust where necessary, tyre pressures is a daily task defined in the relevant Army Equipment Support Publication (AESP). The MOD is currently investigating means to provide the capability of inflating tyres to 110 PSI from systems contained or carried on the vehicle; this work is being conducted in parallel with work to provide a similar capability for the Jackal and Coyote fleets, consisting of circa 700 vehicles. We expect to have identified options to provide this capability by 30 September 2015.” Source location 2015-0164-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 chain of command is responsible for selecting and training personnel able to operate vehicles safely and effectively.
Verbatim wording from the response “Following the conclusion of combat operations in Afghanistan, the Army Capability Directorate for Combat has amended the height policy for vehicle crewmen across the range of in-service platforms to maximise safety for those operating the vehicles. The new policy emphasises the chain of command’s responsibility to select and train personnel able to safely and effectively carry out the tasks required of them. Commanders on operations are still able to re-impose specific height restrictions on crew members should operational circumstances or the enemy threat require it. In response to your concerns the Army Capability Directorate for Combat will further review the wording of current policy on height restrictions for Ridgback and will ensure this is based on seating position, rather than the individual’s role as part of the crew.” Source location 2015-0164-Response-by-Ministry-of-Defence
Open published response
16 Mar 2015 Captain Tom Sawyer and Corporal Danny Winters · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 1 Lack of reliable, complete records of radio communications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Captain Tom Sawyer and Corporal Danny Winters · 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
Captain Tom Sawyer and Corporal Danny Winters died in Afghanistan on 14 January 2009 after a Javelin missile fired by friendly forces struck the compound roof where they were located. The report identified ineffective communications, mistaken identification of their position, poor visibility, loss of situational awareness and inadequate assessment of the weapon’s use in the anti-personnel role as contributing factors. A substantive concern was the absence of FIRESNET logs and the lack of secure recording of radio communications, which hindered investigation of what went wrong.
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 reliable, complete records of radio communications
Wider context from the report “As I indicated in Court I find it hard to understand that in the 21st Century that there is still a huge amount of dependence on hand written radio logs in respect of which “Coms” are recorded subject to the judgement of that particular signaller relative to the skills of that signaller in recognising what is relevant and what is not . One of the objectives of a Coronial Inquest where especially Article 2 is engaged, as was the case in this Inquest, is to consider matters with a view to the prevention of future deaths and of course this is an area which overlaps between my Coronial function and that of a Service Inquiry. The absence of records/logs in relation to the FIRESNET in my view was not helpful in getting to the bottom of what went wrong especially as regards the communication between Tom, as a Forward Artillery Observer with Zulu Company, and his Danish counterpart “Soldier I”. I found that on a balance of probabilities that something a step away from express instruction to fire was said by Tom to Soldier I which was then mutating when he relayed the signal to his colleague Soldier A, located on the rooftop of the compound providing over the watch where of cause the Javelin detachment which fired the Javelin missile was located. It was Soldier A who gave the order to fire. I found on the balance of probabilities that there was ineffective communication between Soldier I and Soldier A.
Investigating such matters requires the best evidence available and as regards current technology I am surprised that there is not the ability at least at one end of the radio communications network to for example, securely digitally record the encrypted signals along the lines of say a cockpit voice recorder. For security reasons such recordings could then be decrypted and made available to any subsequent investigation that needs to be carried out. I fully appreciate that such a system may not be appropriate for those actually on the ground for reasons of additional weight but it was clear to me that communications were being monitored back at the Forward Operating Bases and that perhaps may be a location where communications being monitored/relayed could be recorded at the same time. It may be the case that technology would allow some form of recording say on a 2 hour loop on equipment given to soldiers on the ground but as I said earlier I am conscious of the amount of weight soldiers on the ground have to carry in respect of their combat kit and weapon.
It is worth noting that Tom and Danny’s respective families were also concerned as regards the absence of FIRESNET logs.
Monitoring of the BATTLE GROUP NET in such a way would have also been helpful although there were some logs in relation to communications over this net. The benefit of having accurate records of communications bolsters the integrity and thoroughness of any investigation and may have highlighted matters warranting further consideration with the view to the prevention of future deaths. I am sure that such a system would be beneficial to future investigations aimed at the prevention of future deaths.
” 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 Develop policy determining when and how automated voice-logging capability will be used in future.
Verbatim wording from the response “In terms of our future capabilities, the next generation of tactical command, control and communications system for Defence includes a requirement that “The [User] shall be able to access an automated secure voice log of their primary net.” The full scope of this requirement and its implications will be investigated during the Assessment phase of the programme in the period up to 2018, but it is unlikely that this will include the ability to record all communication networks all the time due to practical limitations. Policy will therefore be developed by the newly appointed Army Chief Information Officer to determine when and how such a capability will be used in the future. I have ensured that your concerns have been passed to him.” Source location 2015-0100-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 Investigate the scope and implications of automated secure voice logging during the tactical communications programme’s Assessment phase.
Verbatim wording from the response “In terms of our future capabilities, the next generation of tactical command, control and communications system for Defence includes a requirement that “The [User] shall be able to access an automated secure voice log of their primary net.” The full scope of this requirement and its implications will be investigated during the Assessment phase of the programme in the period up to 2018, but it is unlikely that this will include the ability to record all communication networks all the time due to practical limitations. Policy will therefore be developed by the newly appointed Army Chief Information Officer to determine when and how such a capability will be used in the future. I have ensured that your concerns have been passed to him.” Source location 2015-0100-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 Army Chief Information Officer will determine when and how future voice-recording capability is used.
Verbatim wording from the response “In terms of our future capabilities, the next generation of tactical command, control and communications system for Defence includes a requirement that “The [User] shall be able to access an automated secure voice log of their primary net.” The full scope of this requirement and its implications will be investigated during the Assessment phase of the programme in the period up to 2018, but it is unlikely that this will include the ability to record all communication networks all the time due to practical limitations. Policy will therefore be developed by the newly appointed Army Chief Information Officer to determine when and how such a capability will be used in the future. I have ensured that your concerns have been passed to him.” Source location 2015-0100-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 Recording all communication networks continuously is unlikely due to practical limitations.
Verbatim wording from the response “In terms of our future capabilities, the next generation of tactical command, control and communications system for Defence includes a requirement that “The [User] shall be able to access an automated secure voice log of their primary net.” The full scope of this requirement and its implications will be investigated during the Assessment phase of the programme in the period up to 2018, but it is unlikely that this will include the ability to record all communication networks all the time due to practical limitations. Policy will therefore be developed by the newly appointed Army Chief Information Officer to determine when and how such a capability will be used in the future. I have ensured that your concerns have been passed to him.” Source location 2015-0100-Response-by-MOD
Open published response
20 Feb 2015 Richard Jeffrey Jones · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 3 Failure to record primary responsibility for patient care during transfers of care View source Failure to share patient information accurately with other agencies involved in care View source Failure to record information obtained from mental health patients, including perceived risk and assessment urgency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard Jeffrey 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
Richard Jeffrey Jones was at home alone and, during 14 to 15 October 2012, voluntarily ingested a quantity of tramadol that led to loss of consciousness, respiratory depression and aspiration of gastric contents, causing his death. The report raised concerns about recording and sharing information on risk and urgency, and about identifying primary responsibility when care was transferred between mental health 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 Failure to record primary responsibility for patient care during transfers of care
Wider context from the report “I am concerned in particular as to the following matters :
a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.
b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.
c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care .
” 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 patient information accurately with other agencies involved in care
Wider context from the report “I am concerned in particular as to the following matters :
a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment.
b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency .
c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care.
” 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 record information obtained from mental health patients, including perceived risk and assessment urgency
Wider context from the report “I am concerned in particular as to the following matters :
a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment .
b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency.
c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care.
” 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 Update JSP 950 Leaflet 2-7-2 with guidance on care transfers, responsibility, NHS coordination, information sharing and access to Defence Medical Services advice.
Verbatim wording from the response “I can confirm that we are now updating leaflet 2-7-2 of the Department’s medical policy document (Joint Service Publication (JSP) 950) which covers the provision and management of Defence mental health services. This will include new guidance and policy on the principles of transfer, which will include addressing both internal transfers of care between different Defence Medical Services (DMS) care providers and the transfers between DMS providers and external agencies.” Source location 2015-0068-Response-by-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 The out-of-hours Service Liaison Officer service is non-clinical and does not assess or assume responsibility for people in mental health crisis.
Verbatim wording from the response “It should be noted that the Service Liaison Officer Service is not a clinical one. The on duty SLO is not expected to carry out an assessment or take responsibility for someone in crisis or discharged from hospital.” Source location 2015-0068-Response-by-Ministry-of-Defence
Open published response
18 Dec 2014 Corporal William Savage and 2 others · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 2 Failure to accurately and widely circulate the nature and duration of threat hits on the relevant intelligence database View source Insufficient consideration before removing and marking route threat warnings as cleared View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Corporal William Savage 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
Corporal William Savage, Fusilier Samuel Flint and Private Robert Hetherington died on 30 April 2013 when their Mastiff armoured patrol vehicle was hit by a large improvised explosive device placed in a tunnel under Route 611 in Helmand, Afghanistan. The principal concerns were that frequent and continuous surveillance hits indicating possible digging were not accurately and widely shared, and that the route may have been marked as cleared without sufficiently detailed consideration of the threat warnings.
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 accurately and widely circulate the nature and duration of threat hits on the relevant intelligence database
Wider context from the report “- The nature of the hits and the period over which they were received should have been more accurately and widely circulated on the relevant Intelligence database . The commanders of the Patrol were aware there had been PISTOL hits at the location (but not frequent and continuous hits over 3/4 days) and were led to believe that the location had been cleared the day before on the 29 April when the US route clearing team travelled along Route 611.
” 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 consideration before removing and marking route threat warnings as cleared
Wider context from the report “- I fully appreciate of course that lessons have been learned as part of the normal process of investigation after such a tragic incident. I understand one of the lessons is in relation to the clearance of threat warnings from routes. It appears there may be a need for more detailed consideration before a threat is removed and marked as ‘cleared’ .
” 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 Treat uncleared PISTOL-hit locations as Vulnerable Areas, record them in route-planning assets, and place them temporarily out of bounds when necessary.
Verbatim wording from the response “• Task Force Helmand Joint Operations Centre was to ensure that all units transiting areas where PISTOL hits had been reported and not cleared should treat such locations as Vulnerable Areas, thus prompting specific clearance techniques. These Vulnerable Areas were also to be entered onto other route planning assets that were in use at the time. Further, should it be felt necessary, areas of concern were to be temporarily placed out of bounds until locations were subject to formal IED clearance by specialist search teams on the ground.” Source location MOD-Response
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 PISTOL hits to be reported to the Battle Captain or Duty Watch Keeper and recorded in JCHAT.
Verbatim wording from the response “Immediately following this incident an in-depth analysis of the circumstances was conducted to ensure we identified and implemented all relevant lessons. The failure of effective communication of PISTOL information was highlighted and on 11 May 2013 a new Standard Operating Procedure (SOP) was issued and briefed to those operating PISTOL and to those using the information that PISTOL produced. This new SOP focussed on the passage of information and implemented the following changes:” Source location MOD-Response
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 Produce daily PISTOL-hit heat maps, analyse them through intelligence staff, and disseminate them to tactical planners and patrol personnel.
Verbatim wording from the response “• On a daily basis all PISTOL hits should be converted into a ‘heat map’ which should be analysed by intelligence staff and promulgated to all those conducting tactical level planning and patrol activity.” Source location MOD-Response
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 Escalate unresolved PISTOL hits to higher surveillance assets and, where appropriate, recommend specialist search-team investigation.
Verbatim wording from the response “• If, following investigation of PISTOL hits with the surveillance assets immediately available to him, the Battle Captain or Duty Watch Keeper was still not confident that a false or non-threatening hit had been confirmed, then he should call upon higher information (i.e. Task Force Helmand) surveillance assets and, following further investigation, he could recommend that the area be investigated by a specialist search team.” Source location MOD-Response
Open published response
9 Oct 2014 Sapper Dylan Reece Gibson · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 1 Lack of master keys held at guard rooms for prompt emergency access to buildings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sapper Dylan Reece Gibson · 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
Sapper Dylan Reece Gibson was found dead in his room on 25 February 2014, and the inquest concluded that he had taken his own life by hanging. A substantive concern was whether master keys should be held at guard rooms to allow prompt access to buildings during emergencies, although the coroner was not satisfied that their availability would have made a difference in this case.
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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 Lack of master keys held at guard rooms for prompt emergency access to buildings
Wider context from the report “As part of the evidence I had before me a copy of The Non Operational Learning Account and After Action Review dated 14 March 2014. One of the recommendations that arose out of the investigation was that rather than relying on the attendance of those responsible for maintenance of the site that a master key to buildings such as living accommodation, offices and other buildings should be held at the guard room so as to enable access to any room, office or building on the camp promptly in case of an emergency . Concern was first raised at around 1900hrs that day and although I was not satisfied there was evidence to support that the availability of a master key would have made a difference here, it may possibly prevent a death in the future if such master keys were made available . This could apply not just at Perham Down Barracks but in relation to other sites across the United Kingdom.
” 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 Update JSP 375 guidance to require consideration and regular testing of rapid emergency access procedures for locked rooms, including silent hours.
Verbatim wording from the response “With regard to the wider MOD estate, I can confirm that we are now updating our Health and Safety risk assessment guidance (contained within Joint Service Publication 375 (JSP 375)) to ensure that all those responsible for conducting site risk assessments on MOD establishments consider procedures for gaining rapid access to locked rooms (including the release of master keys) in emergencies. The amended JSP 375 will also state that these procedures should be tested on a regular basis, including the arrangements for silent hours.” Source location 2014-0436-Response-by-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 Assess emergency-access requirements site by site and identify an appropriate access method where the Defence Infrastructure Organisation is head of establishment.
Verbatim wording from the response “The Defence Infrastructure Organisation have confirmed that they will assess the requirement on a site basis where they are Head of Establishment and identify a method of emergency access where appropriate.” Source location 2014-0436-Response-by-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 Hold keys to all Regiment buildings and rooms in the guardroom for emergency access.
Verbatim wording from the response “As reported in my letter of 3 December 2014 Sapper Gibson’s unit, 26 Engineer Regiment, have implemented your recommendation and now hold keys to all buildings and rooms used by the Regiment in the guardroom where they can be accessed by duty staff in case of an emergency.” Source location 2014-0436-Response-by-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 Direct controlled sites to centrally hold master or spare keys, or provide a known alternative emergency access method for duty staff.
Verbatim wording from the response “While overall responsibility for Health and Safety within the MOD rests with the Secretary of State, this is formally delegated through Permanent Under Secretary to Top Level Budget holders and Chief Executives, who in turn delegate to Commanding Officers and managers within their own area. In order to address your recommendation, the Royal Navy, Army, Royal Air Force, Defence Equipment and Support and Joint Forces Command have all directed that for sites within their control, either:” Source location 2014-0436-Response-by-Ministry-of-Defence
Open published response
3 Jun 2014 Private Robert WOOD and Private Dean HUTCHINSON · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 5 Fire Diary failing to prioritise fire risk assessment reviews before changes of use or structural alterations View source Failure to conduct genuinely random silent-hours checks View source Fire Diary lacking guidance on contacting expert advice about electrical overloading concerns View source Failure of fire risk assessments to identify sleeping in office accommodation View source Lack of specific Junior Fire NCO training to recognise electrical appliance overloading View source See 2 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
Private Robert WOOD and Private Dean HUTCHINSON · 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
Private Robert Wood and Private Dean Hutchinson died on 14 February 2011 from inhalation of products of combustion and severe burns. The report raised concerns about fire risk assessments, training on electrical appliance overloading, identification of sleeping in office accommodation, and the effectiveness of random overnight checks.
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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 Fire Diary failing to prioritise fire risk assessment reviews before changes of use or structural alterations
Wider context from the report “(1) In evidence from ████████ from the Defence Fire Risk Management Organisation, I looked at the modification to the Fire Diary on the subject of fire risk assessments. I have attached a copy of the relevant extract marked “B” and the relevant section is already highlighted. It talks of a review of the fire risk assessment where there has been or there is planned to be a change in use or structure alteration.
In evidence a number of witnesses, in particular ████████ who carries out fire risk assessments, agreed that advice should be sought quickly before any change of use or structural alteration. I appreciate that there will be incidences whereby a change of use can take place extremely quickly however I considered that this section did not weight a preference in favour of a review prior to a change of use or any structural alteration taking place . It is my view that the current version gives equal weighting to the 2 options available when the evidence I heard was in favour of advice being sought before a change of use was carried out or any structural alteration taking place. In this particular case the alterations were phased alterations over a period of time and whilst I formed the view that it was speculative on the facts of this particular case that such a review before the change would have made a difference that cannot be said for future incidences. As the evidence I heard supports a preference for such reviews to be undertaken before a change of use or structural alteration takes place I would ask that this be reviewed insofar as the wording is 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 conduct genuinely random silent-hours checks
Wider context from the report “(4) It may seem a matter of common sense but in relation to the issue of random checks (“silent hours checks”), what was happening insofar as the Transport Troop tent was concerned in relation to satisfying the obligation to carry out checks between the hours of 2300 hours to 0500 hours the following day was that those responsible if they happened to worked late beyond 2300 hours say until 0000 would regard that as sufficient . More senior officers who gave evidence recognised that such checks to be effective needed to be random . I found this to be failure at individual levels and I would be grateful if the matter could be considered to be used as a training example to reinforce the point to Junior Officers and NCOs on the subject of random checks. I found that random checks been undertaken that it more likely than not would have acted as a deterrent and stopped the practice of all sleeping on duty at night.
” 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 Fire Diary lacking guidance on contacting expert advice about electrical overloading concerns
Wider context from the report “(2) Instruction and training is now given specifically to Junior Fire NCOs as regards recognising the possibility of overloading in relation to electrical appliances. In my decision I found that the absence of such training was a systemic failure contributing to the deaths of both Rob and Dean. In evidence from Captain Hamilton from the Royal Engineers he explained insofar as the chiller cabinet that was used inside the Transport Troop tent was concerned that whilst that may have a specific amperage in relation to the draw of current, he commented that at the start of a cycle when the compressor becomes activated that figure can be multiplied by a factor of between 6 to 10. For example a 2 amp appliance suddenly draws a current of between 12 and 20 amps. He commented that in order to recognise such an issue that this required quite specific training and knowledge attributable to the qualifications of an electrician. As the Fire Diary is the guide to any Junior Fire NCO I would be grateful if you could please confirm that this document includes guidance to relevant Fire NCOs as regards who to contact if they have a concern as regard overloading in order to seek expert advice on the matter .
What became very clear during the course of the Inquest is that such matters sometimes have to be explained in very clear terms and levelled so as to be understood at the lowest level of service men/women.
” 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 fire risk assessments to identify sleeping in office accommodation
Wider context from the report “(3) A copy of the fire risk assessment is, of course, given to the relevant Fire NCO and, of course, the sleeping issue is very much highlighted to all fire risk assessment assessors. In the actual fire risk assessment of the General Support Squadron area that was undertaken on the 3 December 2010 it was not picked up by the relevant fire NCO who, of course, subsequently received a copy of the document stating that sleeping was not taking place .
I would be grateful if you could please review the matter in relation to the risk assessment document with a view to considering whether it would be sensible to put a note possibly in bold and/or even capitals on the subject of the declaration in relation to sleeping in office accommodation to act as a reminder to the Fire NCO to check the point. Whilst ████████ referred to the guidance, referring to the use of cots/beds, soldiers of course are resourceful and will sleep at a desk or even on the floor .
” 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 specific Junior Fire NCO training to recognise electrical appliance overloading
Wider context from the report “(2) Instruction and training is now given specifically to Junior Fire NCOs as regards recognising the possibility of overloading in relation to electrical appliances. In my decision I found that the absence of such training was a systemic failure contributing to the deaths of both Rob and Dean. In evidence from Captain Hamilton from the Royal Engineers he explained insofar as the chiller cabinet that was used inside the Transport Troop tent was concerned that whilst that may have a specific amperage in relation to the draw of current, he commented that at the start of a cycle when the compressor becomes activated that figure can be multiplied by a factor of between 6 to 10. For example a 2 amp appliance suddenly draws a current of between 12 and 20 amps. He commented that in order to recognise such an issue that this required quite specific training and knowledge attributable to the qualifications of an electrician . As the Fire Diary is the guide to any Junior Fire NCO I would be grateful if you could please confirm that this document includes guidance to relevant Fire NCOs as regards who to contact if they have a concern as regard overloading in order to seek expert advice on the matter.
What became very clear during the course of the Inquest is that such matters sometimes have to be explained in very clear terms and levelled so as to be understood at the lowest level of service men/women.
” 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 Implement the revised DFRMO Fire Risk Assessment template across Defence by the end of October 2014.
Verbatim wording from the response “Your third concern has been addressed as part of the ongoing review of the DFRMO Fire Risk Assessment template. The template has been updated to further emphasise the need to record if any sleeping is taking place on the premises regardless of its primary purpose. The review is not yet complete but I have attached the latest draft with the changes highlighted for your information. The revised version is planned to be implemented by the end of October 2014.” Source location 2014-0556-Response
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 Amend the DFRMO Fire Diary to require competent fire-risk assessment advice before premises changes or when assessments may be invalid, and strengthen electrical-overloading guidance.
Verbatim wording from the response “In response to your first two concerns, the Defence Fire Risk Management Organisation (DFRMO) Fire Diary has been amended to make it clear that the advice of a competent fire risk assessor must be sought before any changes take place within a premise or if there is a suspicion that the fire risk assessment is no longer valid; and to provide additional guidance and advice on the risks of electrical overloading including the need to contact a competent electrician if there are concerns. The revised Fire Diary is enclosed for your information. The Fire Non-Commissioned Officer (NCO) course content has also been amended and now allocates more time and emphasis on the fire risks associated with electrical overloading. A copy of the PowerPoint presentation delivered on this course is also enclosed for your information.” Source location 2014-0556-Response
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 Amend Fire Non-Commissioned Officer course content to increase time and emphasis on electrical-overloading fire risks.
Verbatim wording from the response “In response to your first two concerns, the Defence Fire Risk Management Organisation (DFRMO) Fire Diary has been amended to make it clear that the advice of a competent fire risk assessor must be sought before any changes take place within a premise or if there is a suspicion that the fire risk assessment is no longer valid; and to provide additional guidance and advice on the risks of electrical overloading including the need to contact a competent electrician if there are concerns. The revised Fire Diary is enclosed for your information. The Fire Non-Commissioned Officer (NCO) course content has also been amended and now allocates more time and emphasis on the fire risks associated with electrical overloading. A copy of the PowerPoint presentation delivered on this course is also enclosed for your information.” Source location 2014-0556-Response
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 Continue reviewing the DFRMO Fire Risk Assessment template to emphasise recording sleeping on premises regardless of primary purpose.
Verbatim wording from the response “Your third concern has been addressed as part of the ongoing review of the DFRMO Fire Risk Assessment template. The template has been updated to further emphasise the need to record if any sleeping is taking place on the premises regardless of its primary purpose. The review is not yet complete but I have attached the latest draft with the changes highlighted for your information. The revised version is planned to be implemented by the end of October 2014.” Source location 2014-0556-Response
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 Amend CLM training documentation to use this incident as an example of incorrect sub-unit duty NCO duties, for delivery from 30 September 2014.
Verbatim wording from the response “In response to your fourth concern, the Army plans to use this incident as an example of what happens when ‘duties’ are not conducted in the correct way. This will include, as part of the biannual command, leadership and management (CLM) training update, an amendment to the training documentation related to the duties of a sub-unit duty NCO to incorporate this incident as an example. The revised documentation will be used by training deliverers from 30 September 2014 onwards.” Source location 2014-0556-Response
Open published response
Concerns raised 2 Insufficient training and follow-up training for staff implementing Suicide Vulnerability Risk Assessment measures View source Lack of specific victim-support provisions for alleged rape by one soldier against another 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
Anne-Marie Katherine Element · 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
Anne-Marie Katherine Element, a corporal, died by suicide outside her accommodation at Kiwi Barracks in Wiltshire on or around 9 October 2011. The inquest identified contributing matters including the lingering mental effects of an alleged rape, workplace bullying, work-related despair, and the effects of a relationship break-up. Concerns included inadequate guidance for responding to an alleged rape by one soldier against another and insufficient training and follow-up training for implementing Suicide Vulnerability Risk Assessments.
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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 Insufficient training and follow-up training for staff implementing Suicide Vulnerability Risk Assessment measures
Wider context from the report “2. The evidence at the Inquest suggested that those responsible for the implementation of measures to be put in place following a Suicide Vulnerability Risk Assessment had insufficient training in the system with no evidence of regular follow-up training . This is in marked contrast with the prison system where those responsible for managing at risk prisoners have specific targeted training with regular updates. The evidence at the Inquest suggested that instruction on the subject of suicide and vulnerability risk assessment formed little more than a lecture .
” 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 specific victim-support provisions for alleged rape by one soldier against another
Wider context from the report “1. There is an existing code of practice entitled “Services to be provided by the Armed Forces to cover the victims of Crime”. It was released in September 2008. The code of practice covers victims of crime generally and although it also makes provision for vulnerable victims it does not specifically deal with the likely repercussions on the victim of an alleged rape by one soldier on another . It is suggested that the code of practice be reviewed either with a view to possible revision or with a view to establishing a separate code of practice to deal specifically with a victim of a serious sexual assault alleged to have been committed by another soldier.
” Open source report
Concerns raised 1 Insufficient time for the Range Conducting Officer’s final assurance check 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
Dean Griffiths · 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
Dean Griffiths died during a live-firing exercise at Lydd Ranges in September 2011 after a shot passed through a target and perimeter wall and struck him. The principal concern was time pressure to complete exercises, with a need for sufficient time for the Range Conducting Officer to complete a final assurance check.
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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 Insufficient time for the Range Conducting Officer’s final assurance check
Wider context from the report “There were time pressures of completing the exercises within the allocated time available to the Range Conducting Officer. I believe that the Exercise Director must ensure that the Planning Officer allows sufficient time for the RCO to complete his final assurance check .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations