Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0436, written 9 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Oct 2014 |
|---|---|
| Reference | 2014-0436 |
| Deceased | Sapper Dylan Gibson |
| Coroner | David Ridley |
| Coroner area | Wiltshire & Swindon |
| Category | Service Personnel related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
DAVID W. G. RIDLEY Senior Coroner for Wiltshire and Swindon | REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Rt Hon Mark Francois MP Minister of State for the Armed Forces House of Commons London SW1A OAA 4 CORONER lam DAVID W. G. RIDLEY, Senior Coroner for Wiltshire and Swindon Jz 2 CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made 3 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. The conclusion of the Inquest was that as a result of hanging that Dylan Gibson took his own life on 25 February 2014. 4 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 and he was last seen alive at around 1700hrs on Tuesday 25 February 2014. He had the previous day 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 day 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. 5 CORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concern and in my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — 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 the site that_a_ master key to buildings such as living accommodation, offices and other Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tet 01722 438900 | Fax 01722 332223 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 day and although | was not satisfied there was evidence to support that the availability of a master key 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. 6 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 04 December 2014. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. =| COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons Defence Inquest Unit | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated 09 October 2014 ¢ N ) x. = ~ Signature. Sd “eee Senior Coroner for Wiltshire and Swindon Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP Tel 01722 438900 | Fax 01722 332223
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Se “RECEIVED 29 JAN 20'5 MINISTRY OF DEFENCE FLOOR 5 ZONE B MAIN BUILDING Ministry Sper ssesesooses WHITEHALL LONDON SW1A 2HB of Defence Telephone: 020 7218 9000 (Switchboard) ANNA SOUBRY MP MINISTER OF STATE FOR DEFENCE PERSONNEL WELFARE AND VETERANS Se 2 January 2015 c oc (ea. ions dy 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 hoid keys to all buildings and rooms used by the Regiment in the guardroom where they can be accessed by duly 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 ona 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); or * that an alternative method of access to rooms will be available and known to duty staff on site. The Defence Infrastructure Organisation have confirmed that they will assess the requirement on a site basis where they are 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 to meet your recommendation. | am happy for you to copy this response to other Interested Persons and the Chief Corner. Win aU yor LA, ANNA SOUBRY MP
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