Report evidence summary
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 22
Action
Develop advice for serving soldiers on sickle-cell-trait and exertional-collapse risk, including bespoke advice for identified sickle-cell-trait-positive personnel.
Stated by Capita PLC and Ministry of Defence Stated in progressThe respondent said that this action was in progress when they made their response on 30 December 2019. View source
Action
Use the Family Origins Questionnaire to screen all Army assessment-centre candidates for sickle cell trait risk before the 2000-metre run.
Stated by Capita PLC and Ministry of Defence Stated completedThe respondent said that this action was complete when they made their response on 30 December 2019. View source
Action
Assess and assure the pre-conditioning course, incorporating lessons learned and improvements into subsequent courses.
Stated by Capita PLC and Ministry of Defence Stated in progressThe respondent said that this action was in progress when they made their response on 30 December 2019. View source
Action
Revise and circulate Army-wide policy on preventing, recognising and managing exertional collapse, including sickle-cell-trait risks and treatment.
Stated by Capita PLC and Ministry of Defence Stated completedThe respondent said that this action was complete when they made their response on 30 December 2019. View source
Action
Suspend the 2000-metre best-effort run for Commonwealth candidates pending revised safety arrangements.
Stated by Capita PLC and Ministry of Defence Stated completedThe respondent said that this action was complete when they made their response on 30 December 2019. View source
Action
Issue interim sickle-cell-trait training guidance and awareness information across all initial training establishments, including prevention, recognition and treatment measures.
Stated by Capita PLC and Ministry of Defence Stated completedThe respondent said that this action was complete when they made their response on 30 December 2019. View source
Action
Deliver a bespoke four-week pre-conditioning course for sickle-cell-trait-positive candidates, using progressive training and individual heart-rate monitoring before the 2000-metre run.
Stated by Capita PLC and Ministry of Defence Stated in progressThe respondent said that this action was in progress when they made their response on 30 December 2019. View source
Action
Blood-test candidates identified by the questionnaire as being at high risk of sickle cell trait before they undertake the 2000-metre run.
Stated by Capita PLC and Ministry of Defence Stated in progressThe respondent said that this action was in progress when they made their response on 30 December 2019. View source
Action
Provide enhanced Sickle Cell Trait and exertional-collapse training, candidate-identification procedures, quarterly simulations and induction education for assessment staff.
Stated by Capita PLC and Ministry of Defence Stated completedThe respondent said that this action was complete when they made their response on 30 December 2019. View source
Action
Maintain integrated oversight of parallel accident-reporting systems through shared access, a reporting register, common reporting ownership and monthly tracking.
Stated by Capita PLC and Ministry of Defence Stated completedThe respondent said that this action was complete when they made their response on 30 December 2019. View source
Action
Incorporate exertional-collapse scenarios into Defence Medic training to support early differential diagnosis and appropriate intervention.
Stated by Capita PLC and Ministry of Defence Stated in progressThe respondent said that this action was in progress when they made their response on 30 December 2019. View source
Action
Standardize Sickle Cell Trait wristband design across the Army, Royal Navy and Royal Air Force.
Stated by Capita PLC and Ministry of Defence Stated completedThe respondent said that this action was complete when they made their response on 30 December 2019. View source
Action
Direct incident reports to medical and health-and-safety leaders and provide them with joint investigation accountability.
Stated by Capita PLC and Ministry of Defence Stated completedThe respondent said that this action was complete when they made their response on 30 December 2019. View source
Action
Prevent unscreened or high-risk candidates from attending assessment centres or undertaking the Role Fitness Test.
Stated by Capita PLC and Ministry of Defence Stated completedThe respondent said that this action was complete when they made their response on 30 December 2019. View source
Action
Review Joint Service Publication 950 wording and rationale concerning cola-coloured urine questions.
Stated by Capita PLC and Ministry of Defence Stated plannedThe respondent said that this action was planned when they made their response on 30 December 2019. View source
Action
Audit incident processing through Clinical Oversight Board, joint assurance forums, Defence oversight and a commissioned external review of Sickle Cell Trait risk management.
Stated by Capita PLC and Ministry of Defence Stated plannedThe respondent said that this action was planned when they made their response on 30 December 2019. View source
Action
Maintain generic exertional-collapse clinical policy and review it annually for coherence with Sickle Cell Trait guidance.
Stated by Capita PLC and Ministry of Defence Stated completedThe respondent said that this action was complete when they made their response on 30 December 2019. View source
Action
Operate joint Army–Capita health-and-safety governance forums and shared risk-management processes.
Stated by Capita PLC and Ministry of Defence Stated completedThe respondent said that this action was complete when they made their response on 30 December 2019. View source
Action
Operate the Joint Lessons Learnt Panel and Learning Account process to investigate incidents, assign recommendations, disseminate learning and monitor completion.
Stated by Capita PLC and Ministry of Defence Stated completedThe respondent said that this action was complete when they made their response on 30 December 2019. View source
Action
Mandate and operate two-stage Sickle Cell Trait screening for all Army, Royal Navy and Royal Air Force recruits and potential recruits.
Stated by Capita PLC and Ministry of Defence Stated completedThe respondent said that this action was complete when they made their response on 30 December 2019. View source
Action
Continue reviewing and refining Sickle Cell Trait screening and risk-management processes, with twice-yearly assurance scrutiny.
Stated by Capita PLC and Ministry of Defence Stated in progressThe respondent said that this action was in progress when they made their response on 30 December 2019. View source
Action
Issue revised Standing Operating Instruction 20 governing responses when candidates become unwell during assessment-centre events.
Stated by Capita PLC and Ministry of Defence Stated completedThe respondent said that this action was complete when they made their response on 30 December 2019. View source See 19 more actions
× 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 Lack of a mechanism to broadcast a medical emergency by tannoy at the base
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of a standardised method for identifying SCT candidates during selection
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of understanding of the significance of cola-coloured urine as an indicator
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” 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 of the clinical oversight board to review or audit near misses
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of Army representation on the clinical oversight board
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” 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 Lack of staff awareness of SCT-associated risks during selection and RFT assessments
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of a system for obtaining urgent medical attention at the Lichfield base
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Increased risk of death or collapse during military exercise for people with sickle cell trait
Wider context from the report “2. Consideration should be given to all non UK selection candidates who have been through the process already having an urgent blood test to check whether they have sickle cell trait. If a person has sickle cell trait they are a significant increased risk of death/collapse during military exercise.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to follow the SCT screening process before high-risk candidates undertake the 2km run
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of a clearly identifiable person responsible for reviewing and investigating health and safety incidents
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of understanding of the unpredictable risks associated with SCT
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” 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 Lack of pre-selection sickle cell trait screening for non-UK selection candidates
Wider context from the report “1. Consideration should be given to all non UK selection candidates being screened for sickle cell trait before embarking on any selection process . A blood test can be undertaken to assess whether candidates have sickle cell trait.
” 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 investigate near misses when they occur
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” Is this part of a recurring concern? Yes — Inadequate safety incident investigations .
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 Use of parallel incident reporting forms on separate IT systems
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of urgent sickle cell trait testing for previously processed non-UK selection candidates
Wider context from the report “2. Consideration should be given to all non UK selection candidates who have been through the process already having an urgent blood test to check whether they have sickle cell trait . If a person has sickle cell trait they are a significant increased risk of death/collapse during military exercise.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of SCT screening for Air Force and Navy candidates
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of a system to audit incident processing and investigation
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Lack of clear lines of responsibility for organisation-wide health and safety risk assessment and incident information gathering
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Unresolved or unclear functionality problems in the Casper incident reporting system
Wider context from the report “Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective.
Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate.
Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses.
Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop advice for serving soldiers on sickle-cell-trait and exertional-collapse risk, including bespoke advice for identified sickle-cell-trait-positive personnel.
Verbatim wording from the response “e. Work is also underway to develop the advice that will be given to all serving soldiers. In addition, those who have been identified as SCT positive will be given bespoke advice.” Source location 2019-0416-Response-by-MOD
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the Family Origins Questionnaire to screen all Army assessment-centre candidates for sickle cell trait risk before the 2000-metre run.
Verbatim wording from the response “b. Action taken since the issue of HM Senior Coroner's PFDR. The PFDR was issued on 6 Dec 19; earlier that day the Deputy Chief of the General Staff (DCGS) – the Army's Principal Personnel Officer – directed that the Army (on medical advice) implement a screening process to identify those candidates who are SCT positive prior to participating in the 2000m best effort run. This is being conducted in two phases:” Source location 2019-0416-Response-by-MOD
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess and assure the pre-conditioning course, incorporating lessons learned and improvements into subsequent courses.
Verbatim wording from the response “How these individuals perform and the effectiveness of the course in supporting them to meet the Army entry standards will be the subject of ongoing assessment and assurance. Lessons learned and improvements will be incorporated into the next course due to start in Feb 20.” Source location 2019-0416-Response-by-MOD
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and circulate Army-wide policy on preventing, recognising and managing exertional collapse, including sickle-cell-trait risks and treatment.
Verbatim wording from the response “c. The Army’s Personnel Directorate has revised and circulated Army-wide the relevant policy to ensure that the prevention, recognition and effective handling of anybody suffering from Exertional Collapse, from any cause, is fit for purpose. AGAI Vol 1 Ch 7 (Annex F) has been updated with a new paragraph called Risk of Exertional Collapse. The revised document includes information on SCT positive personnel, including risk factors, recognition and treatment. The policy changes have been directed to the Army’s Chain of command through an Army Briefing Note, at Annex G.” Source location 2019-0416-Response-by-MOD
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Suspend the 2000-metre best-effort run for Commonwealth candidates pending revised safety arrangements.
Verbatim wording from the response “(2) The 2000m RFT(E) best effort run was suspended on 28 Nov 19 for all CW candidates. CW candidates completed the rest of the selection activities as normal. As a result, approx. 150 candidates were placed ‘on hold’ pending a way forward.⁵” Source location 2019-0416-Response-by-MOD
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue interim sickle-cell-trait training guidance and awareness information across all initial training establishments, including prevention, recognition and treatment measures.
Verbatim wording from the response “a. Action taken since the issue of HM Senior Coroner's PFDR. The Interim Training Direction (Annex E) was issued to the Army Recruiting and Initial Training Command (ARITC) training establishments¹² by Director Operations on 13 Dec 19, with specific direction for the information to be briefed to or seen by all training staff, including Physical Training Instructors and medical staff. The SCT” Source location 2019-0416-Response-by-MOD
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a bespoke four-week pre-conditioning course for sickle-cell-trait-positive candidates, using progressive training and individual heart-rate monitoring before the 2000-metre run.
Verbatim wording from the response “The Senior Health Advisor (Army) was also able to draw on contemporary US Armed Forces experience of managing SCT risk, provided through the British Medical Liaison Officer in Washington, to advise that a progressive 4-week pre-conditioning course for SCT positive candidates will reduce the risk to ALARP.” Source location 2019-0416-Response-by-MOD
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Blood-test candidates identified by the questionnaire as being at high risk of sickle cell trait before they undertake the 2000-metre run.
Verbatim wording from the response “(2) Stage 2 – Blood Test. The FOQ will identify those candidates who will need to undergo a blood test to determine if they are SCT positive or negative.⁷” Source location 2019-0416-Response-by-MOD
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide enhanced Sickle Cell Trait and exertional-collapse training, candidate-identification procedures, quarterly simulations and induction education for assessment staff.
Verbatim wording from the response “In three cases, other measures failed, these are therefore classified as ‘near miss’ incidents. Two of these took place at a facility administered by the Army, and additional controls have now been introduced, including enhanced staff training and awareness of Sickle Cell Trait and exertional collapse, and procedural changes that ensure that Sickle Cell Trait candidates are clearly identifiable. One case took place at a Recruiting Group Assessment Centre (Pirbright), and specific enhancements have been introduced at this site, including an amendment to the Assessment Centre loading process that prevents high-risk Family Origin Questionnaire candidates from attending an Assessment Centre until blood test results are known, therefore removing the potential for at-risk candidates to undertake the run.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain integrated oversight of parallel accident-reporting systems through shared access, a reporting register, common reporting ownership and monthly tracking.
Verbatim wording from the response “Both partners within Recruiting Group (Army and Capita) have organisational obligations that necessitate the ongoing use of two accident reporting systems. Recognising the risk of a lack of coherence between these two systems, Recruiting Group, in consultation with Army Recruiting and Initial Training Command, has implemented a number of changes to maintain consistency. The Capita Health and Safety Executive Manager now has access to the Defence Unified Reporting and Lessons System so he can ensure consistency between this system and Capita Accident, Safety, Property and Environmental Reports. He also maintains an accident reporting register (a new post-inquest measure) that details all reports received – this is presented to the Corporate Governance Board each month.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate exertional-collapse scenarios into Defence Medic training to support early differential diagnosis and appropriate intervention.
Verbatim wording from the response “Work is under way with the Defence Medical Academy to ensure Defence Medic training (our most likely first responders) incorporates exertional collapse scenarios to ensure early differential diagnosis, particularly where this requires any specific interventions (for example, cooling with heat illness).” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Standardize Sickle Cell Trait wristband design across the Army, Royal Navy and Royal Air Force.
Verbatim wording from the response “The Army have shared their wristband design with the Royal Air Force and the Royal Navy. The Royal Air Force and the Royal Navy have decided to adopt the Army’s approach to and design of wristbands in their entirety. This is covered under Matters of Concern 1b.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
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 Direct incident reports to medical and health-and-safety leaders and provide them with joint investigation accountability.
Verbatim wording from the response “The Recruiting Group Clinical Oversight Board was established on 19 May 2022. Nine of the twelve identified Sickle Cell Trait related near misses occurred before this date. The Clinical Oversight Board did not examine three incidents following its establishment because, while Incident Reports were filed in all cases, they were not disseminated to key stakeholders at the time due to Incident Reports not going to functional leads such as the Chief Medical Officer and Health and Safety Manager. That has changed – the Chief Medical Officer, Deputy Chief Medical Officer and Health and Safety Executive Manager now directly receive all Incident Reports and initiate the Joint Lessons Learnt Panel process and subsequent review by the Clinical Oversight Board.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prevent unscreened or high-risk candidates from attending assessment centres or undertaking the Role Fitness Test.
Verbatim wording from the response “Following a post-inquest review of Sickle Cell Trait risk management by six sigma qualified professionals, additional process control measures have been established to prevent high risk or unknown Family Origin Questionnaire candidates from attending an Assessment Centre. Individuals will not be loaded onto the course prior to being screened through the Family Origin Questionnaire or receiving their Sickle Cell Trait blood test results. This measure has been put into place to ensure that there is no prospect of such a candidate attempting the Role Fitness Test (Entry). If the candidate’s Sickle Cell Trait status is positive or is not known prior to the Role Fitness Test (Entry), they will not participate in the Role Fitness Test (Entry) Multi-Stage Fitness Test.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
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 Joint Service Publication 950 wording and rationale concerning cola-coloured urine questions.
Verbatim wording from the response “The Joint Service Publication 950 which includes this wording will be reviewed through the Medical Employment Standards Military Judgement Panel in early 2023.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
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 Audit incident processing through Clinical Oversight Board, joint assurance forums, Defence oversight and a commissioned external review of Sickle Cell Trait risk management.
Verbatim wording from the response “As detailed in the response to Matter of Concern 3a above, all actual and ‘near miss’ incidents are reviewed at the monthly Clinical Oversight Board. Audit takes place at the quarterly Joint Health and Safety Executive Manager’s Conference, the quarterly Joint” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain generic exertional-collapse clinical policy and review it annually for coherence with Sickle Cell Trait guidance.
Verbatim wording from the response “There is joint clinical policy in place for exertional collapse including Joint Service Publication 950 Leaflet 2-4-4: Exertional Heat Illness: Acute Treatment (v1.3 February 2022).” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate joint Army–Capita health-and-safety governance forums and shared risk-management processes.
Verbatim wording from the response “Recruiting Group acts as one entity for health and safety issues through joint (Army and Capita) forums including a Joint Risk Management Board, the Joint Lessons Learned Panel, Clinical Oversight Board, quarterly Joint Health, Safety and Environment reviews and the quarterly Joint Assurance Group. Policies and procedures are reviewed and approved by both partners to ensure clarity and coherence. This joint governance framework supports a proactive and coherent approach to risk management and a more robust, timely and effective response to reported incidents and organisational learning.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Joint Lessons Learnt Panel and Learning Account process to investigate incidents, assign recommendations, disseminate learning and monitor completion.
Verbatim wording from the response “Reporting processes have also been enhanced; any similar future incident will be investigated promptly and jointly by the medical and health and safety teams. These include automated notification of Recruiting Group’s Chief Medical Officer and Head of Health and Safety, to enable them to trigger an investigation by a newly established Joint Lessons Learnt Panel. This panel includes senior Recruiting Group and Army colleagues in operational, clinical, and health and safety leadership roles. The Panel has an enduring remit to review all reported accidents and near misses within 96 hours and make appropriate recommendations, although in practice incidents are reviewed within 48 hours. The panel also directs a suitably qualified individual or body (such as Recruiting Group’s Clinical Oversight Board) to conduct a more detailed Learning Account investigation.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandate and operate two-stage Sickle Cell Trait screening for all Army, Royal Navy and Royal Air Force recruits and potential recruits.
Verbatim wording from the response “Updated policy (Defence Instructions and Notice (DIN 2022DIN06-021) was issued on 04 November 2022, that mandates that all military recruits or potential military recruits, across the Army, Royal Navy and Royal Air Force, be screened for Sickle Cell Trait. The screening process for identifying Sickle Cell Trait is split into two stages:” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing and refining Sickle Cell Trait screening and risk-management processes, with twice-yearly assurance scrutiny.
Verbatim wording from the response “From an Army perspective, the Sickle Cell Trait screening process for all streams of candidates continues to be reviewed and refined on a regular basis (and informed where necessary, by the outcomes of any Joint Lessons Learnt Panel, Clinical Oversight Board or Learning Account recommendations) within the four Soldier Assessment Centres and the Army Officer Selection Board. Similarly, Recruiting Group and Army Recruiting and Initial Training Command have reviewed the Sickle Cell Trait risk-management process and associated Risk Assessments for moving a candidate from the initial stages of recruiting activity through to the Pre-Service Medical Assessment and Role Fitness Test (Entry).” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue revised Standing Operating Instruction 20 governing responses when candidates become unwell during assessment-centre events.
Verbatim wording from the response “Following the request, Recruiting Group has issued revised guidance (Standing Operating Instructions 20), which details how to respond if a candidate becomes unwell during an Assessment Centre event. The document details that Recruiting Group Doctors (Capita staff) should assist in an emergency as a ‘Good Samaritan’ drawing upon paragraph 26 of the General Medical Council’s ‘Good Medical Practice’ guidance which states that ‘You must offer help if emergencies arise in clinical settings or in the community, taking account of your own safety, your competence and the availability of other options for care’.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Sickle Cell Trait screening process is considered as safe and effective as practicable, subject to twice-yearly scrutiny.
Verbatim wording from the response “Accordingly, the Sickle Cell Trait screening process is now deemed to be as safe and as effective as it can practicably be and will be subject to twice-yearly scrutiny by both the Recruiting Group assurance team, and Army-directed assurers.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Nine reported incidents involved no risk of harm because manual checks of candidates’ Sickle Cell Trait status worked as intended.
Verbatim wording from the response “In addition, a thorough review has now been completed of each of the twelve incidents identified following Recruiting Group’s Business Assurance Review. In all cases, the medical screening component worked as intended. However, in nine instances, a post-screening control measure failed due to an administrative error; Defence Recruitment System record was not updated, or an error was made in completing/recording pre-service screening medical outcomes. However, other measures such as manual checks of an individual’s Sickle Cell Trait status worked as intended, so there was no risk of harm to the candidates involved.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
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 Two separate accident-reporting systems must continue because Army and Capita have distinct organisational reporting obligations.
Verbatim wording from the response “Both partners within Recruiting Group (Army and Capita) have organisational obligations that necessitate the ongoing use of two accident reporting systems. Recognising the risk of a lack of coherence between these two systems, Recruiting Group, in consultation with Army Recruiting and Initial Training Command, has implemented a number of changes to maintain consistency. The Capita Health and Safety Executive Manager now has access to the Defence Unified Reporting and Lessons System so he can ensure consistency between this system and Capita Accident, Safety, Property and Environmental Reports. He also maintains an accident reporting register (a new post-inquest measure) that details all reports received – this is presented to the Corporate Governance Board each month.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
Open published response
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 8 1 Establish an enduring, UKAS-accredited contracted arrangement for blood-testing every candidate identified as high risk.
Stated by Capita PLC and Ministry of Defence Stated plannedThe respondent said that this action was planned when they made their response on 30 December 2019. View source 2 Require full echocardiography for candidates with abnormal ECG findings under Army cardiology protocol.
Stated by Capita PLC and Ministry of Defence Stated completedThe respondent said that this action was complete when they made their response on 30 December 2019. View source 3 Maintain the Sickle Cell Trait Steering Group to review and revise Army recruiting and in-service policies and procedures.
Stated by Capita PLC and Ministry of Defence Stated in progressThe respondent said that this action was in progress when they made their response on 30 December 2019. View source 4 Formally review whether asymptomatic sickle cell trait should remain compatible with the Army entry medical standard.
Stated by Capita PLC and Ministry of Defence Stated plannedThe respondent said that this action was planned when they made their response on 30 December 2019. View source 5 Screen personnel not identified during recruitment for sickle cell trait by the end of their first week of Basic Training, before maximal exercise.
Stated by Capita PLC and Ministry of Defence Stated plannedThe respondent said that this action was planned when they made their response on 30 December 2019. View source 6 Introduce coloured bibs to supplement wristbands and identify high-risk candidates during assessment-centre activities.
Stated by Capita PLC and Ministry of Defence Stated plannedThe respondent said that this action was planned when they made their response on 30 December 2019. View source 7 Replicate immediate reporting requirements in Recruiting Group policy and mandatory e-learning, including prompt reporting of serious incidents and exertional collapse.
Stated by Capita PLC and Ministry of Defence Stated in progressThe respondent said that this action was in progress when they made their response on 30 December 2019. View source 8 Expand external tannoy coverage at Defence Medical Services Whittington to improve audibility of emergency announcements.
Stated by Capita PLC and Ministry of Defence Stated in progressThe respondent said that this action was in progress when they made their response on 30 December 2019. View source Recipient positions A position is what a recipient says about a concern when they do not describe a specific action. 2 1 The Defence clinical policy cannot direct civilian healthcare providers or replace their established emergency-response procedures.
Stated by Capita PLC and Ministry of Defence Outside remitThe respondent said that this matter was outside its role or authority. View source 2 A joint clinical policy already covers exertional collapse, applies generically to other causes, and is reviewed annually.
Stated by Capita PLC and Ministry of Defence Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
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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 Establish an enduring, UKAS-accredited contracted arrangement for blood-testing every candidate identified as high risk.
Verbatim wording from the response “f. Further action that will be taken. Following the decision to screen all candidates for SCT when applying to join the Army, the Army in partnership with Capita are working to put in place an enduring solution to test the blood of every candidate whom the FOQ identifies as high risk of being SCT positive. This” Source location 2019-0416-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 Require full echocardiography for candidates with abnormal ECG findings under Army cardiology protocol.
Verbatim wording from the response “(1) As the first death was believed to be cardiac related, it was decided that any candidate, regardless of origin who presents with an abnormal Electrocardiogram (ECG) (as directed within current Army Cardiology protocol) would undergo a full Echocardiogram (ECHO).” Source location 2019-0416-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 Maintain the Sickle Cell Trait Steering Group to review and revise Army recruiting and in-service policies and procedures.
Verbatim wording from the response “3. An Army SME group⁴ has been formally established as the Sickle Cell Trait Steering Group which reports to Director Personnel and the Army Health Committee. This Group will continue to review and revise current Army recruiting and in-service policies and procedures to mitigate the risk of further Sickle Cell Trait (SCT) related incidents to As Low as Reasonably Practicable (ALARP). It has been agreed for now that those with SCT still meet the entry medical standard for the Army, but this will be formally reviewed by the Army Health Committee.” Source location 2019-0416-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 Formally review whether asymptomatic sickle cell trait should remain compatible with the Army entry medical standard.
Verbatim wording from the response “3. An Army SME group⁴ has been formally established as the Sickle Cell Trait Steering Group which reports to Director Personnel and the Army Health Committee. This Group will continue to review and revise current Army recruiting and in-service policies and procedures to mitigate the risk of further Sickle Cell Trait (SCT) related incidents to As Low as Reasonably Practicable (ALARP). It has been agreed for now that those with SCT still meet the entry medical standard for the Army, but this will be formally reviewed by the Army Health Committee.” Source location 2019-0416-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 Screen personnel not identified during recruitment for sickle cell trait by the end of their first week of Basic Training, before maximal exercise.
Verbatim wording from the response “b. Further actions that will be taken. In order to ensure that the Army has identified all SCT positive individuals, all personnel not captured during the application process will be screened on entry, by the end of the first week of Basic Training (BT).¹⁴ It is intended to have this process, which will be developed with and delivered by the Defence Primary Healthcare Service, in place by as soon as possible and not later than 1 Apr 20. In addition, the Army is considering an Army-wide screening programme for serving personnel.” Source location 2019-0416-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 Introduce coloured bibs to supplement wristbands and identify high-risk candidates during assessment-centre activities.
Verbatim wording from the response “Recruiting Group will clearly comply with Defence direction to utilise coloured wristbands to identify Sickle Cell Trait Candidates but, as an additional control measure, also intends to use coloured bibs to ensure that high risk candidates are easily identifiable from a distance for all Assessment Centre staff during the assessment process. The wristbands and bibs will be issued by the Doctor to the candidate following the Pre-Service Medical Assessment. This process should be in place by early 2023.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
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 Replicate immediate reporting requirements in Recruiting Group policy and mandatory e-learning, including prompt reporting of serious incidents and exertional collapse.
Verbatim wording from the response “Immediate action has been taken to ensure that all colleagues within Recruiting Group are clear that deaths, incidents that result in serious injury or illness and all suspected or confirmed cases of exertional collapse are reported to the Defence Accident Investigation Branch without delay by the person closest to the incident. This direction will be replicated in Recruiting Group incident reporting policy and in a revised mandatory e-learning training module by 31 January 2023.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
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 Expand external tannoy coverage at Defence Medical Services Whittington to improve audibility of emergency announcements.
Verbatim wording from the response “new Defence Infrastructure Organisation Headquarters the tannoy system unfortunately suffered some damage. The tannoy system went through a complete overhaul in 2021 and the early part of 2022. The system was fully functional by May 2022. If an emergency tannoy announcement is required, the request would be sent to the Guard Commander either via Head of Establishment Second in Command, the Adjutant or Regimental Sergeant Major. Any member of staff can also ring the Guardroom to state an emergency. A site wide broadcast is then made. Additional works are being undertaken to increase the number of external speakers around the site to ensure any announcement is heard, no matter where personnel are on the site.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
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 Defence clinical policy cannot direct civilian healthcare providers or replace their established emergency-response procedures.
Verbatim wording from the response “The policy enables establishment processes and procedures in the recruiting/selection/training where Defence clinical personnel provide support to emergency healthcare cover. It does not and cannot direct civilian healthcare providers, nor replace their well-rehearsed establishment processes and procedures in the delivery of an emergency response.” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A joint clinical policy already covers exertional collapse, applies generically to other causes, and is reviewed annually.
Verbatim wording from the response “There is joint clinical policy in place for exertional collapse including Joint Service Publication 950 Leaflet 2-4-4: Exertional Heat Illness: Acute Treatment (v1.3 February 2022).” Source location 2019-0416 - Response from Secretary of State for Defence and Capita
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