Wayne Brown
PFD Report
All Responded
Ref: 2025-0235
All 1 response received
· Deadline: 15 Jul 2025
Coroner's Concerns (AI summary)
The fire service lacked policy for investigating work-related suicides and provided inadequate mental health support for senior staff, failing to record welfare concerns during investigations.
View full coroner's concerns
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.
2. Neither WMFS health and wellbeing policy nor the mental health policy make any provision for supporting senior staff members who are facing significant stressors 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.
2. Neither WMFS health and wellbeing policy nor the mental health policy make any provision for supporting senior staff members who are facing significant stressors 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.
Responses
Action Planned
West Midlands Fire Service will review the level and nature of support provided to senior officers undergoing a disciplinary process, including specific provisions within its Health and Wellbeing Policy, and mechanisms to record and act upon welfare concerns. It is also participating in national work to establish a new emotional and wellbeing support provision for senior officers. (AI summary)
West Midlands Fire Service will review the level and nature of support provided to senior officers undergoing a disciplinary process, including specific provisions within its Health and Wellbeing Policy, and mechanisms to record and act upon welfare concerns. It is also participating in national work to establish a new emotional and wellbeing support provision for senior officers. (AI summary)
View full response
Dear Senior Coroner Hunt,
Inquest Touching the Death of Wayne Steven Brown (Date of death 24 January 2024) Response to Regulation 28 Prevention of Future Deaths Report
On behalf of West Midlands Fire Service (“WMFS”), I acknowledge your Regulation 28 Prevention of Future Deaths Report following the inquest into the sad death of Wayne Brown, the former Chief Fire Officer of WMFS. This letter outlines WMFS’s response and planned actions.
Your report raised two matters of concern. “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”. “2. Neither WMFS health and wellbeing policy nor the mental health policy make any provision for supporting senior staff members who are facing significant stressors 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.”
Post-Incident Investigation and Learning
To reiterate what was said at the inquest, following Mr Brown’s death, we sought the advice of external, specialist health and safety enforcement and compliance solicitors to provide legal advice, part of which involved investigating and assessing the evidence then available to advise upon:
• Whether the mental health and wellbeing support available within WMFS met good practice within guidance published for all employers by the Health and Safety Executive.
- 2 -
• Whether Mr Brown was aware of and accessed that support in the period prior to his death; and
• If he did access that support, to what effect?
The review concluded that Mr Brown had been made aware of the support available and had been signposted to it and encouraged to access the support available multiple times in the period leading to his death, but sadly he had not accessed it in the relevant period.
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.
We will therefore thoroughly review our crisis management and death-in-service protocols for deaths that occur in the workplace to ensure that they extend to situations where the death of a colleague is linked to their employment. This will also include how we support other members of staff who might be affected. The review and the implementation of linked policies will be completed within 6 months of this response letter.
Support for Senior Staff Facing Significant Stressors
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.
In addition, because of his seniority, Mr Brown was also offered funding for externally provided counselling, but this was not utilised and, as the record of inquest notes, tragically the risk of suicide was not identified by anyone.
In addition to the policies disclosed, in accordance with the Orders made during the inquest process, WMFS also had a Disciplinary Procedure which is written in accordance with the ACAS Code of Practice and the National Joint Council for Local Authority Fire and Rescue Service’s. Under this procedure, a Service Liaison Officer (SLO) is appointed for someone undergoing a disciplinary process. As you will recall, the WMFS Monitoring Officer emphasised that matters were only at a preliminary stage during the discussions in the couple of days before Mr Brown died. In preparation for a formal meeting, Mr Brown had already engaged the assistance of a representative from his representative body, and he would have then also been allocated a SLO.
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:
- 3 -
• Incorporating specific provisions within our Health and Wellbeing Policy and / or ‘The WMRFA / WMFA Constitution’ to address the unique support requirements of senior staff.
• Ensure mechanisms are in place to record and act upon welfare concerns raised during any informal or fact-finding processes.
• Exploration of additional third-party support options outside of internal Occupational Health, which we recognise may be more appropriate and accessible for senior officers.
• Review and strengthening of the process and risk assessments for personnel involved in disciplinary proceedings in line with best practice.
We will complete this review and make the necessary changes within the next 6 months
Sector-Wide Learning and Support
We are committed to sharing the learning from this case to help improve support nationally.
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.
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.
Our thoughts and condolences remain with Mr Brown’s family, friends and colleagues.
Inquest Touching the Death of Wayne Steven Brown (Date of death 24 January 2024) Response to Regulation 28 Prevention of Future Deaths Report
On behalf of West Midlands Fire Service (“WMFS”), I acknowledge your Regulation 28 Prevention of Future Deaths Report following the inquest into the sad death of Wayne Brown, the former Chief Fire Officer of WMFS. This letter outlines WMFS’s response and planned actions.
Your report raised two matters of concern. “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”. “2. Neither WMFS health and wellbeing policy nor the mental health policy make any provision for supporting senior staff members who are facing significant stressors 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.”
Post-Incident Investigation and Learning
To reiterate what was said at the inquest, following Mr Brown’s death, we sought the advice of external, specialist health and safety enforcement and compliance solicitors to provide legal advice, part of which involved investigating and assessing the evidence then available to advise upon:
• Whether the mental health and wellbeing support available within WMFS met good practice within guidance published for all employers by the Health and Safety Executive.
- 2 -
• Whether Mr Brown was aware of and accessed that support in the period prior to his death; and
• If he did access that support, to what effect?
The review concluded that Mr Brown had been made aware of the support available and had been signposted to it and encouraged to access the support available multiple times in the period leading to his death, but sadly he had not accessed it in the relevant period.
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.
We will therefore thoroughly review our crisis management and death-in-service protocols for deaths that occur in the workplace to ensure that they extend to situations where the death of a colleague is linked to their employment. This will also include how we support other members of staff who might be affected. The review and the implementation of linked policies will be completed within 6 months of this response letter.
Support for Senior Staff Facing Significant Stressors
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.
In addition, because of his seniority, Mr Brown was also offered funding for externally provided counselling, but this was not utilised and, as the record of inquest notes, tragically the risk of suicide was not identified by anyone.
In addition to the policies disclosed, in accordance with the Orders made during the inquest process, WMFS also had a Disciplinary Procedure which is written in accordance with the ACAS Code of Practice and the National Joint Council for Local Authority Fire and Rescue Service’s. Under this procedure, a Service Liaison Officer (SLO) is appointed for someone undergoing a disciplinary process. As you will recall, the WMFS Monitoring Officer emphasised that matters were only at a preliminary stage during the discussions in the couple of days before Mr Brown died. In preparation for a formal meeting, Mr Brown had already engaged the assistance of a representative from his representative body, and he would have then also been allocated a SLO.
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:
- 3 -
• Incorporating specific provisions within our Health and Wellbeing Policy and / or ‘The WMRFA / WMFA Constitution’ to address the unique support requirements of senior staff.
• Ensure mechanisms are in place to record and act upon welfare concerns raised during any informal or fact-finding processes.
• Exploration of additional third-party support options outside of internal Occupational Health, which we recognise may be more appropriate and accessible for senior officers.
• Review and strengthening of the process and risk assessments for personnel involved in disciplinary proceedings in line with best practice.
We will complete this review and make the necessary changes within the next 6 months
Sector-Wide Learning and Support
We are committed to sharing the learning from this case to help improve support nationally.
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.
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.
Our thoughts and condolences remain with Mr Brown’s family, friends and colleagues.
Sent To
- West Midlands Fire Service
Response Status
Linked responses
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56-Day Deadline
15 Jul 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 5 February 2024 I commenced an investigation into the death of Wayne Stephen BROWN. The investigation concluded at the end of the Inquest . The conclusion of the inquest was; Suicide
Circumstances of the Death
Mr Brown was found hanging at his home address on 24/01/24 after concerns were raised for his welfare. He was confirmed deceased by police at 10.50am. He had raised a complaint of harassment and had recently been suffering extreme stress arising from the ongoing harassment case and a recent work investigation regarding his qualifications which had become public. In the days leading up to his death nothing had indicated to others that he would take his own life but his intention to do so was clear from the note he left. Following a post mortem, the medical cause of death was determined to be: 1a Hanging 1b 1c 1d II
Copies Sent To
West Midlands Police
Mr Walker the His majesty's Inspectorate of Constabulary and Fire and rescue services
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.