Mr Brown · Prevention of Future Deaths report

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Issued 20 May 2025•Birmingham and Solihull

Published report and response evidence

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

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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

Report evidence summary

Concerns raised3

  1. Failure to investigate deaths and learn from work-related events and welfare support
    Part of recurring concern: Failure to learn from deaths through systematic reviewPart of recurring concern: Inadequate safety incident investigations
  2. Lack of a formal mechanism for recording welfare concerns during investigations
  3. Lack of policy provision for supporting senior staff facing significant stress or potential disciplinary investigations

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

  1. West Midlands Fire Service

    Participate in and help fund national work establishing emotional and wellbeing support provision for senior officers.

  2. West Midlands Fire Service

    Review crisis management and death-in-service protocols for employment-linked workplace deaths, including support for affected staff, and implement linked policy changes.

  3. West Midlands Fire Service

    Share learning from the case to improve support for senior officers nationally.

  4. West Midlands Fire Service

    Play an active role in ongoing national work considering support for senior fire-service managers.

  5. West Midlands Fire Service

    Review and enhance support for senior officers undergoing disciplinary processes, including welfare recording, external support options, and strengthened processes and risk assessments.

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

  1. West Midlands Fire Service

    Existing health, wellbeing, employee assistance and disciplinary support arrangements already apply to staff and officers at all levels.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 deaths and learn from work-related events and welfare support

Wider context from the report

“1. WMFS did not undertake any investigation after Mr Brown’s death and have no policy requiring them to do so. Any opportunity to learn from a death such as a suicide related to work events including what welfare support was provided has not been addressed. This creates a risk of future deaths and action should be taken. ”

Is this part of a recurring concern?

Yes — Failure to learn from deaths through systematic review; Inadequate safety incident investigations.

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Source evidence

How this individual concern was interpreted

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

PFD Monitor interpretation

Lack of a formal mechanism for recording welfare concerns during investigations

Wider context from the report

“2. Neither WMFS health and wellbeing policy nor the mental health policy make any provision for supporting senior staff members who are facing significant stress and/or potential disciplinary investigations beyond the person approaching Occupational health themselves. The policy offers further support to lower ranks. In addition, there was no formal mechanism for recording concerns about welfare that arise during either an informal or a fact finding investigation. This creates a risk of future deaths and action should be taken. ”

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 policy provision for supporting senior staff facing significant stress or potential disciplinary investigations

Wider context from the report

“2. Neither WMFS health and wellbeing policy nor the mental health policy make any provision for supporting senior staff members who are facing significant stress and/or potential disciplinary investigations beyond the person approaching Occupational health themselves. The policy offers further support to lower ranks. In addition, there was no formal mechanism for recording concerns about welfare that arise during either an informal or a fact finding investigation. This creates a risk of future deaths and action should be taken. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Participate in and help fund national work establishing emotional and wellbeing support provision for senior officers.

Verbatim wording from the response

“Therefore, alongside our own internal review, we have also agreed to be part of, and help fund, the national work that is being undertaken by the National Fire Chiefs’ Council (NFCC), alongside the Fire Fighters’ Charity (FFC), to establish a new emotional and wellbeing support provision specifically designed for senior officers.”

Source location

Response from West Midlands Fire Service
Page 3 · response
Published 22 May 2025

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review crisis management and death-in-service protocols for employment-linked workplace deaths, including support for affected staff, and implement linked policy changes.

Verbatim wording from the response

“However, we acknowledge that the terms of reference of a review of this nature could be enhanced to ensure that learning is maximised and built into our policies and the outcomes from it better analysed to ensure that appropriate actions are built into our structures.”

Source location

Response from West Midlands Fire Service
Page 2 · response
Published 22 May 2025

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Share learning from the case to improve support for senior officers nationally.

Verbatim wording from the response

“We are committed to sharing the learning from this case to help improve support nationally.”

Source location

Response from West Midlands Fire Service
Page 3 · response
Published 22 May 2025

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

Play an active role in ongoing national work considering support for senior fire-service managers.

Verbatim wording from the response

“We also want to note the active ongoing work being undertaken by the NFCC that is considering how to best support senior managers in the fire service. This includes peer-to-peer mentoring, new CFO induction sessions, provision of a 24/7 helpline and liaising with central Government to consider changes in legislation. WMFS will play an active role in this area.”

Source location

Response from West Midlands Fire Service
Page 3 · response
Published 22 May 2025

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 and enhance support for senior officers undergoing disciplinary processes, including welfare recording, external support options, and strengthened processes and risk assessments.

Verbatim wording from the response

“Notwithstanding the above, the Service is committed to enhancing available support. Therefore, we will carry out a review of the level and nature of support provided to senior officers undergoing a disciplinary process, including before and after any suspension, and make any enhancements identified in that process. The review will include:”

Source location

Response from West Midlands Fire Service
Page 2 · response
Published 22 May 2025

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Existing health, wellbeing, employee assistance and disciplinary support arrangements already apply to staff and officers at all levels.

Verbatim wording from the response

“WMFS’s Health and Wellbeing policies apply to all members of staff and officers at all levels who may experience significant stressors within their roles. The Employee Assistance Programme (EAP) provides internal support to anyone within the organisation, and signposts external assistance such as The Samaritans and GP assistance where appropriate.”

Source location

Response from West Midlands Fire Service
Page 2 · response
Published 22 May 2025

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

Official responses located
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Data last updated 7 September 2026