Ministry of Defence

PFD Addressee

Reports: 31 Earliest: Jun 2014 Latest: 15 Oct 2025

83% 2-year response rate (matches average). 54% of classified responses show concrete action taken.

Responded 5 No Response 1

Action Taken 54%

Action Planned 26%

Noted 18%

Disputed 3%

Based on 39 classified responses

PFD Reports

31 results

Martyn Horton, David Ramsden, Douglas Halliday and Alexander Isaac

2015-0164 28 Apr 2015 Wiltshire & Swindon

Service Personnel related deaths

Concerns summary (AI summary) The Ridgeback vehicle, introduced for operational service, has unspecified "suspension issues" that raise concerns for safety.

Action Planned (AI summary) The Ministry of Defence is conducting a review of the vehicle suspension system, including data analysis and investigation into alternative bolts. They are also addressing the Vehicle Emergency Lighting System (VELS) modification, aiming for completion by the end of 2016.

Richard Jones

2015-0068 20 Feb 2015 Wiltshire & Swindon

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) Inadequate recording of patient information, perceived risk levels, and assessment urgency was observed. There was also contradictory evidence and confusion regarding responsibilities and communication between mental health services.

Noted (AI summary) The Ministry of Defence is adding guidance to JSP 950 Leaflet 2-7-2 regarding medical information handling, entitlement of service personnel to NHS services, liaison between DCMHs and local NHS services, and information needs for NHS providers. It also highlights the existing out-of-hours Service Liaison Officer service and the MOD's commitment to the Mental Healthcare Crisis Concordat. The Trust will conduct a root cause analysis investigation jointly with Salisbury District Hospital and the Armed Forces to explore the issues raised in the report and review relevant policies and procedures. The Department of Health is in discussion with the Ministry of Defence and NHS England to address concerns about mental health care for armed forces members, and is working to secure the MoD's commitment to the Mental Health Crisis Care Concordat by the end of April 2015. Following the case review, the SFT Emergency Department implemented a new mental health risk assessment tool, improved information sharing with mental health services, and implemented a system to record and review patients who leave before being seen, also they updated policy to inform GP if patient fails to wait for assessment. Public Health England states its role is to help the public health system achieve 'public health parity' for mental health. They are aware the Department of Health is in discussion with the MoD and will address the concerns raised in the report.

William Savage

Historic (No Identified Response)

18 Dec 2014 Oxfordshire

Service Personnel related deaths

Concerns summary (AI summary) Intelligence regarding frequent "PISTOL hits" was inaccurately circulated, leading commanders to believe a route was cleared when it was not. More detailed consideration is needed before removing threat warnings.

Sapper Dylan Gibson

2014-0436 9 Oct 2014 Wiltshire & Swindon

Service Personnel related deaths

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

Action Taken (AI summary) 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).

Dean Hutchinson

2014-0556 3 Jun 2014 Wiltshire and Swindon

Service Personnel related deaths

Concerns summary (AI summary) The wording in the modification to the Fire Diary gives equal weighting to options when the evidence supports a preference for reviews to be undertaken before a change of use or structural alteration takes place; this wording should be reviewed.

Action Taken (AI summary) The Ministry of Defence has amended the Defence Fire Risk Management Organisation (DFRMO) Fire Diary, updated the Fire NCO course, and is reviewing the DFRMO Fire Risk Assessment template to emphasize recording sleeping arrangements. A Defence Instruction or Notice (DIN) has also been published covering these issues.

Robert Wood

2014-0556-wp26758 3 Jun 2014 Wiltshire and Swindon

Service Personnel related deaths

Concerns summary (AI summary) Fire risk assessment guidelines did not prioritise pre-alteration reviews, and Junior Fire NCOs lacked specific training on complex electrical overload risks, including high current draw appliances.

Action Taken (AI summary) • The Defence Fire Risk Management Organisation (DFRMO) Fire Diary has been amended to clarify that a competent fire risk assessor must be consulted before changes take place or if the fire risk assessment is no longer valid. • The Fire Non-Commissioned Officer (NCO) course content has been amended to allocate more time and emphasis on the fire risks associated with electrical overloading. • The DFRMO Fire Risk Assessment template has been updated to further emphasize the need to record if any sleeping is place on the premises regardless of its primary purpose.