Edward Maher, James Dunsby and Craig Roberts

® . MINISTRY OF DEFENCE

FLOOR 5 ZONE B MAIN BUILDING

; Ministry WHITEHALL LONDON SW1A 2HB
of Defence Telephone: 020 7218 9000 (Switchboard)
PENNY MORDAUNT MP

MINISTER OF STATE FOR THE ARMED FORCES

D/MSU/4/7/1 (42~ September 2015

Thank you for your letter of 20 July in which you enclosed a copy of your Regulation 28
Report following the Inquest into the deaths of Corporal James Dunsby, Lance Corporal
Craig Roberts and Lance Corporal Edward Maher.

As you will be aware, my Department takes very seriously its relationship with HM
Coroners and we fully recognise how important it is that we learn all possible lessons to
ensure that deaths under similar circumstances in the future can be prevented. We are
also committed to supporting our servicemen and their families and we recognise fully
that it is unacceptable to lose three soldiers in such circumstances. In your report you
have raised concerns about a number of issues which | will address in the paragraphs
below.

1. A new tracker system has been introduced recently. The new system's slow
man/static function does not work. It is therefore still the case that those running the
exercise have no means to identify static or slow moving soldiers. :

The new tracker system was introduced in to service in November 2014 and first used

. onan exercise in January 2015. The system functions correctly in that it provides alerts -

if any beacon breaches the slow moving parameters. However there are challenges in
how this is interpreted by those using it, as the system can not identify the cause (e.g.
an individual taking a break or stopping to fill water bottles) which can overload the
operators making it difficult to identify those at risk.

In addition there are issues with the system’s ability to cope with the volume of data it
receives when in continuous contact with a large number of beacons, as this was ‘not
how it was designed. This will be rectified in an upgrade scheduled to take place before
the end of this calendar year. In order to overcome the issues with interpretation of the
slow man/static function in the intervening period, the following mitigation measures
have been put in place:

Mrs Louise Hunt
HM Senior Coroner the City of Birmingham and Solihull
Coroner's Court

~ 50 Newton Street

Birmingham
BN4 6NE

« Each candidate’s beacon is visually monitored by Directing Staff to ensure they
are on track. If their position is not updating automatically the indicator on screen
changes colour, alerting Directing Staff that there may be a problem.

e The rate of refresh of the system has been reduced to once every 5 minutes,
which overcomes some of the issues with both overload on Directing Staff and
the system itself, as brief stops (e.g. to check navigation) are less likely to be
detected.

¢ Directing Staff at Check Points will alert the Command Vehicle if a candidate does
not arrive at the expected time.

¢ Where a candidate’s pace or location raises cause for concern a quick reaction
force (QRF) is immediately sent to their last known location. In addition to the
QRF (e.g. if they are addressing another issues) one of the directing staff is able
to move from the closest check point to their last known location to investigate as
necessary.

e The system allows text messaging between candidate and Directing Staff and is
used to check candidates’ status and location.

e Nocandidates are allowed to commence or continue the exercise until the
Directing Staff have confirmation from the system that their beacon is working.
Spare beacons are available at checkpoints and any delays while these are
allocated and checked does not impact on candidate exercise times.

2. Those in a senior commanding position were unaware that the new tracker
system's slow man/static function did not work until the inquest- this came to light as |
asked for a demonstration of the new system which was undertaken on the Malvem's
on Sunday 21 June 2015. | was informed the slow man/static function did not work, |

__ heard no evidence that any steps have been taken to address this problem and no

interim measures have been put in place to mitigate the risk.

All commanders on the exercise now have a full understanding of the new tracker
system, its capabilities and limitations. Representatives from the company who produce
the system attended the last exercise (and will attend future iterations) to update on any

__ issues and better understand the concems of the Directing Staff. In addition the

company are contracted to provide direct support to exercises as well as 24/7 remote
advice as required.

Upgrades outlined under Point 1 should address remaining concerns, however to
ensure all matters raised during the inquest and in the various investigations are being

. addressed, a meeting will take place in October between the delivery authorities

(Defence Equipment and Support) and the Directing Staff. The timing of this meeting
will ensure all requirements are captured and either addressed or alternative mitigations
put in place before the next planned selection exercise.

3. Witnesses at the inquest confirmed that before this tragedy they were unaware
of the main guidance for heat iliness namely JSP539- joint service code of practice-
climatic iliness and injury in the armed forces Version 2:1 November 2012. Some
witnesses in a very senior position -AA and SR44- claimed, retrospectively, that this
guidance was not applicable to this endurance exercise. Others EEE and
EEE confirmed it was the current guidance and no separate guidance had been
issued for exercises with this specialist group. | am concemed that the MOD still do
not have a clear plan and guidance for the detection of Heat iliness in this type of
exercise and have failed to instruct commanders of the importance of adhering to
JSP539 for this type of activity.

JSP 539 provides the principles which should be applied by all UK Armed Forces in

order to minimise the risk of climatic injuries. To ensure all commanders are aware of
the importance of adhering to JSP 539, the Defence Safety Authority recently issued an
Urgent Safety Advice notice on Climatic Illness and Injury Awareness and Prevention.
This advice reminds Armed Forces personnel of the sources of information and risk
assessments to be undertaken in order to try and prevent and treat heat illness (and

_ cold injury).

The Medicai Plan for the exercise was completely revised in advance of the most
recent iteration (June 2015). Prior to all future exercises this plan must be reviewed
and signed off by the Senior Medical Officer and Chief Instructor of the Lead Regular
Unit (see response to Point 7 for further detail). Oversight is provided by medical staff in
HQ Specialist Military Units. The revised Medical Plan requires that a comprehensive

training package on climatic illness and injury and JSP539 is established. This has

improved knowledge and awareness of the JSP and climatic illness and injury. In
addition, the Medical Plan has introduced a requirement for all professional medics on
the exercise to conduct virtual exercises and rehearsals prior to future exercises.

4. Senior commanders had received no training before this tragedy on JSP539.
There was no clear system for disseminating information to different regiments and
no means to check those commanding this type of exercise had the requisite
knowledge and training.

Commanders of Specialist Military Units are all now briefed on JSP 539 as part of their

- pre-appointment training. All specialist units will now receive appropriate training

packages on JSP 539, heat iliness and its treatment. If a requirement to operate outside
the parameters of JSP 539 is identified by the Directing Staff, then a formal waiver must
be issued by Director Specialist Military Units. This approval requires an explanation of
the measures in place to justify such a deviation as well as the operational necessity for
them. .

The Medical Plan for the exercise provides for training of all Directing Staff in JSP 539
and is signed off by the Training Officer of the Specialist Military Unit responsible.
Furthermore, all students are required to sign declarations that they have read and
understood Standard Operating Instructions (which include JSP 539), which ensures
they are aware of all relevant procedures.

5. Senior commanders were unaware that the staff who completed the risk
assessment for this exercise and who conducted the exercise had not been trained in
the preparation of risk assessments. The risk assessment used simply adopted a risk
assessment that had been prepared by the lead regular unit.

Training in the conduct of Risk Assessments was addressed in the immediate
aftermath of the incident in 2013 and following the improvement notice issued by the
HSE. In addition to this, work is being conducted to review how the organisation can
improve training in this area and HQ specialist military units is reviewing and rewriting

__ its Training Govemance and Assurance Policy which will lead to further changes in

the policy and procedures of subordinate units. The revised Training Governance and
Assurance Policy was completed in August and changes by the subordinate units will
be in place before the end of the calendar year, prior to the next iteration of the
exercise.

6. Senior commanders were unaware that the staff who conducted this exercise
were unaware of climatic guidance in JSP539 and therefore did not understand the
implications of the weather forecast and the importance of heat illness and its
treatment.

As explained under point 4 above, all specialist units will now receive appropriate

- training packages on JSP 539, heat illness and its treatment.

7. Senior commanders were unaware that the reservist units had a different build up
to test week. The reservists had a military skills week the week before test week
whereas the signals regiment had build up marches. None of the signals regiment
students suffered heat iliness.

The overall command of the exercise, including the preparatory training immediately
preceding it, now rests with the Commanding Officer of the Lead Regular Unit. This
has simplified the reporting chains and command responsibilities and ensured that
information can be provided to a single command chain which has the authority to

; make changes to the exercise in light of this information as appropriate.

In consultation with the HSE the preparatory training undertaken by Reserve Units
was reviewed following the incident. Following this Reserves were included in the
build up marches undertaken by Regulars in the week preceding the exercise. A
further review was undertaken at the end of June 2015 which concluded that this had
failed to fully mitigate the risk. A further change was made prior to the most recent

exercise with Reserves now undertaking instructor-led marches (at controlled pace)

before moving on to the more demanding build up marches undertaken by Regulars.

As explained below, | have also directed that a non-statutory inquiry be conducted to
look at, amongst other issues, the requirement of the Reserve Units to undertake this

__ exercise and the exact training requirement dictated by their role.

1

8. The general system for reporting heat illness cases is disjointed and results in
cases being missed and therefore not reported. Inaccurate data impedes the ability of
the MOD to assess the true incidence of heat illness during exercises and to put in

‘place any plan that's required to mitigate ongoing risks of heat iliness.

| acknowledge that there have been failings in the accurate recording of cases of heat
illness historically. The Defence People Health Board’s Heat Illness Working Group, in
collaboration with the Defence Safety Authority, is working to improve the process for

reporting of heat illness and injury. Progress will be reported to the Defence People

Health Board in October and | will write to you in November with an update on this
important work. The revised Medical Plan for the specialist exercise requires prompt
and accurate reporting of all climatic injuries, so as to enable an accurate capture of the
required data.

At the time of the incident there was no mechanism to record Reserve medical

* information on the Defence Medical information Capability Programme (DMICP). There

was a system for Medical Reporting of cases of heat illness but this relied on the use of
paper forms which may have contributed to failings in their recording. Medical
information relating to Reservists is now being loaded on to DMICP, thus statistics
relating to climatic injuries sustained by both Regular and Reserve personnel will show

__ up in health audits by Defence Statistics. This has been reflected in the exercise

Medical Plan.

9. The tracker system used at the time was known to be unfit for purpose in that the
slow man/static function did not work effectively. No commander at any level
addressed this deficiency in any directions to staff or further risk assessments.

| accept that there were issues with the tracker system in place at the time, which was
not designed to provide the slow man/static functionality being developed in the new
system. | also accept that these issues were not appropriately mitigated by other
means. Our actions to address these issues are outlined at Point 1.

10. A previous fatality, Soldier G see LAIT report October 2012, had identified that
treatment for casualties should be within the “golden hour". In addition following
Private Poole’s death in 2009 it was identified that the tracker was not fit for purpose
and standard operating procedures were issues dated January 2011. None of these
recommendations were implemented by those involved in this exercise. | am
concerned that lessons had not been learnt from these previous events. There
appears to be no clear pathway for communicating this sort of information.

There is a formal process in place for the capturing of lessons leamt/identified (Land
Forces Standing Order (LFSO) 1118 — Learning Lessons in the Land Environment).
Lessons are managed through the Defence Lessons Implementation and Management
System (DLIMS) process which provides for a comprehensive way in which to consider

‘ that appropriate lessons are leamt, and that all appropriate steps are taken to prevent or

minimise a recurrence. There is a clear and well established process, which is now
being reinforced through the Training and Governance Policy review referred to under

Point 5 which will formalise the DLIMS process as a core part of the biannual review of

_ normal training, including exercises such as this.

The lessons identified in the two incidents you refer to were captured by this process. The
‘Golden Hour’ is normally applicable to circumstances where patients have suffered from
major trauma or severe injury and need to access definitive emergency treatment in that

time frame. It is not always relevant to environmental injury/illness which should be

_ judged on a case by case basis. In cases of heat stroke, the immediate and most

pressing medical and first aid action (after attending to airway, breathing and circulation)
is to cool the patient as quickly as possible. The cooling can often be initiated in the field
fairly quickly and, in some circumstances, this can be done more effectively in the pre-
hospital environment.

In the case of the issues with the tracker in use at the time of Marine Poole’s death;
work was undertaken to enhance its capability and improvements were introduced in
December 2010. It was subsequently identified that there was a need to replace the
system and this led to revised set of ‘User Requirements’ which included statements
taken from the Lessons Identified. The time it took to implement the new system was
not a result of a failure to identify the lessons, but a result of the complexity of procuring

- guch a piece of equipment. | accept that further mitigation should have been put in

place to address the gap in capability while the systems were being upgraded and
replaced, these issues have now been addressed through the improvements in training
and the conduct of risk assessments and improved awareness throughout the command
chain of the capabilities of the system.

11. There is no system in place to ensure that WBGT readings obtained at
Sennybridge camp are communicated to exercise commanders in the area during the

day.

{ accept that the lack of a system to obtain and monitor WBGT readings from
Sennybridge Camp was a failing. Having reviewed this it has been concluded that

* obtaining readings from Sennybridge Camp would be of limited value in determining

the climatic risks in the training area, which is some distance from and of different
terrain to the camp area. WBGT readings are now taken at the command vehicle
(located in the exercise area) and at the highest point in order to understand the
range of conditions out on the course being used. They are continuously monitored
throughout the exercise and any changes in the readings are recorded in the

* gommunications log and all check points notified of these and any control measures

required as a result.

in order to improve on this and to provide as accurate information as possible, a scoping
exercise is currently being conducted to look at establishing further WBGT meters

__ across the routes used. This will allow geographical variations to be better taken into

account and Dynamic Risk Assessments to be conducted to inform route planning and
overall timings and/or objectives in light of the prevailing conditions. This work will be
completed in time to allow any changes to be implemented in advance of the next
iteration of the exercise.

12. There was no involvement of a doctor experienced in heat iliness detection and
treatment when devising the medical plan for this exercise; the medical plan was
prepared by a junior combat medical technician. .

The revised Medical Plan, outlined at point 3, put in place for the most recent and all
future exercises is to be reviewed (and signed) by the Senior Medical Officer and Chief
Instructor of the Training Squadron from the Lead Regular Unit, following consultation
with the medical team in the higher headquarters. The Senior Medical Officer is trained
in and has experience of heat illness detection as well as wider medical risks with
exercises of this type. They are also able to draw on the expertise within the
organisation and across the Defence medical community. The revised Medical Plan
also requires that a professional medic (who would be experienced in heat illness
detection and treatment), reviews the Medical Plan each day, prior to the start of
exercises, taking account of the prevailing and forecast climatic conditions, route
changes, availability of support assets and any students who are considered to be ‘at
risk’. Any changes to the Medical Plan must be made in consultation with the Senior
Medical Officer and Chief Instructor from the Lead Regular Unit.

13. There was no prior liaison with the NHS and Mountain rescue before this
exercise about what their involvement might be in the case of any injuries or iliness.

Local Commanders now liaise with local Police and Mountain Rescue prior to the start of
every exercise. In addition, communications are established with the closest Search
and Rescue location to confirm the communications plan and Medical Staff are required
to liaise with local hospitals. The Medical Plan directs that rehearsals and virtual
exercises be undertaken to consider the response, including likely timelines, to medical
emergencies.

In addressing your concerns | have sought assurances from the Royal Navy, Army,
Royal Air Force and Joint Forces Command as to whether any wider lessons from your
recommendations apply to their activities. | have received assurances that activities are
conducted in line with the appropriate MOD policies, for example on risk assessments,
climatic illness and injury. This work has identified a number of improvements; most
notably the Royal Navy identified lessons in three of its training activities all of which
have been addressed or will be addressed by March 2016 with mitigation in place until
that time.

We continue to work with the Health and Safety Executive to take forward their
recommendations and seek their advice on implementing improved processes. | have
directed that two further inquiries be conducted by the Ministry of Defence. Firstly, a
Service Inquiry will look at the events of 13 July 2013 to try and ensure that all safety-
related lessons, including those identified in your Regulation 28 report, are learnt for
endurance training across the whole of Defence. This will be conducted by a Service
Inquiry Panel, convened by the Director General Defence Safety Authority, which will
provide an independent, thorough and objective review outside of the chain of
command. In order to ensure ail relevant issues are captured and considered by the
Service Inquiry, | have also written to the Director of Specialist Military Units,

Commander Joint Forces Command and the Chief of the General Staff directing that
they identify areas of arduous activity that may be relevant to the Service Inquiry and
make these known to the Service Inquiry panel.

. Secondly, a non-statutory inquiry will look at the care and support provided to the
bereaved families in this case and to those members of the MOD who were closely
involved in the incident; and review the training needs analysis for the reserve units
involved in this incident in light of their current role.

i hope that this response helps to address your specific concerns regarding the tragic

. deaths of Corporal Dunsby, Lance Corporal Roberts Lance Corporal Maher. | am
content for you to copy this response to the Chief Coroner and other Interested Persons.
I have also undertaken to place a copy of this response in the Library of the House of
Commons. ! will do so when Parliament returns from the conference recess in October,
as per your request for a slight delay to rightly afford the bereaved families time to
consider my reply.

Yor oom

PENNY MORDAUNT MP