Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0556, written 3 Jun 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Jun 2014 |
|---|---|
| Reference | 2014-0556 |
| Deceased | Dean Hutchinson |
| Coroner | David Ridley |
| Coroner area | Wiltshire and 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
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
Ministry of Defence
Floor 5, Zone A
Main Building
Whitehall
London
SW1A 2HB
CORONER
| am David Ridley Senior Coroner, for the coroner area of Wiltshire & Swindon
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.
3 | INVESTIGATION and INQUEST
On the 12 May 2014 | resumed the Inquest into the deaths of both Private Robert
WOOD and Private Dean HUTCHINSON (“Rob & Dean”) at my Court here in Salisbury,
Wiltshire. The Inquest concluded on the 22 May 2014. | found that both Rob and Dean
had died from:-
1a) Inhalation of products of combustion and severe burns.
In relation to the conclusion | handed down a narrative conclusion, a generic version of
which is attached to this report marked “A”.
4 | CIRCUMSTANCES OF THE DEATH
These are clearly set out in my narrative conclusion attached to this report. |
5 | CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. 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 final day of evidence looked closely at the various processes undertaken by the
Ministry of Defence to learn from the tragic deaths of both Rob and Dean, on the
14 February 2011 and | am aware that a significant number of changes have already
been introduced. Concerns numbered 1 and 3 focus in the main on the Fire Risk
Assessment document and the Fire Diary. Item 4 is a general concern and is self
evident.
The MATTERS OF CONCERN are as follows. —
(1) In evidence from a the Defence Fire Risk Management
Organisation, | looked at the modification to the Fire Diary on the subject of fire risk
assessments. | have attached a copy of the relevant extract marked “B" and the
relevant section is already highlighted. It talks of a review of the fire risk assessment
where there has been or there is planned to be a change in use or structure alteration.
In evidence a number of witnesses, in particular gggiguguiiigg who carries out fire risk
assessments, agreed that advice should be sought ideally before any change of use or
structural alteration. | appreciate that there will be incidences whereby a change of use
can take place extremely quickly however | considered that this section did not weight a
preference in favour of a review prior to a change of use or any structural alteration
taking place. It is my view that the current version gives equal weighting to the 2 options
available when the evidence ! heard was in favour of advice being sought before a
change of use was carried out or any structural alteration taking place. In this particular
case the alterations were phased alterations over a period of time and whilst | formed
the view that it was speculative on the facts of this particular case that such a review
before the change would have made a difference that cannot be said for future
incidences. As the evidence | heard supports a preference for such reviews to be
undertaken before a change of use or structural alteration takes place | would ask that
this be reviewed insofar as the wording is concerned.
(2) Instruction and training is now given specifically to Junior Fire NCOs as regards
recognising the possibility of overloading in relation to electrical appliances. In my
decision | found that the absence of such training was a systemic failure contributing to
the deaths of both Rob and Dean. In evidence from Captain Hamilton from the Royal
Engineers he explained insofar as the chiller cabinet that was used inside the Transport
Troop tent was concerned that whilst that may have a specific amperage in relation to
the draw of current, he commented that at the start of a cycle when the compressor
becomes activated that figure can be multiplied by a factor of between 6 to 10. For
example a 2 amp appliance suddenly draws a current of between 12 and 20 amps. He
commented that in order to recognise such an issue that this required quite specific
training and knowledge attributable to the qualifications of an electrician. As the Fire
Diary is the guide to any Junior Fire NCO | would be grateful if you could please confirm
that this document includes guidance to relevant Fire NCO’s as regards who to contact if
they have a concern as regard overloading in order to seek expert advice on the matter.
What became very clear during the course of the Inquest is that such matters sometimes
have to be explained in very clear terms and levelled so as to be understood at the
lowest level of service men/women.
(3) A copy of the fire risk assessment is, of course, given to the relevant Fire NCO and,
of course, the sleeping issue is very much highlighted to all fire risk assessment
assessors. In the actual fire risk assessment of the General Support Squadron area that
was undertaken on the 3 December 2010 it was not picked up by the relevant fire NCO
who, of course, subsequently received a copy of the document stating that sleeping was
not taking place.
| would be grateful if you could please review the matter in relation to the risk
assessment document with a view to considering whether it would be sensible to put a
note possibly in bold and/or even capitals on the subject of the declaration in relation to
sleeping in office accommodation to act as a reminder to the Fire NCO to check the
point. Whilst{——eferred to the guidance, referring to the use of cots/beds,
soldiers of course are resourceful and will sleep at a desk or even on the floor.
(4) It may seem a matter of common sense but in relation to the issue of random checks
(‘silent hours checks’), what was happening insofar as the Transport Troop tent was
concerned in relation to satisfying the obligation to carry out checks between the hours
of 2300 hours to 0500 hours the following day was that those responsible if they
happened to worked late beyond 2300 hours say until 0000 would regard that as
sufficient. More senior officers who gave evidence recognised that such checks to be
effective needed to be random. | found this to be failure at individual levels and | would
be grateful if the matter could be considered to be used as a training example to
reinforce the point to Junior Officers and NCOs on the subject of random checks. |
found that had random checks been undertaken that it more likely than not would have
acted as a deterrent and stopped the practice of all sleeping on duty at night.
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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 29 July 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
‘ellogg Brown & Root Ltd.
Messrs. Hilary Meredith, Solicitors for the family of Robert Wood.
Messrs. Hogan Lovells International LLP Solicitors for the family of Dean Hutchinson.
Treasury Solicitor representing the MOD.
| 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.
3 June 2014 David Ridley CORONER
_
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.
(ste) MINISTRY OF DEFENCE
We FLOOR 5 ZONE B MAIN BUILDING
oe WHITEHALL LONDON SW1A 2HB
Ministry
of Defence
THE RT HON MARK FRANCOIS MP
MINISTER OF STATE FOR THE ARMED FORCES
Telephone: 020 7218 9000 (Switchboard)
MSU/4/4/3/1/is [ 27 July 2014
tor My Ridley,
Thank you for your Regulation 28 report of 2 June 2014 following the inquest into the
tragic deaths of Private Dean Hutchinson and Private Robert Wood. The Ministry of
Defence takes its relationship with HM Coroners extremely seriously and we fully
recognise how important it is that we learn all possible lessons to ensure that deaths in
similar circumstances in the future are prevented.
In response to your first two concerns, the Defence Fire Risk Management Organisation
(DFRMO) Fire Diary has been amended to make it clear that the advice of a competent
fire risk assessor must be sought before any changes take place within a premise or if
there is a suspicion that the fire risk assessment is no longer valid; and to provide
additional guidance and advice on the risks of electrical overloading including the need
to contact a competent electrician if there are concerns. The revised Fire Diary is
enclosed for your information. The Fire Non-Commissioned Officer (NCO) course
content has also been amended and now allocates more time and emphasis on the fire
risks associated with electrical overloading. A copy of the PowerPoint presentation
delivered on this course is also enclosed for your information.
Your third concern has been addressed as part of the ongoing review of the DFRMO
Fire Risk Assessment template. The template has been updated to further emphasise
the need to record if any sleeping is taking place on the premises regardless of its
primary purpose. The review is not yet complete but | have attached the latest draft with
the changes highlighted for your information. The revised version is planned to be
implemented by the end of October 2014.
In response to your forth concern, the Army plans to use this incident as an example of
what happens when ‘duties’ are not conducted in the correct way. This will include, as
part of the biannual command, leadership and management (CLM) training update, an
amendment to the training documentation related to the duties of a sub-unit duty NCO to
incorporate this incident as an example. The revised documentation will be used by
training deliverers from 30 September 2014 onwards.
Mr D Ridley
H M Senior Coroner for Wiltshire and Swindon
26 Endless Street
Salisbury
Wiltshire
SPI 1 DP
You should note that while the above action in relation to the fire risk assessment
template is applicable across Defence, the matters relating to the Fire Diary only apply
to the Army. The other Services do not use the DFRMO Fire Diary; all fire safety related
information is contained in Unit Stations Standing Orders, Fire Orders, Standard
operating Procedures and Fire Notices. DFRMO has written to all Top Level Budget!
Chief Environment and Safety Officers to inform them of actions DFRMO has taken in
response to your concerns and to make them aware of the need to implement any
necessary changes and update the relevant documentation.
A Defence Instruction or Notice® has also been published covering these issues and the
action that is required to address them, to ensure that the matters receive the widest
distribution and any gaps in distribution are covered. This was published earlier this
month; | enclose a copy for your information.
| hope this letter provides the assurance you were seeking and | am content for you to
copy it to other Interested Persons and the Chief Coroner.
yove wer,
oe
THE RT HON MARK FRANCOIS MP
' The Ministry of Defence is organised into six Top Level Budget areas: Head Office and Corporate Services, the four commands
{Navy Command, Army Command, Air Command, and Joint Forces Command) and the Defence Infrastructure Organisation.
? A Defence Instruction or Notice (DIN) is an official document that tells people in the Services or MOD about important instructions,
guidance or other information that they need to know to do their job properly. DINs are distributed widely, electronically and on
paper, throughout the Defence establishment including to MOD buildings, military bases and ships at sea. They are also published
on the Ministry of Defence Intranet.
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