UK Inquiry Tracker

Sapper Dylan Gibson

PFD Report All Responded Ref: 2014-0436

Date of Report 9 October 2014

Coroner David Ridley

Coroner Area Wiltshire & Swindon

Response Deadline ✓ from report 4 December 2014

Service Personnel related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 4 Dec 2014

Coroner's Concerns (AI summary)

The absence of master keys in the guard room for all camp buildings prevents prompt access in emergencies, potentially delaying critical interventions.

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As part of the evidence 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_thesite_that a master to_buildings_such_as_living_ accommodation, offices and other Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury; Wiltshire, SP1 1DP Tel 01722 438900 Fax 01722 332223 and The day day key 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 and although was not satisfied there was evidence to support that the availability of master would have 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.

Responses

Ministry of Defence Central Government

8 Dec 2014

Action Taken
Sapper Gibson's unit now holds keys to all buildings and rooms in the guardroom. The MOD is updating its Health and Safety risk assessment guidance to ensure site risk assessments consider rapid access to locked rooms, and procedures are tested regularly; the Royal Navy, Army, Royal Air Force, Defence Equipment and Support and Joint Forces Command have all directed that master or spare keys to all rooms will be held centrally in the guardroom (or similar where there is no guardroom). (AI summary)

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RFCEIVED 2 9 JAN Z0j MINISTRY OF DEFENCE FLOOR 5 ZONE B MAIN BUILDING Ministry WHITEHALL LONDON SWIA 2HB of Defence Telephone: 020 7218 9000 (Switchboard) ANNA SOUBAY MP MINISTER OF STATE FoR DEFENCE PERSONNEL WELFARE AND VETERANS January 2015 ea av d / Thank you for your letter of 8 December 2014 in which you allowed the Ministry of Defence additional time in which to consider how to address your Regulation 28 Report following the Inquest into the death of Sapper Dylan Reece Gibson. 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 can be accessed by duty staff in case of an emergency: With regard to the wider MOD estate, ! 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 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: Master or spare keys to all rooms will be held centrally in the guardroom (or similar where there is no guardroom); %r that an alternative method of access to rooms will be available and known to duty staff on site 25 they '

The Defence Infrastructure Organisation have confirmed that will assess the requirement on a site basis where they Head of Establishment and identify a method of emergency access where appropriate. hope these measures are satisfactory and thank you again for allowing uS some extra time to consider how best t0 meet your recommendation: am happy for you to copy this response to other Interested Persons and the Chief Corner. kn 0 4 >67 L4U _ ANNA SOUBRY MP they are

Sent To

Ministry of Defence

Response Status

Linked responses 1 of 1

56-Day Deadline 4 Dec 2014

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 26 February 2014 commenced an investigation into the death of Sapper Dylan Reece Gibson aged 21_ The investigation concluded at the end of the Inquest on 07 October 2014. conclusion of the Inquest was that as a result of hanging that Dylan Gibson took his own life on 25 February 2014_

Circumstances of the Death

The circumstances of his death were that Dylan had a volatile relationship with his wife and had previously self harmed back in November 2012 His Military Care Assessment Plan was discharged on around September 2013_ An argument involving his wife erupted during the weekend prior to his death ad he was last seen alive at around 1700hrs on Tuesday 25 February 2014_ He had the previous sent a text message to his wife saying "goodbye" however she did not believe him and in the past had indicated and made threats of self harm but never carried anything out aside from the 2012 incident: Dylan was found following welfare concerns shortly after 2135hrs the same in his room and his death was confirmed at the scene at 2205hrs by an attending paramedic There were already signs of rigor mortis which pointed to the death occurring closer to the time he was last seen than the time he was discovered.

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.