Service Personnel related deaths

PFD Category

Reports: 32 Areas: 18 Earliest: Jan 2014 Latest: 31 Jan 2025

91% response rate (above 63% average). 47% of classified responses show concrete action taken.

Responded 29 Historic 3

Action Taken 47%

Action Planned 26%

Noted 21%

Disputed 6%

Based on 34 classified responses

PFD Reports

32 results

Tom Sawyer and Danny Winters

2015-0100 16 Mar 2015 Wiltshire & Swindon

Minister of State for the Armed Forces

Concerns summary (AI summary) Reliance on insecure handwritten radio logs, absence of critical communication records, and ineffective communication between soldiers hindered investigation. There is a lack of secure digital recording for encrypted radio signals in combat scenarios.

Action Planned (AI summary) The MOD will investigate the inclusion of automated secure voice logs in the next generation tactical command system, with a decision expected by 2018. The Army Chief Information Officer will determine how such a capability will be used.

William Savage

Historic (No Identified Response)

18 Dec 2014 Oxfordshire

Ministry of Defence

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

Ministry of Defence

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

Ministry of Defence

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

Ministry of Defence

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.

Anne-Marie Katherine Ellement

Historic (No Identified Response)

2014-0181 4 Mar 2014 Wiltshire & Swindon

Armed Forces Minister Provost Marshall (Army)

Concerns summary (AI summary) The Armed Forces' victim support code lacks specific provision for serious sexual assault victims within the military, and staff managing suicide vulnerability risk assessments receive insufficient training and follow-up.

Lee Bonsall

2014-0044 31 Jan 2014 Carmarthenshire & Pembrokeshire

Department of Health and Social Care

Concerns summary (AI summary) Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it an unviable treatment alternative.

Noted (AI summary) The Department of Health acknowledges the coroner's concerns regarding repeat prescriptions of citalopram, referencing NICE guidelines. It states that NICE guidelines are not rules and do not restrict prescribing, including repeat prescribing, and that prescribing remains the clinical responsibility of the doctor concerned. The response indicates it will copy the concerns to NICE for their next guideline review. The Department of Health acknowledges the coroner's concerns regarding citalopram prescriptions and psychotherapy waiting times but states these are the responsibility of the Welsh Government. It includes information about Citalopram's Summary of Product Characteristics and monitoring requirements for potential suicide risks.