PFD report

Sapper Dylan Reece Gibson · Prevention of Future Deaths report

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Issued 9 Oct 2014•Wiltshire and Swindon

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised1

  1. Lack of master keys held at guard rooms for prompt emergency access to buildings
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.4

  1. Action

    Update JSP 375 guidance to require consideration and regular testing of rapid emergency access procedures for locked rooms, including silent hours.

    Stated by Ministry of DefenceStated in progressThe respondent said that this action was in progress when they made their response on 9 October 2014.
  2. Action

    Assess emergency-access requirements site by site and identify an appropriate access method where the Defence Infrastructure Organisation is head of establishment.

    Stated by Ministry of DefenceStated plannedThe respondent said that this action was planned when they made their response on 9 October 2014.
  3. Action

    Hold keys to all Regiment buildings and rooms in the guardroom for emergency access.

    Stated by Ministry of DefenceStated completedThe respondent said that this action was complete when they made their response on 9 October 2014.

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 master keys held at guard rooms for prompt emergency access to buildings

Wider context from the report

“As part of the evidence I had before me a copy of The Non Operational Learning Account and After Action Review dated 14 March 2014. One of the recommendations that arose out of the investigation was that rather than relying on the attendance of those responsible for maintenance of the site that a master key to buildings such as living accommodation, offices and other buildings should be held at the guard room so as to enable access to any room, office or building on the camp promptly in case of an emergency. Concern was first raised at around 1900hrs that day and although I was not satisfied there was evidence to support that the availability of a master key would have made a difference here, it may possibly prevent a death in the future if such master keys were made available. This could apply not just at Perham Down Barracks but in relation to other sites across the United Kingdom. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Update JSP 375 guidance to require consideration and regular testing of rapid emergency access procedures for locked rooms, including silent hours.

Verbatim wording from the response

“With regard to the wider MOD estate, I can confirm that we are now updating our Health and Safety risk assessment guidance (contained within Joint Service Publication 375 (JSP 375)) to ensure that all those responsible for conducting site risk assessments on MOD establishments consider procedures for gaining rapid access to locked rooms (including the release of master keys) in emergencies. The amended JSP 375 will also state that these procedures should be tested on a regular basis, including the arrangements for silent hours.”

Source location

2014-0436-Response-by-Ministry-of-Defence
Page 1 · response
Published 9 October 2014

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Assess emergency-access requirements site by site and identify an appropriate access method where the Defence Infrastructure Organisation is head of establishment.

Verbatim wording from the response

“The Defence Infrastructure Organisation have confirmed that they will assess the requirement on a site basis where they are Head of Establishment and identify a method of emergency access where appropriate.”

Source location

2014-0436-Response-by-Ministry-of-Defence
Page 2 · response
Published 9 October 2014

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Hold keys to all Regiment buildings and rooms in the guardroom for emergency access.

Verbatim wording from the response

“As reported in my letter of 3 December 2014 Sapper Gibson’s unit, 26 Engineer Regiment, have implemented your recommendation and now hold keys to all buildings and rooms used by the Regiment in the guardroom where they can be accessed by duty staff in case of an emergency.”

Source location

2014-0436-Response-by-Ministry-of-Defence
Page 1 · response
Published 9 October 2014

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Direct controlled sites to centrally hold master or spare keys, or provide a known alternative emergency access method for duty staff.

Verbatim wording from the response

“While overall responsibility for Health and Safety within the MOD rests with the Secretary of State, this is formally delegated through Permanent Under Secretary to Top Level Budget holders and Chief Executives, who in turn delegate to Commanding Officers and managers within their own area. In order to address your recommendation, the Royal Navy, Army, Royal Air Force, Defence Equipment and Support and Joint Forces Command have all directed that for sites within their control, either:”

Source location

2014-0436-Response-by-Ministry-of-Defence
Page 1 · response
Published 9 October 2014

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

Data last updated 7 September 2026