20 May 2025 Mr Brown · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 3 Failure to investigate deaths and learn from work-related events and welfare support View source Lack of a formal mechanism for recording welfare concerns during investigations View source Lack of policy provision for supporting senior staff facing significant stress or potential disciplinary investigations View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Participate in and help fund national work establishing emotional and wellbeing support provision for senior officers.
View source
Action
Review crisis management and death-in-service protocols for employment-linked workplace deaths, including support for affected staff, and implement linked policy changes.
View source
Action
Share learning from the case to improve support for senior officers nationally.
View source
Action
Review and enhance support for senior officers undergoing disciplinary processes, including welfare recording, external support options, and strengthened processes and risk assessments.
View source See 1 more action
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AI-generated summary
Mr Brown · 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
Mr Brown was found hanging at his home on 24 January 2024 and was confirmed deceased by police. The report identified concerns about the lack of post-death investigation and the absence of adequate welfare support and welfare-recording mechanisms for senior staff experiencing significant stress or disciplinary investigations.
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 West Midlands Fire Service; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate deaths and learn from work-related events and welfare support
Wider context from the report “1. WMFS did not undertake any investigation after Mr Brown’s death and have no policy requiring them to do so . Any opportunity to learn from a death such as a suicide related to work events including what welfare support was provided has not been addressed . This creates a risk of future deaths and action should be taken.
” 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 West Midlands Fire Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal mechanism for recording welfare concerns during investigations
Wider context from the report “2. Neither WMFS health and wellbeing policy nor the mental health policy make any provision for supporting senior staff members who are facing significant stress and/or potential disciplinary investigations beyond the person approaching Occupational health themselves. The policy offers further support to lower ranks. In addition, there was no formal mechanism for recording concerns about welfare that arise during either an informal or a fact finding investigation . This creates a risk of future deaths and action should be taken.
” 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 West Midlands Fire Service; that does not assign responsibility.
PFD Monitor interpretation Lack of policy provision for supporting senior staff facing significant stress or potential disciplinary investigations
Wider context from the report “2. Neither WMFS health and wellbeing policy nor the mental health policy make any provision for supporting senior staff members who are facing significant stress and/or potential disciplinary investigations beyond the person approaching Occupational health themselves . The policy offers further support to lower ranks . In addition, there was no formal mechanism for recording concerns about welfare that arise during either an informal or a fact finding investigation. This creates a risk of future deaths and action should be taken.
” 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 Participate in and help fund national work establishing emotional and wellbeing support provision for senior officers.
Verbatim wording from the response “Therefore, alongside our own internal review, we have also agreed to be part of, and help fund, the national work that is being undertaken by the National Fire Chiefs’ Council (NFCC), alongside the Fire Fighters’ Charity (FFC), to establish a new emotional and wellbeing support provision specifically designed for senior officers.” Source location Response from West Midlands Fire Service
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 Review crisis management and death-in-service protocols for employment-linked workplace deaths, including support for affected staff, and implement linked policy changes.
Verbatim wording from the response “However, we acknowledge that the terms of reference of a review of this nature could be enhanced to ensure that learning is maximised and built into our policies and the outcomes from it better analysed to ensure that appropriate actions are built into our structures.” Source location Response from West Midlands Fire Service
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 Share learning from the case to improve support for senior officers nationally.
Verbatim wording from the response “We are committed to sharing the learning from this case to help improve support nationally.” Source location Response from West Midlands Fire Service
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 Review and enhance support for senior officers undergoing disciplinary processes, including welfare recording, external support options, and strengthened processes and risk assessments.
Verbatim wording from the response “Notwithstanding the above, the Service is committed to enhancing available support. Therefore, we will carry out a review of the level and nature of support provided to senior officers undergoing a disciplinary process, including before and after any suspension, and make any enhancements identified in that process. The review will include:” Source location Response from West Midlands Fire Service
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 health, wellbeing, employee assistance and disciplinary support arrangements already apply to staff and officers at all levels.
Verbatim wording from the response “WMFS’s Health and Wellbeing policies apply to all members of staff and officers at all levels who may experience significant stressors within their roles. The Employee Assistance Programme (EAP) provides internal support to anyone within the organisation, and signposts external assistance such as The Samaritans and GP assistance where appropriate.” Source location Response from West Midlands Fire Service
Open published response
22 Feb 2017 Mr Christopher Brookes · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 Risk of falling to the road below at the location View source Failure of security guards to attend alarms indicating unauthorised use of the fire exit View source
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
Mr Christopher Brookes · 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
Mr Christopher Brookes, aged 22, fell around 40 feet from a gate at Wolverhampton bus station after leaving through a fire exit and died from his injuries on 29 October 2017. The inquest heard that there had been a similar previous incident at the same location and that security guards failed to attend when an alarm indicated unauthorised use of the fire exit.
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 West Midlands Fire Service; that does not assign responsibility.
PFD Monitor interpretation Risk of falling to the road below at the location
Wider context from the report “1. Evidence emerged during the inquest that there was a previous incident at the same location involving a member of public who narrowly escaped falling to the road below in April 2017 in similar circumstances .
” 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 West Midlands Fire Service; that does not assign responsibility.
PFD Monitor interpretation Failure of security guards to attend alarms indicating unauthorised use of the fire exit
Wider context from the report “2. Evidence also emerged during the inquest that an alarm would be activated if the fire exit was used . It appears that security guards employed to deal with unauthorised use of the fire exit failed to attend .
” 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