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.

Response Status (last 2 years, 6 reports)
Responded 5 No Response 1
AI Classification
Action Taken 54%
Action Planned 26%
Noted 18%
Disputed 3%
Based on 39 classified responses
PFD Reports Received by Quarter
Clear
PFD Reports
26 results
Malik Bunton
All Responded
2025-0519 15 Oct 2025 North Yorkshire and York
Suicide
Concerns summary (AI summary) Inadequate inquiry into a previous incident, flawed clinical review processes, and deliberate obstructions to evidence gathering impeded the RAF's ability to assess suicide risk and learn lessons.
Action Taken (AI summary) The RAF has directed that all suspected suicides will now be subject to an immediate fact-finding investigation, formally brought into the RAF Postvention Suicide Response policy. Further direction and guidance has been issued to ensure delays in providing statements to the Service Inquiry panel are avoided in the future, and the Defence Inquests Unit is working to implement a process to retain email accounts of deceased service personnel.
Aeran Taylor
All Responded
2025-0057 31 Jan 2025 West Sussex, Brighton and Hove
Alcohol, drug and medication related deaths Service Personnel related deaths
Concerns summary (AI summary) Deficient mental health assessments at military discharge, lack of inquiry into drug use linked to potential PTSD, and insufficient long-term rehabilitation options for veterans with substance abuse were identified.
Noted (AI summary) The Ministry of Defence acknowledges the concerns but states that existing processes are in place to identify correlations between service and behaviour, and to provide support to veterans. They will ensure continued work to raise awareness of available support.
Charlie Owen
All Responded
2024-0665 29 Nov 2024 Berkshire
Service Personnel related deaths Suicide
Concerns summary (AI summary) The army's vulnerability risk management process fails to ensure 'check-ins' for high-risk soldiers, and suicide prevention training for welfare officers is not mandatory. Inadequate information sharing and documentation between medical and command personnel further hinder support and risk reduction.
Action Planned (AI summary) The Ministry of Defence is currently undergoing a comprehensive review of the policy that supports the Army’s VRM Process, with plans to reissue the policy by the end of March 2025. Additionally, record keeping and information sharing improvements will be factored into the policy review of the Army's VRM process.
Paul Chase
All Responded
2024-0546 14 Oct 2024 Liverpool and Wirral
Service Personnel related deaths Suicide
Concerns summary (AI summary) There is a critical lack of mental health, alcoholism, and addiction support for veterans, both serving and after release. Resources are extremely limited, leading to extensive waiting times for essential treatment and therapy.
Noted (AI summary) The Ministry of Defence expresses sympathy and highlights existing mental health support for service personnel and veterans, stating that the deceased received treatment for addiction issues before discharge, but requests to be engaged earlier in inquests where service history is relevant.
Harry Dunn
All Responded
2024-0412 4 Jul 2024 Northamptonshire
Hospital Death (Clinical Procedures and medical management) related deaths Road (Highways Safety) related deaths
Concerns summary (AI summary) Lack of adequate UK driver training and road sign familiarisation for US diplomatic personnel contributed to a fatal road collision. Concerns exist about the current training's coverage of wrong-way driving risks.
Action Taken (AI summary) The government has sought assurances from US authorities regarding driver training for US Visiting Forces and diplomats, emphasizing driving on the left. The FCDO has also written to all diplomatic missions in the UK reminding them of road safety responsibilities. Ministers are considering further actions.
James Day
All Responded
2024-0061 7 Feb 2024 Manchester South
Alcohol, drug and medication related deaths Service Personnel related deaths
Concerns summary (AI summary) Inadequate and difficult-to-access mental health support for service personnel with PTSD, both during and after service, forces individuals to self-medicate, leading to poor outcomes.
Noted (AI summary) The Ministry of Defence expresses condolences and states that Mr Day received significant medical input, including mental healthcare, occupational health, and primary medical care. While open to improvements, they don't feel a need to change MOD policies in response to the report, given existing mental health services.
Benjamin McQueen
All Responded
2023-0285 28 Jul 2023 London City
Accident at Work and Health and Safety related deaths Other related deaths Service Personnel related deaths
Concerns summary (AI summary) Military diving training had critical safety shortcomings, including no spare breathing gas for standby divers, inappropriate acceleration of training, lack of readily available defibrillators, and inconsistent safety pressure guidelines.
Action Taken (AI summary) The Ministry of Defence has reviewed and aligned figures in the Divers Policy (JSP286) and the maintenance Policy (BR2807), stipulating the minimum abort pressure as 50 Bar, and updated the figures prescribed for tolerances to the minimum pressure to start a dive.
Jonathan Cole
All Responded
2023-0186 5 Jun 2023 Derby and Derbyshire
Other related deaths
Concerns summary (AI summary) There is a critical shortage of psychiatrists and psychologists within the Ministry of Defence, impacting serving personnel's access to appropriate mental health diagnosis and treatment, compounded by ongoing recruitment difficulties.
Noted (AI summary) The Ministry of Defence outlines existing strategies and policies related to mental health support for military personnel, transition to civilian life, and assistance to veterans and describes reviews of the Armed Forces Compensation Scheme but does not describe specific actions taken or planned in direct response to the concerns. The Trust has developed guidance for investigators to consider neurodiversity and reasonable adjustments. They will also proactively review completed investigations and upcoming inquests to identify further learning, ensure family engagement, and summarize key themes to support improvement work.
Stephen Chapple and Jennifer Chapple
All Responded
2023-0073Deceased 28 Feb 2023 Somerset
Other related deaths
Concerns summary (AI summary) The British Army's practice of presenting fully functional ceremonial daggers to retiring soldiers poses a significant risk, particularly given the potential for recipients to have mental health issues from combat service.
Action Planned (AI summary) The MOD has written to the Service Chiefs to remind them of their duty to ensure that misappropriation of MOD items is identified and investigated. The issue of potentially lethal items is to be scrutinised to ensure genuine requirement, and that misappropriation of such items, including combat knives of any type, should be thoroughly investigated and the strictest sanctions applied as a future deterrent.
Jonathan Bayliss
All Responded
2021-0413 7 Dec 2021 North West Wales
Accident at Work and Health and Safety related deaths Product related deaths Service Personnel related deaths
Concerns summary (AI summary) Urgent investigations into an artificial stall warning for the Hawk Mk 1 aircraft, which can stall without warning, are stalled. The training simulator also inaccurately models the aircraft with a smoke pod.
Action Planned (AI summary) The MOD is undertaking investigations into incorporating an artificial stall warning capability in the Hawk T Mk1, with a decision expected in summer 2022. The RAF is developing options for a RAFAT-focused Hawk Synthetic Training Facility, expected to be in place by 2025, and will update the current Hawk Synthetic Training Facility software to reflect a RAFAT aircraft by 2023.
Alexander Tostevin
All Responded
2021-0407 6 Dec 2021 Dorset
Mental Health related deaths Service Personnel related deaths Suicide
Concerns summary (AI summary) Military mental health care lacks independence, potentially causing underreporting of symptoms due to disclosure fears. The absence of a composite risk assessment and DCMH's primacy in MDT meetings can lead to inadequate risk management.
Action Taken (AI summary) The Ministry of Defence outlines mental health support strategies including the Defence People Mental Health and Wellbeing Strategy. The Royal Navy, Army and RAF have implemented various initiatives, such as mental fitness training and wellbeing programmes, to improve mental health literacy and support.
Victoria Harrild-Jones
All Responded
2021-0386 17 Nov 2021 Suffolk
Other related deaths Service Personnel related deaths
Concerns summary (AI summary) Military personnel and dependents treated overseas receive post-operative care, specifically regarding prophylactic anti-coagulation medication, that does not comply with UK NICE guidance.
Action Planned (AI summary) The Defence Professor of General Practice has committed to add this case and reflective discussion to the mandatory course for all Defence GP trainees held in Cyprus each June. The DMS Overseas Assurance Working Group is reviewing the assurance process to create supporting policy and a common framework.
Cpl Ryan Lovatt
All Responded
2021-0373 3 Aug 2021 Oxfordshire
Alcohol, drug and medication related deaths Other related deaths Service Personnel related deaths
Concerns summary (AI summary) The alcohol policy for Op Cabrit is unrealistic and poorly understood, potentially promoting binge drinking, while the critical "shark watch" role for sober supervision lacks formalization and clear communication.
Action Taken (AI summary) The Ministry of Defence has amended its Sharkwatch policy to include written orders for the nominated sober individual, requiring them to keep the group together, ensure safe return, and report deviations, with signed orders retained by the commander; also Part 1 Orders are issued daily containing repeats of all aspects of the Force Protection policy, including alcohol restrictions and actions for duty personnel.
Youngson Nkhoma
All Responded
2019-0416 6 Dec 2019 Birmimgham and Solihull
Service Personnel related deaths
Concerns summary (AI summary) Non-UK military selection candidates are not screened for sickle cell trait, posing a significant increased risk of death or collapse during military exercise.
Action Taken (AI summary) The Ministry of Defence outlines changes made to the Army recruitment process, including revised medical screening for Sickle Cell Trait, updated risk management processes for physical training, and clarified roles and responsibilities for training staff. They also removed previous versions of AGAI Vol 1 Ch 7 from use and circulation. The Ministry of Defence reports on actions taken, including improvements to sickle cell trait screening, mandating training for staff on exertional collapse, and implementing a joint clinical policy for exertional collapse. They also ensure Defence Medic training incorporates exertional collapse scenarios.
Kamil Iddrisu
All Responded
2019-0416-wp26929 6 Dec 2019 Birmimgham and Solihull
Service Personnel related deaths
Concerns summary (AI summary) There is a critical need to screen all non-UK military selection candidates for sickle cell trait, both before and after selection, due to the significant risk of collapse or death during military exercise.
Noted (AI summary) • Following the death of two candidates, the 2000m run was suspended for all Commonwealth Candidates. • Multidisciplinary meetings have taken place, informed by an Evidence-Based Medicine approach, to address the risk of Exertional Collapse Associated with Sickle Cell Trait (ECAST). • Actions taken have been applied to all candidates applying to join the Army, not just non-UK candidates.
Joshua Hoole
All Responded
2019-0458 1 Nov 2019 Birmingham and Solihull
Service Personnel related deaths
Concerns summary (AI summary) A persistent failure to learn from previous heat-related deaths is evident, with commanders lacking awareness and training on critical heat illness guidance (JSP539), which itself is complex and lacks clear protocols for individual risk and new fitness tests.
Action Taken (AI summary) The Ministry of Defence has taken corrective action following concerns raised regarding the death of Corporal Joshua Hoole, including improved awareness of Joint Service Publication 539, updating the User Guide video for WBGT monitors, and providing refresher training for staff delivering Physical Training, whilst robust plans are in place to deliver remaining requirements.
Darren Neilson
All Responded
2018-0231 18 Jul 2018 Birmingham
Service Personnel related deaths
Concerns summary (AI summary) The tank was able to fire without the BVA assembly being present, a hazard not adequately considered during production and manufacture. There was also no written process to check for the BVA assembly's presence or confirm when it should be removed and stored.
Action Taken (AI summary) Following the accident, a ban on all 120mm training ammunition natures was ordered and an Extraordinary Safety and Environmental Management Panel (SEMP) was convened. Three systemic issues relating to safety have been identified across DE&S and will be resolved. Following the incident in June 2017 the MoD and BAE Systems are developing a design solution to eliminate the risk of this happening again and to bring the current Challenger 2 gun up to date with the Standard. Progress on four solutions will be reviewed by the MoD Challenger 2 Safety and Environmental Management Panel in October 2018.
Matthew Hatfield
All Responded
2018-0231-wp26293 18 Jul 2018 Birmingham
Service Personnel related deaths
Concerns summary (AI summary) Soldiers lacked clarity on gun safety drills, and the officer in charge lacked critical information on tank status. Risk assessments also failed to identify a design flaw allowing guns to fire without a vital safety assembly.
Disputed (AI summary) • Immediately following the tragic accident; ban on all 12Omm training ammunition natures was ordered by Defence General Munitions ("DGM"). • Once all live fire training on Challenger 2 ("CR2") tanks was halted, an Extraordinary Safety and Environmental Management Panel ("SEMP") was convened. • The SEMP held a series of four extraordinary meetings (20 June, 12 July, 24 July and August 2017) to investigate the incident.
Ben Jukes
All Responded
2017-0335 24 Jul 2017 Manchester (City)
Service Personnel related deaths
Concerns summary (AI summary) The army's drug-testing regime failed to detect a serviceman's regular drug use, partly because tests were not random or unannounced, allowing evasion.
Action Planned (AI summary) The need for absolute discretion during drug testing will be reiterated to units during initial notification.
Cameron Laing
All Responded
2015-0268 10 Jul 2015 Exeter and  Greater Devon
Service Personnel related deaths
Concerns summary (AI summary) Soldiers lacked critical understanding of trailer braking systems and safe extraction methods, leading to a fatal accident. The Ministry of Defence irrationally refused to teach alternative maneuvers not in official publications.
Action Taken (AI summary) The Ministry of Defence improved the training package for DROPS operators qualified to tow the KINGS trailer, supported by a video detailing coupling and uncoupling procedures. The Army will include clearer guidance for operation of the Shunt Valve in the AESP, and amend the Trainer instructor Specifications (ISpec).
Paul McGuigan
All Responded
2015-0185 12 May 2015 Manchester (South)
Other related deaths
Concerns summary (AI summary) General concerns were raised across relevant agencies about risks that could lead to future deaths, requiring action.
Action Planned (AI summary) The Home Office states that the Notifiable Occupations Scheme (NOS) was withdrawn and replaced with a new police-led scheme, the Common Law Police Disclosure (CLPD) scheme, which provides greater consistency across forces in the disclosure of information. GMP will train officers in understanding their responsibilities under the pressing social need test, including classroom and NCALT training. They will be entering and holding notifications on the intelligence file of offenders. The SIA offered training and guidance to all UK police forces. The Trust states that following the Bradley Report (2009), the MDO teams transferred into single line management and implemented operational policy and approved documentation for assessment of needs and risks. They are rolling out an electronic clinical record (PARIS) and clinical staff have adequate time to access information from case notes.
Martyn Horton, David Ramsden, Douglas Halliday and Alexander Isaac
All Responded
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
All Responded
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.
Sapper Dylan Gibson
All Responded
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
All Responded
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.