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.
PFD Reports
26 resultsAeran Taylor
All Responded
2025-0057
31 Jan 2025
West Sussex, Brighton and Hove
Ministry of Defence
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
Ministry of Defence
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
Ministry of Defence
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.
James Day
All Responded
2024-0061
7 Feb 2024
Manchester South
Ministry of Defence
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
Ministry of Defence
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 Bayliss
All Responded
2021-0413
7 Dec 2021
North West Wales
Ministry of Defence
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
Ministry of Defence
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.
Joel Robinson
All Responded
2021-0398
25 Nov 2021
Berkshire
Army Headquarters
Concerns summary (AI summary)
Insufficient progress on suicide prevention strategies, lack of practical risk factor identification, and inadequate independent mental health screening for soldiers outside their chain of command were identified.
Action Planned
(AI summary)
The Army outlines several actions planned or underway, including establishing a dedicated sub-group by March 2022 to improve information sharing processes and the MOD developing a Defence Suicide Prevention Plan with an initial draft to be produced by the summer. It is also testing a pilot scheme to provide virtual means of reporting a complaint.
Victoria Harrild-Jones
All Responded
2021-0386
17 Nov 2021
Suffolk
Ministry of Defence
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
Ministry of Defence
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
Capita
MOD
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
Capita
MOD
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
MOD
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.
Alexandre Parr
All Responded
2019-0001
2 Jan 2019
Wiltshire and Swindon
Civil Aviation Authority
Concerns summary (AI summary)
The provided text is incomplete and does not detail any specific concerns regarding future deaths.
Action Taken
(AI summary)
The CAA now requires calendar periods for engine overhaul for low-utilisation aircraft, reinforced the replacement lifespan of the YAK-52 engine with a new MPD, and will revise Safety Notice 2018/005 to emphasize calendar lives for safety harnesses and provide guidance on harness assessments; however, the CAA concluded it would not be appropriate to request the manufacturer to specify a rate for the Fuel Primer Pump, but will include its use in emergencies for discussion at the next CAA led YAK & Nanchang ‘Continuing Airworthiness Forum’.
Abigail Hall
All Responded
2018-0286
12 Sep 2018
South Yorkshire (West)
Derwent Students
Concerns summary (AI summary)
The continued absence of a defibrillator and first aid trained staff at the premises creates a critical risk for emergency medical response in critical situations.
Action Planned
(AI summary)
Derwent Facilities Management Limited has commenced a program of emergency first aid training for staff, highlighted the location of the nearest AED within the Premises reception area, and approved the purchase and installation of an AED.
Darren Neilson
All Responded
2018-0231
18 Jul 2018
Birmingham
BAE Systems Ltd
MOD
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
BAE Systems Ltd
MOD
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)
Ministry of Defence
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.
John Lomas
All Responded
2015-0396
1 Oct 2015
Stoke-on-Trent and North Staffordshire
Sports Camp Tirol
Concerns summary (AI summary)
Inadequate risk assessment of river conditions, lack of essential safety protocols for white water rafting (e.g., training, safety kayak, appropriate raft capacity), and poor communication between organisers and the Army contributed to the death.
Disputed
(AI summary)
Sport Camp Tirol disputes several factual points in the coroner's report, asserts its guides acted appropriately, and blames the army for allowing a non-swimmer on the trip. It will require evidence of swimming qualifications from participants in the future, and says that the HYDRO Company are now obligated to inform the rafting companies well in advance about "stowage discharge".
Cameron Laing
All Responded
2015-0268
10 Jul 2015
Exeter and Greater Devon
Ministry of Defence
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).
Martyn Horton, David Ramsden, Douglas Halliday and Alexander Isaac
All Responded
2015-0164
28 Apr 2015
Wiltshire & Swindon
Ministry of Defence
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.
Tom Sawyer and Danny Winters
All Responded
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.
Sapper Dylan Gibson
All Responded
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
All Responded
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
All Responded
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.