Lee Richard Gaunt · Prevention of Future Deaths report

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Issued 4 Mar 2016•Manchester South

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Delays in access to Occupational Health medical assessment
    Part of recurring concern: Unreliable Occupational Health support before and during assessment
  2. Failure to provide support staff in stressful situations
  3. Failure to adjust strenuous First-Responder duties for staff experiencing bereavement-related distress

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Greater Manchester Fire and Rescue Service

    Amend procedures to allow employees to self-refer for counselling through the occupational health provider.

  2. Greater Manchester Fire and Rescue Service

    Feed back the inquest outcome and coroner’s concerns to occupational health providers.

  3. Greater Manchester Fire and Rescue Service

    Retender and operate occupational health provision with triage, escalation and automatic doctor follow-up where required.

  4. Greater Manchester Fire and Rescue Service

    Continue the trade-union working group examining support facilities for stressful situations and informing organisational strategy and structure.

  5. Greater Manchester Fire and Rescue Service

    Pilot and evaluate Trauma Risk Management as a proactive, peer-led support system following traumatic events.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Greater Manchester Fire and Rescue Service

    The organisation was unaware that ill health had recurred when additional duties and cardiac-arrest responsibilities were undertaken.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in access to Occupational Health medical assessment

Wider context from the report

“1. There appeared to be rather less than effective support from Occupational Health and it took a long time for the deceased to be able to see the doctor. ”

Is this part of a recurring concern?

Yes — Unreliable Occupational Health support before and during 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide support staff in stressful situations

Wider context from the report

“4. It became apparent in the course of the evidence, that the deceased and his wife felt there was a general failure by the GMFRS to provide support staff in stressful situations. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to adjust strenuous First-Responder duties for staff experiencing bereavement-related distress

Wider context from the report

“3. In the aftermath of the death of his colleague, and whilst being forced to take on the extra Watch Manager job, he was also having to cope with the extra (and as he regarded it, strenuous) task of leading the fire-fighters as First-Responders to assist North West Ambulance Service in attending cardiac arrest calls. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Ineffective Occupational Health support

Wider context from the report

“1. There appeared to be rather less than effective support from Occupational Health and it took a long time for the deceased to be able to see the doctor. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to adjust additional managerial duties for staff known to be suffering bereavement-related distress

Wider context from the report

“2. Whilst it was known by the Fire and Rescue Service that he was suffering as a result of the death of his colleague, nonetheless he was required to take on the extra duties of Crew manager and Watch Manager. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Amend procedures to allow employees to self-refer for counselling through the occupational health provider.

Verbatim wording from the response

“3. GMFRS has amended its procedures to allow employees to self-refer for counselling via its occupational health provider.”

Source location

Lee-Gaunt-Response
Page 2 · response
Published 4 March 2016

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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

Feed back the inquest outcome and coroner’s concerns to occupational health providers.

Verbatim wording from the response

“We have for completeness fed back the outcome of the inquest and your concerns to them.”

Source location

Lee-Gaunt-Response
Page 1 · response
Published 4 March 2016

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Retender and operate occupational health provision with triage, escalation and automatic doctor follow-up where required.

Verbatim wording from the response

“1. GMFRS’s occupational health providers in 2013 were different to the current providers. GMFRS retendered its occupational health service provision on the expiry of the previous contract on 31 January 2015. The current providers are Healthwork and you heard from one of their directors, ████████ at the inquest.”

Source location

Lee-Gaunt-Response
Page 1 · response
Published 4 March 2016

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Continue the trade-union working group examining support facilities for stressful situations and informing organisational strategy and structure.

Verbatim wording from the response

“In addition to the matters referred to under Concerns 2 & 3, GMFRS established a working group with trade union participation examining the facilities available for addressing the effects of dealing with stressful situations. This working group will continue and seek on-going involvement and contribution from all relevant trade unions and will inform GMFRS’s strategy and new organisational structure in this regard, which is currently under review.”

Source location

Lee-Gaunt-Response
Page 2 · response
Published 4 March 2016

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Pilot and evaluate Trauma Risk Management as a proactive, peer-led support system following traumatic events.

Verbatim wording from the response

“GMFRS operates a mandatory system of critical incident debriefing following attendance at traumatic incidents. Since November 2015 GMFRS has been piloting a system known as Trauma Risk Management (TRiM) which is a proactive, peer led initiative for supporting individuals following exposure to traumatic events. The TRiM protocol is widely used in the Armed Forces and Police services and is fully compliant with the National Institute of Health & Clinical Excellence (NICE) guidelines for the delivery of post trauma support.”

Source location

Lee-Gaunt-Response
Page 2 · response
Published 4 March 2016

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 organisation was unaware that ill health had recurred when additional duties and cardiac-arrest responsibilities were undertaken.

Verbatim wording from the response

“Crew Manager. GMFRS was not aware that the deceased had begun to suffer ill health again when he took on additional duties on the retirement of his Watch Manager on 30 August 2015 and the implementation of the collective agreement to respond to cardiac arrests on 15 September 2015.”

Source location

Lee-Gaunt-Response
Page 2 · response
Published 4 March 2016

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026