Youngson Nkhoma

Date of report	6 Dec 2019
Reference	2019-0416
Deceased	Youngson Nkhoma
Coroner	Louise Hunt
Coroner area	Birmimgham and Solihull
Category	Service Personnel related deaths
Source	judiciary.uk record · original PDF
Responses published	2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

1. Rt Hon Ben Wallace MP, Secretary of State for Defence
2. Chief Executive for Capita Business Services Limited
CORONER

I am Louise Hunt, Senior Coroner for Birmingham and Solihull
CORONER’S LEGAL POWERS

I 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.
INVESTIGATION and INQUEST

On 24 January 2022 I commenced an investigation into the death of Youngson John
Jumbe NKHOMA. The investigation concluded at the end of the inquest . The conclusion of the
inquest was;

Mr Youngson Nkhoma died from the consequences of exertional rhabdomyolysis due to Sickle
Cell Trait. Additionally, he was diagnosed with hypertrophic cardiomyopathy, which was a
condition he died with and not from.
During his application process there was a lack of questions in the online questionnaire and the
Recruitment Group Medical Declaration form regarding Sickle Cell Disease and Sickle Cell Trait. It
is unlikely that many candidates would know the true nature of their Sickle Cell Trait status and the
failure to test candidates to confirm their status increases the risk of exertional collapse associated
with Sickle Cell Trait.
In 2019 there was a significant increase in commonwealth candidates but not risk assessment to
compensate for the influx that would adequately identify conditions more commonly experienced
by commonwealth candidates, specifically from African-Caribbean countries. Consequently, this
would be more than likely have led to inadequate institutional awareness within the Recruiting
Group specifically regarding JSP950 Annex N and the risks of Sickle Cell Trait. Risk Assessments
were still not reviewed or amended following the collapse of the three commonwealth candidates
and the death of Kamil Iddrisu.
Both organisations' reporting systems were inadequate, not properly understood by all staff and
therefore incorrectly used resulting in the failure to report the three collapses and the death of
Kamil Iddrisu to the Defence Accident Investigation Branch, who more than likely would have
conducted a thorough investigation.
The pattern was not recognised and the link between Sickle Cell Trait and exertional
rhabdomyolysis was missed. Following the first candidates collapse, during his appeal process,
the GP's letter was sent to the Recruiting Group confirming the link between Sickle Cell Trait and
exertional rhabdomyolysis. At the point of receiving the letter there was a failure to seek further
medical information regarding this and the next two collapses.
Additionally, the cause of death for Kamil Iddrisu on the 18/11/2019 was communicated to the
Recruiting Group and the link between Sickle Cell Trait and exertional rhabdomyolysis was
discovered on the 25/11/2019. However, the connection was not made to the first three collapses.
Had an investigation been carried out, the trend would have more than likely been identified at this
point. Despite concerns being raised by staff at Lichfield Assessment Centre, specifically requests
to stop the Role Fitness Test 2km best effort run for commonwealth candidates, no formal
investigations took place. Had this been carried out it would have more than likely resulted in steps
being taken in a timely manner to mitigate the risks of over exertion which would have avoided the
death of Youngson Nkhoma, who was unaware of is Sickle Cell Trait status.

CIRCUMSTANCES OF THE DEATH

On the 01/03/2019, Mr Youngson Nkhoma submitted an online application to become an Army
candidate. This application included an online Medical Questionnaire which was completed by the
candidate. Youngson met the criteria and progressed onto stage 2.
On the 08/05/2019 Youngson was required to complete the Recruitment Group Medical
Declaration, in which a Doctor from his home country was required to complete the second half of
the form. This was received by The National Recruitment Centre on the 22/05/2019.
On the 29/08/2019 Youngson was booked on to attend Lichfield Assessment Centre on the
26/11/2019 . Youngson arrived in the UK on the 09/11/2019 where he stayed with his brother who
was his sponsor.
On the 25/11/2019 Youngson arrived at Lichfield Assessment Centre. During this day he
underwent initial checks of his documentation and to ensure that he met the criteria of a minimum
10-day acclimatisation period.
On the 26/11/2019 Youngson undertook the standard cognitive and physical tests in which the
pre-assessment ECG showed abnormal voltage criteria and left ventricular hypertrophy. This
resulted in an echocardiogram being conducted which confirmed nothing abnormal enabling him
to continue with the selection process. He completed version 4 of the Waiting Room Questionnaire
a Medical Self Declaration form. Within this form, Youngson did not declare any knowledge of any
genetic inherited diseases, including Sickle Cell. He indicated he undertook between 6 - 8 hours of
exercise per week including running and gym exercises.
There was a face-to-face interview between Youngson and the Lead Clinician of Lichfield
Assessment Centre where the questions and answers of the Waiting Room Questionnaire were
discussed in detail. It was indicated that during these meetings there was the opportunity to
discuss Sickle Cell Disease and Sickle Cell Trait. However, not all candidates may have been
aware of their Sickle Cell Trait Status, and there were no tests required to confirm this.
On the 27/11/2019 Youngson took part in the 800m warm up which was a lap of the course used
for the 2km run to follow. The warm up was also used to familiarise candidates of the route. After
the warm up, the 2km best effort run commenced which included a downhill and uphill slope. At
8:27am Youngson became unsteady and collapsed 1800m in, just after the incline of the course.
He was assisted into the safety vehicle upon which an ambulance was called. Shortly after, he
was removed from the vehicle and placed into a recovery position to maintain his airway, by a
Specialist Medical Officer who was alerted to the incident on the way into the building.
The Specialist Medical Officer reported that he understood the severity of Youngson's illness as he
was only responsive to a pain stimulus on the AVPU Scale and was very cold to the touch. He
removed his jacket and covered up Youngson. He noted that the outside temperature was 9 ͦc.
At 8:44am the ambulance arrived, and Youngson was taken to Good Hope Hospital, accompanied
by Litchfield assessment centres lead interviewer, arriving at 9:53am. Youngson was taken to the
Intensive Care Unit where he was treated for severe rhabdomyolysis due to Sickle Cell Trait.
Despite best efforts, Youngson died on the same day around 8:00pm.
On the same day, Lichfield's Assessment Centre Manager reported Youngson's incident through
CASPER and INCREP systems , which were sent to the Recruiting Group.
On the 28/11/2019, after Youngson's death the Defence Accident Investigation Branch were
informed of the deaths of Kamil Iddrisu and Youngson Nkhoma. This was the first account of the
Defence Accident Investigation Branch being informed of Kamil's death. After this notification, at
around 3pm, the Role Fitness Test 2km run was ordered to be stopped.
On the 25/11/2019, after Kamil's death, the Recruiting Group were informed that Kamil collapsed
due to exertional rhabdomyolysis associated with Sickle Cell Trait.
Prior to Youngson's death, two commonwealth candidates from West African and Caribbean
countries, collapsed at Lichfield Assessment Centre and had become extremely unwell and
hospitalised. The first candidate was treated for exertional rhabdomyolysis caused by Sickle Cell
Trait. This was communicated to the Recruiting Group by a GP's letter dated 22/10/2019 during
his appeal process. The second candidate was treated for acute exertional myocardial necrosis
which was caused by Sickle Cell Trait. This was not known until the Service Inquiry was done.
As well as these two candidates, there was a third candidate from Western Africa who collapsed
during the 2km run on the 19/09/2019 at the Glencorse Assessment Centre. This candidate
required CPR on site before being taken to hospital. His condition was severe, and he was treated
for exertional rhabdomyolysis which was later to be found due to his Sickle Cell Trait status. As
well as these three collapses mentioned, there was a fourth collapse of Kamil Iddrisu on the

17/11/2019 at Lichfield Assessment Centre. Kamil subsequently died the following day as a result
of exertional rhabdomyolysis associated with Sickle Cell Trait.
For the first three candidate collapses, and the death of Kamil Iddrisu, the relevant incident reports
were completed but the severity of the incidents were not identified. The CASPER reports were
marked as a 'non-work-related ill health' incident leading to these reports being marked as 'closed'
so they could not be added to, amended, or updated. The INCREP reports were marked as
'routine' incident, meaning no investigation was required. Due to an overall lack of training in
completing these reports, those who needed to know about these incidents, did not know. Also,
the correct procedure to notify the Defence Accident Investigation Branch immediately was not
followed. There was also a delay in filing the reports initially which led to inadequate action being
taken in a timely manner. Out of these reports it transpired that two of them were left unread and
unactioned in an inbox.
There was no evidence of a formal review of the reasons the three candidates collapsed, or of the
death of Kamil Iddrisu, at the end of the 2km run.
There was a missed opportunity to connect the reason for the collapses and Kamil's death to
exertional rhabdomyolysis, given that there is a document known as the JSP950 Annex N, which
clearly identifies that candidates with Sickle Cell Trait had a higher risk of developing acute
exertional rhabdomyolysis which may lead to renal failure and death, in severe cases. A footnote
is also recorded to state that it was more common in the African-Caribbean population. However,
the Doctors at Lichfield Assessment Centre conducting the Assessments were not specifically
trained on diseases from outside the United Kingdom. They were aware of the JSP950 document
including Annex N.
The opportunity was again missed when the GP's letter regarding the first candidates collapse
confirmed the cause as being exertional rhabdomyolysis due to Sickle Cell Trait. This letter was
received by Lead Clinician at Lichfield Assessment Centre on the 25/10/2019.
There were discussions, none of which were recorded, between the senior leadership teams and
Health and Safety during months July to October regarding the emerging trends but there was a
lack of medical expertise and guidance on whose responsibility it was to take preventative action
on similar incidents occurring again, carry out relevant risk assessments and to then take
corrective measures.
Following Kamil's death on the 18/11/2019 the Recruiting Group Head of Selection visited Lichfield
Assessment Centre where he considered environmental factors and undertook a welfare check.
He also updated Kamil's INCREP report with Additional information of the first three collapses who
had been hospitalised.
The Chief Medical Officer requested the physical case files for all collapsed candidates. As there
is usually a delay in these arriving, he and his team looked into the electronic case files which
were not comprehensive. He also advised the medical staff at Lichfield Assessment Centre to be
more vigilant on taking candidate's family history.
On the 19/11/2019 the Health & Safety Manager emailed the Health and Safety Director reporting
Kamil's death but there was no evidence of any further action taken down this route. Two days
after Kamil's death, a CASPER report was submitted and received at the Army incident
Notification Cell on the 27/11/2019 at 9:25am.
On the 25/11/2019 the Chief Medical Officer was informed that Kamil's death was caused by
exertional rhabdomyolysis associated with Sickle Cell Trait. Even with the knowledge of this
information, the Role Fitness Test 2km run was not halted until 28/11/2019 after Youngson's
death.

Following a forensic post mortem, the medical cause of death was determined to be:

1a MULTI ORGAN FAILURE

1b EXERTIONAL RHABDOMYOLYSIS

1c SICKLE CELL TRAIT

HYPERTROPHIC CARDIOMYOPATHY

II
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 MATTERS OF CONCERN are as follows. –

Sickle cell trait (SCT) screening process and identifying SCT in candidates:
1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident
includes 2 people) near misses where the process that had been put in place following these
tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to
their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group
Leader prior to the exercise but was directed to complete the RFT(E) run element in any case.
This raises a concern about the screening process may not be safe and effective.
2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The
Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest
confirmed screening was the only way to safely identify candidates at risk. This raises a concern
that the recruitment process is not safe and effective.

Training and Education
1. The near miss incidents lead to a concern that staff involved in the selection process and RFT
assessments are still not aware of the risk associated with SCT given that in one case the person
was directed to undertake the run despite knowing he was at high risk of developing exertional
rhabdomyolysis associated with SCT.
2. The lack of screening in the Navy and Air Force leads to a further concern about the level of
understanding regarding the risks associated with SCT – the evidence at the inquest said this risk
was unpredictable .
3. The inquest heard evidence that there is no standardised way to identify SCT candidates who
are going through the selection process as the different services were considering using different
colours wrist bands in different services. The raises a concern about the ability to identify those
candidates who have SCT.
4. There should be a review of the wording used and rationale for including questions for
candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the
inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine
from hepatitis. This raises a concern about the level of understanding of the significant of "cola
coloured urine" and what it might indicate.

Reporting and investigation
1. The inquest heard how Capita have set up a clinical oversight board to review any incidents.
First this board did not appear to have reviewed or audited any of the near misses referred to
above and second it does not include a representative from the Army. This raises concerns about
the lack of joined up thinking for an incident between capita and the army and the safety of the
new process.
2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they
occurred which indicates the present process is not safe and effective.
3. There is no system to audit whether incidents are being correctly processed and investigated.
4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the
Army (Durals). These are on separate IT systems. This raises a concern that there is no "one
version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the
issue in their Casper system associated with the drop down menu options and the fact that non
work related incidents close investigations automatically.
5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to
take responsibility for the review health and safety incidents and to ensure adequate investigation
is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within
the remit of the Capita Head of Health and Safety.
6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding
health and safety issues with a clear lines of responsibility for global risk assessment (and
promoting information gathering & investigation) of incidents of any nature. The Inquest heard
evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the
lack of investigation of the near misses.

Medical response:
1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but
there was no system for getting urgent medical attention on the base if needed. There was no
mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this
could be done for a cake sale.
2. All the services should consider whether there should be a generic policy for the treatment of
exertional collapse (of any cause) as per US Army where during training there is a clear medical
plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation.
ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I 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
19 December 2022. I, 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

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:

The family of Kamil Iddrisu

The family of Yougson Nkhoma

Chief Constable for Staffordshire Police

The Health and safety executive

I 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.
24 October 2022

Signature:

Louise Hunt

Senior Coroner for Birmingham and Solihull

Responses

2 responses 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.

Response from Mod (PDF)

SECRETARY OF STATE 
MINISTRY OF DEFENCE 
FLOOR 5, ZONE D, MAIN BUILDING 
WHITEHALL  LONDON  SW1A 2HB 

Telephone 020 7218 9000 
Fax: 020 721 87140 
E-mail: defencesecretary-
group@mod.gov.uk 

30 January 2020 

4.4.3 

Dear Senior Coroner, 

RESPONSE TO HM SENIOR CORONER’S REGULATION 28 REPORT TO 
PREVENT FUTURE DEATHS 

Reference:   

HM Senior Coroner’s Letter 132897 – KAMIL IDDRISU (LH/RP) dated 6 Dec 

British Army/Capita Statement to the Coroner Following the Collapse of Mr 

A.   
19. 
B. 
Iddrisu at Assessment Centre Lichfield dated 13 Dec 19. 
C. 
Nkhoma at Assessment Centre Lichfield dated 13 Dec 19. 

British Army/Capita Statement to the Coroner Following the Collapse of Mr 

BACKGROUND 

In Nov 19 two candidates1 collapsed and subsequently died whilst taking part in 
1. 
the 2000 metre (m) run at the Assessment Centre Lichfield (AC(L)) as part of the Role 
Fitness Test Entry (RFT(E)) for joining the Regular Army.2 A copy of the Army 
Recruitment and Assessment Centre Selection process is at Annex A.  

Following the death of Mr Iddrisu (‘the first death’), appropriate action was taken 

2. 
to manage the risk, which was assumed at the time to most likely be a cardiac 
event.  After the death of Mr Nkhoma (‘the second death’), the 2000m run was 
suspended for all Commonwealth Candidates.  Once the cause of death was 
presumed to be Exertional Collapse Associated with Sickle Cell Trait (ECAST)3 several 
multidisciplinary meetings, with many medical experts, have taken place.  These have 
been informed by an Evidence-Based Medicine approach drawing on available 
research and current NHS best practice, tempered by best available experience of UK 
Subject Matter Experts (SMEs) and US Armed Forces.  It was also recognised that 
ECAST is a condition potentially applying to both UK and non UK candidates, therefore 
all subsequent actions have been applied to all candidates applying to join the Army.  

1 Mr Kamil Iddrisu from Ghana and Mr Youngson John Jumbe Nkhoma from Malawi. 
2 The ACs are contracted to be run by Capita as part of the Army Recruiting Partnering Programme.  
3 SCT is a hereditary condition that is normally benign but is known to be associated with sudden death on exertion 
following a breakdown of skeletal muscle. ECAST can rapidly lead to death when the large muscles break down, 
causing kidney and other organ failure, and is regarded as a ‘metabolic crisis’. 
Mrs Louise Hunt 
Senior Coroner for Birmingham & Solihull 
50 Newton Street 
Birmingham 
B4 6NE 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                 
 An Army SME group4 has been formally established as the Sickle Cell Trait 

3. 
Steering Group which reports to Director Personnel and the Army Health Committee.  
This Group will continue to review and revise current Army recruiting and in-service 
policies and procedures to mitigate the risk of further Sickle Cell Trait (SCT) related 
incidents to As Low As Reasonably Practicable (ALARP). It has been agreed for now 
that those with SCT still meet the entry medical standard for the Army, but this will be 
formally reviewed by the Army Heath Committee.   

HM SENIOR CORONER MATTERS OF CONCERN 

HM Senior Coroner raised two Matters of Concern in the PFDR dated 6 Dec 19, 

4. 
which are answered in the detail below. 

Matter of Concern 1.  Consideration should be given to all non-UK selection 

5. 
candidates being screened for sickle cell trait before embarking on any selection 
process.  A blood test can be undertaken to assess whether candidates have sickle cell 
trait. 

a. 
Action taken after the two deaths and before HM Senior Coroner 
issued the PFDR.  A number of actions were taken, the most pertinent being:  

(1)  As the first death was believed to be cardiac related, it was decided 
that any candidate, regardless of origin who presents with an abnormal 
Electrocardiogram (ECG) (as directed within current Army Cardiology 
protocol) would undergo a full Echocardiogram (ECHO).  

(2)  The 2000m RFT(E) best effort run was suspended on 28 Nov 19 for 
all CW candidates.  CW candidates completed the rest of the selection 
activities as normal.  As a result, approx. 150 candidates were placed ‘on 
hold’ pending a way forward.5  

Action taken since the issue of HM Senior Coroner's PFDR.  The PFDR 

b. 
was issued on 6 Dec 19; earlier that day the Deputy Chief of the General Staff 
(DCGS) – the Army's Principal Personnel Officer – directed that the Army (on 
medical advice) implement a screening process to identify those candidates who 
are SCT positive prior to participating in the 2000m best effort run.  This is being 
conducted in two phases:   

(1)  Stage 1 – Screening Questionnaire to identify those at risk of 
being SCT positive.  The NHS has already developed a Family Origins 
Questionnaire (FOQ) which helps to identify individuals whose family 
background indicates high risk of SCT. The Army has adopted, developed 
and implemented the FOQ which was issued on 13 Dec 19 (Annex B); it will 
be used to determine which individuals are at high risk and will be filled out 
in all Army ACs by all candidates regardless of origin and application 

4 Chaired by Senior Health Advisor (Army) and attended by, amongst others: Director Operations of the Army Recruiting 
and Initial Training Command, Head Advisory Army Legal Services, Defence Consultant Advisor for Occupational 
Medicine, Consultant Advisor General Practice (Army), Defence Consultant Advisor in Pathology, Recruiting Group 
Chief Medical Officer, Assistant Head of Professional Development (Army), and Occupational Medicine Representatives 
from the Royal Navy and Royal Air Force. 
5 The 2000m run assesses a candidate’s cardiovascular fitness.  The minimum standard is determined by intended job 
role requirements, considering the benefits offered by progressive development in Basic Training and aims to minimise 
risk of injury during training and throughout their career.   

 
                                                 
 stream (officer, soldier, Regular and Reserve).  This recognises that SCT is 
present in all family origins.6   

(2)  Stage 2 – Blood Test.  The FOQ will identify those candidates who 
will need to undergo a blood test to determine if they are SCT positive or 
negative.7    

Since the FOQ was implemented, the first cohort of 24 high risk candidates 

c. 
were blood tested at the Army Training Centre Pirbright (ATC(P)), through an 
interim process set up between the Defence Primary Healthcare (DPHC) and 
Frimley Park Hospital, on 19-20 Dec 19.  Seven were SCT positive, the 
remaining high risk candidates on hold will follow the same process. 

An Evidence-Based Medicine approach was adopted to swiftly manage the 

d. 
risk, using the available research albeit limited; “In military populations who had 
completed basic training there was a much lower risk of unexplained Exertional 
Death in SCT”.  Gardner et al attributed this to “elimination of a vulnerable set of 
recruits, the removal of the unique and novel stresses to succeed during basic 
training, and/or protection conferred by sustained enhanced fitness and 
environmental acclimation”.8  In the same paper O’Connor et al recommend that 
“appropriate progression in exercise intensity are critical factors in mitigating risk”.  
The Senior Health Advisor (Army) was also able to draw on contemporary US 
Armed Forces experience of managing SCT risk, provided through the British 
Medical Liaison Officer in Washington, to advise that a progressive 4-week pre-
conditioning course for SCT positive candidates will reduce the risk to ALARP. 

e. 
The Army already runs a well-established Soldier Development Course 
(SDC), (Annex C) 9 which has been designed to progressively assist potential 
Army recruits who have marginally failed at AC to develop in a range of areas to 
meet the Army’s entry standards.  The seven SCT positive candidates 
commenced a bespoke 4-week period of pre-conditioning, on 8 Jan 20, which is 
being run within the parameters of the SDC.  This pre-conditioning activity has 
been endorsed by the Army’s Senior Health Advisor.  For the SCT personnel 
their conditioning programme is to mitigate the risk of ECAST to enable them to 
undertake RFT(E) at the end of the course, which includes the 2000m run.  There 
will be a specific focus on avoiding over exertion by using individual heart rate 
monitors to assist their progression.  How these individuals perform and the 
effectiveness of the course in supporting them to meet the Army entry standards 
will be the subject of ongoing assessment and assurance.  Lessons learned and 
improvements will be incorporated into the next course due to start in Feb 20.  

Further action that will be taken.  Following the decision to screen all 

f. 
candidates for SCT when applying to join the Army, the Army in partnership with 
Capita are working to put in place an enduring solution to test the blood of every 
candidate whom the FOQ identifies as high risk of being SCT positive. This 

6 Medical advice highlights that SCT is present in 1 in 4 West Africans, 1 in 10 Caribbeans, 1 in 640 Caucasian and 1 in 
76 of all babies born in the UK (of all ethnicities). Currently JSP 950 entry policy excludes candidates with a history that 
indicates exertional rhabdomyolysis, whether caused by SCT or not, but not those with known asymptomatic SCT. 
There is no current intent to make asymptomatic SCT (without exertional rhabdomyolysis) a disbarring condition.   
7 Candidates will not be allowed to undertake to 2000m run until their SCT status has been determined. 
8 O’Connor et al.  “ACSM and CHAMP Summit on Sickle Cell Trait: Mitigating Risks for Warfighters and Athletes in 
Medicine and Science in Sports and Exercise”, June 2012 pp 2045-2056. Gardner JW et al.  Non-traumatic Exercise 
related deaths in the US military 1996-1999. Mil Med 2002:167(12):964-70. 
9 This was originally launched in Jan 17 as a pre-conditioning course and was retitled the Soldier Development Course 
in Apr 19. 

                                                 
 process enables a medical assessment to be made identifying those at risk of 
SCT with a follow on blood test to confirm their status, where required.  Unless 
proven to be SCT negative, no candidate at risk of SCT participates in the 2000m 
run, without attending a pre-conditioning course first.  The blood test screening 
process will be delivered through a future contracted arrangement, which will be 
United Kingdom Assurance Service (UKAS) accredited.  Details on the 
assurance mechanism will be known once the enduring solution has been 
implemented (not expected before 1 Apr 20). 

Assurance measures in place to ensure adherence to new 

g. 
measures/policy.  The following measures have been implemented, to date: 

(1)  Assurance of the pre-conditioning course.  Those SCT positive 
personnel (and non-SCT candidates) attending the SDC come under the 
same strict assurance and Duty of Care regime of all Defence training 
schools in terms of the Joint Service Publication (JSP) 822 and Army 
Command Standing Order 3216.  This includes the requirement for Risk 
Assessments and the implementation of practices that reduce any Risk to 
Life to ALARP.  The course has its own specific Risk Assessment and SCT 
positive personnel have an individual Appendix 910 which communicates 
the restrictions and limitations of that individual to the staff running the 
SDC.  The course will also receive additional and specialist assurance visits 
to ensure complete compliance with both the Duty of Care and SCT 
physical development direction.  

(2)  Control of SCT positive personnel on the pre-conditioning 
course.  The day-to-day management of the SCT positive personnel is 
tightly controlled.  Specifically, their progressive physical conditioning 
programme is individually tailored and includes specialist medical input. 
They will be overseen by qualified Army Physical Training Instructors and 
training staff dedicated to the course.  These SCT positive individuals will 
also wear personally issued watches with in-built heart rate monitors11 at all 
times to educate and minimise risk of over-exertion.  All candidates on the 
SDC (whether SCT positive or not) will be assessed using a sub maximal 
aerobic test.  This will provide the information to create individual heart rate 
training zones.  It is worth noting that all those attending the pre-
conditioning course still must meet the Army’s physical entry standards in 
order to proceed to Basic Training; if they fail to achieve the set standards 
by the end of the course they will be discharged. 

Matter of Concern 2.  Consideration should be given to all non-UK selection 

6. 
candidates who have been through the process already having an urgent blood test to 
check whether they have sickle cell trait.  If a person has sickle cell trait, they are a 
significant increased risk or death/collapse during military exercise. 

Action taken since the issue of HM Senior Coroner's PFDR.  The 

a. 
Interim Training Direction (Annex E) was issued to the Army Recruiting and Initial 
Training Command (ARITC) training establishments12 by Director Operations on 
13 Dec 19, with specific direction for the information to be briefed to or seen by all 
training staff, including Physical Training Instructors and medical staff.  The SCT 

10 Appendix 9 is taken from AGAI Volume 2 Chapter 78 (Annex D) 
11 The current issued model is Polar Ignite.   
12 The Royal Military Academy Sandhurst Group, The Initial Training Group and the School of Infantry. 

                                                 
 awareness and information document has been adopted across all initial training 
establishments from 5 Jan 20 and is at Annex C.  The Interim Direction is based 
on current US military practice and is designed to mitigate the risk for those who 
might be at risk of ECAST, how to recognise the symptoms and what immediate 
treatment is needed if ECAST is suspected.  Also contained in the document are 
the universal precautions designed to reduce the risk of those factors believed to 
contribute to the onset of ECAST, such as dehydration and dietary supplements 
containing stimulants.  Further, every individual identified as SCT positive is 
being issued with information on SCT in the form of a Public Health England 
information leaflet13 to understand the implications of their condition and how they 
can personally help to mitigate risk. 

b. 
Further actions that will be taken.  In order to ensure that the Army 
has identified all SCT positive individuals, all personnel not captured during the 
application process will be screened on entry, by the end of the first week of 
Basic Training (BT).14  It is intended to have this process, which will be developed 
with and delivered by the Defence Primary Healthcare Service, in place by as 
soon as possible and not later than 1 Apr 20.  In addition, the Army is considering 
an Army-wide screening programme for serving personnel. 

The Army’s Personnel Directorate has revised and circulated Army-wide 

c. 
the relevant policy to ensure that the prevention, recognition and effective 
handling of anybody suffering from Exertional Collapse, from any cause, is fit for 
purpose.  AGAI Vol 1 Ch 7 (Annex F) has been updated with a new paragraph 
called Risk of Exertional Collapse.  The revised document includes information 
on SCT positive personnel, including risk factors, recognition and treatment.  The 
policy changes have been directed to the Army’s Chain of command through an 
Army Briefing Note, at Annex G. 

The Army is also assessing further options for what pre-conditioning 

d. 
activity can be applied to SCT positive Regular officer and Junior Entry 
candidates.  Likewise, for candidates wishing to serve in the Reserves or those 
who apply to the Officer Training Corps whilst at university.  As lessons are learnt 
from the current conditioning course then more bespoke courses may be put in 
place elsewhere, notably for the Reserves and Junior Entry candidates. 

Work is also underway to develop the advice that will be given to all 

e. 
serving soldiers.  In addition, those who have been identified as SCT positive will 
be given bespoke advice.   

Secretary of State for Defence 

Chief Executive Capita plc 

13https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/701031/SCT28_Hb
_AS_carrier_leaflet_180418_web.pdf 
14 Screening will take place before recruits conduct the RFT(E) or any maximal heart rate activity. 

    
                                                    
                                 
 
 
 
                                                 
 Annexes 

A. 
B. 
C. 
D. 
E. 
F. 
G. 

Army Recruitment and Assessment Centre Selection Process. 
British Army Family Origins Questionnaire. 
Army Guide to ARITC re Soldier Development Course.  
AGAI Vol 2 Ch 78 Appendix 9. 
British Army Interim Training Directive. 
AGAI Vol 1 Ch7 Physical Training AEL 120 dated Jan 20. 
AGAI Vol 1 Ch7 Physical Training (ABN New Release). 

Enclosures: 

1. 
2 

JSP 950 Leaflet 6-7-7 Annex N Pre-Entry Other Conditions.  
JSP 539 Heat Illness and Cold Injury: Prevention and Management  

 
 
 
 Annex A to 
PFDR RESPONSE 
Dated 30 Jan 20 

ARMY RECRUITMENT AND ASSESSMENT CENTRE SELECTION PROCESS 

Army Recruitment Process.  For context and to help describe the recruiting process for an 

3. 
applicant wishing to join the Regular Army the following, noting there are nuances between 
Soldier/Officer and Regular/Reserve (primarily at selection15 and medical screening16), outlines the 
common soldier recruiting pipeline activity: 

Key Stages. The Army recruitment process delivers soldier candidates in to the British Army 

4. 
(via Training) in a series of stages.  Army entry standards are role specific and common for both 
UK Nationals and Commonwealth (CW) citizens.  CW candidates conduct the initial stages of 
recruitment at reach, due to the vast majority not being physically in the UK at point of 
application17.  The result is a subtly different journey from Application to Selection, managed by 
Candidate Support Managers (CSM) in the National Recruitment Centre (NRC) rather than 
Regional Recruiters.  The stages are as follows:   

a. 
Application. All candidates apply to join the British Army online via the Defence 
Recruiting System (DRS). This system then manages and tracks a candidates journey all the 
way to starting Basic Training.  This stage also includes an Initial Eligibility Check.  Due to 
these checks CW candidates require a manual intervention by the team based in the NRC to 
bypass the minimum UK residency requirement.  

b.  Online Medical Questionnaire (OMQ). The OMQ is conducted online using the DRS 
interface and seeks to filter out candidates early in the process, who are extremely unlikely to 
pass medical screening and therefore fail to achieve the Army medical entry standards.  

Army Brief (AB) and Initial Career Discussion (ICD).  Candidates who successfully 

c. 
pass the OMQ are invited to attend an AB/ICD.  This is most commonly held at an Army 
Careers Centre (ACC) and consists of two key parts.  The AB is an opportunity for Recruiting  
Group (RG) to explain to the candidate what the Army is and what it offers whilst the ICD is 
an opportunity for the candidate to discuss any personal preferences and ask any questions 
they may have with a recruiter.  CW candidates conduct the majority of the AB/ICD remotely 
with the CW Team in the NRC. 

d.  Medical Screening.  Candidates are medically screened against the Army Medical 
Entry Standards18.  For Regular Soldier this is facilitated using a candidates PHCR that is 
reviewed by a doctor.  For Regular Officer, all Reserve candidates and CW candidates the 
Recruiting Group Medical Declaration (RGMD) is used.  The RGMD is completed by the 
candidate’s doctor.  At both OMQ and Medical Screening Further Medical Evidence (FME) 
may be requested from a candidate and a medical fail can be appealed. 

e. 
Assessment Centre (AC). Soldier Selection, conducted at an AC, consists of a Pre-
Service Medical Assessment (PSMA), cognitive testing and physical assessment.  The run 
element of the physical assessment is not conducted by candidates until they have been 
cleared ‘medically fit’ by the AC doctors, post full PSMA.  

PSMA.  PSMA includes several tests and a thorough one-to-one examination 
f. 
conducted by a Doctor.  Prior to the one-to-one, medical technicians and nurses conduct a 
series of ‘run-ups’ including urine tests, basic measurements and vision/hearing testing.   All 

15 Officer candidates (Regular and Reserve) attend Westbury (Army Officer Selection Board), rather than one of the 4 (Pirbright, Lichfield, Glencorse 
and Belfast) soldier Assessment Centres. 
16 Regular Soldier candidates have their PHCR (Primary Healthcare Records). 
17 CW Candidates are formally invited to attend AC in writing to help support their Visa Application (when required).  The CW recruitment process is 
influenced by immigration requirements and security vetting.  
18 Joint Service Publication 950 Medical Policy Leaflet 6-7-7 (20 Aug 19 Revise).   

A-1 
OFFICIAL – SENSITIVE  

 
                                                 
 candidates have an ECG and all ACs can conduct both an exercise Spirometry and ECHO 
when a requirement is highlighted in a candidate’s ECG. 

The cognitive assessment consists of 4 elements detailed below. (1) and (2) are 

g. 
common to all and therefore tested for all soldier candidates. (1), (2) and (3) are scored 
refining which soldier roles a candidate is eligible for. They are as follows:  

(1)  General Trainability Index (GTI). As the name would suggest the GTI score 
gives an indication as to the trainability of a candidate. Each soldier role has subtly 
different training requirements, which is reflected in the GTI score required.  

(2)  Functional Skills Assessment (FSA). The FSA assesses a candidate’s 
numeracy and literacy level. Functional Skills Entry Level (EL) 2 is the minimum level to 
enter Basic Training in the British Army.  

(3)  Technical Selection Test (TST). More technical soldier roles require candidates 
to conduct the TST. This test is primarily maths focused.  

(4)  Further Educational Evidence. Some roles require Mandatory Academic 
Qualifications (MAQ) that are provided at AC, if not before, in the form of educational 
certificates.  

h. 

The physical assessment19 consists of 3 elements:20  

(1)  Mid-Thigh Pull. Very similar to a dead lift, this assessment assesses/indicates 
strength and capacity. This has multiple correlations with military tasks. Score required 
is dictated by role (but minimum 46 kgs).  

(2)  Medicine Ball Throw. This measures upper-limb strength and involves throwing 
a 4 kg medicine (weighted) ball from the sitting position with legs extended and back 
against a wall. The score required is dependent on role (minimum 2.9 metre throw).  

(3)  2000m Run. This activity is best effort and determines a candidate’s 
cardiovascular fitness. A 500-metre run/walk is conducted as a squad as a warm-up. 
This is to be completed in 6:30 – 7:00 minutes (as a warm-up) immediately prior to the 
2000 metre best effort run. The score required is dependent on role (minimum 
Standard Entry requirement is 11:15 minutes). The run element of RFT(E) is only 
completed when a candidate has been deemed medically fit at PSMA.  

Assessment Centre Pass/Fail.  All Regular Soldier Candidates can only be loaded to 
4. 
Basic Training having passed the Army Entry Standards for a specific soldier role.  Therefore a 
candidate’s result is dependent upon their preferred/chosen role (this is often a two way 
discussion).  Each soldier role has different cognitive, educational and physical entry standards 
specific to their future employment.  Providing a candidate passes for this role and there is training 
space available candidates are loaded to the event by the Load to Train Team in the NRC.   

19 Role Fitness Test (Entry) (RFT(E)), effective as of 1 Apr 19. 
20 The current RFT(E) tests and standards have been developed using an internationally-recognised scientific method which combines scientific 
technical analysis and military judgement.  This approach considers the benefits of progressive physical development afforded during Basic Training 
and is intended to minimise risk of injury both during training and throughout career. 

A-2 
OFFICIAL – SENSITIVE  

 
                                                 
 
 Annex B to 
PFDR RESPONSE 
Dated 30 Jan 20 

FAMILY ORIGIN QUESTIONNAIRE 

Candidate URN 

Candidate Date of Birth 

Candidate Surname (Last name/family name) 

Candidate Forename (First name) 

INFORMED CONSENT 

This questionnaire is to assist in establishing a candidate’s genetic heritage.  This will enable the 
assessment of the candidate’s sickle cell status. 

The results of this questionnaire will be used to inform whether a blood test will be needed to 
ascertain the candidate’s sickle cell status.  This information will then be used to assess the risk of 
exertional collapse when taking part in the Army physical tests.   

The candidate is required to sign and date this form to confirm that they have had the 
questionnaire explained to them and understand its purpose and that they consent to being asked 
these questions to ascertain if there is a requirement to progress to a blood test21.  A copy of this 
form will be held in the candidate’s case file.  The health professional who has explained the 
purpose of this form must also sign below. 

Candidate signature………… 

Date…………   

Health Professional’s Name………… 

Signature………… 

If the candidate does NOT consent to the completion of this form and has been informed that their 
application to join the Army cannot continue at this time, the Health Professional needs to confirm 
this and sign. 
Health Professional’s Name………… 

Signature………… 

Date…………   

Once the form below is completed the outcome is to be circled or ticked on this front page: 

FOQ Outcome 

Proceed 

Held pending blood test 

21Candidates who do not consent to completing the FOQ are unable to progress with their recruitment at this time. 

B-1 
OFFICIAL – SENSITIVE  

 
 
 
 
 
  
 
  
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                 
 FAMILY ORIGINS: 

The following questions relate to the candidate’s BIOLOGICAL parents.  Please tick all boxes in ALL 
sections that apply to the biological mother and biological father. 

Biological Mother 

Biological father 

A.  AFRICAN OR AFRICAN-
CARIBBEAN (BLACK) 
Caribbean Islands 
Africa (excluding North Africa) 
Any other African family origins 

B.  SOUTH ASIAN (ASIAN) 
India or African-Indian 
Pakistan, Bangladesh, Sri Lanka 
Nepal 

C.  SOUTHEAST ASIAN 
(ASIAN)  
China including Hong Kong, 
Taiwan 
Singapore, Thailand, Indonesia 
Malaysia, Vietnam, Philippines  
Cambodia, Laos, Myanmar 
Any other Asian family origins 

Any Melanesian/Polynesian 
country (includes Fiji, Tonga) 

D.  OTHER NON-EUROPEAN 
(OTHER) 

North Africa, South / Central 
America 
Middle East, Saudi Arabia, Iran 

Any other non-European family 
origins 

E.  SOUTHERN AND OTHER 
EUROPEAN (WHITE)  
Sardinia 
Greece, Turkey, Cyprus 
Italy, Portugal, Spain 
Albania, Czech Republic 
Poland, Romania, Russia 
Any other Mediterranean country 

Biological Mother 

Biological father 

Biological Mother 

Biological father 

Biological Mother 

Biological father 

Biological Mother 

Biological father 

B-2 
OFFICIAL – SENSITIVE  

 
 
 
 
 
  
  
  
  
  
  
 
  
 
 
  
  
  
  
  
  
 
  
 
 
  
  
  
  
  
  
  
  
  
  
  
  
 
  
 
 
  
  
  
  
  
  
 
  
 
 
  
  
  
  
  
  
  
  
  
  
  
  
 F.  UNITED KINGDOM (WHITE)  

England, Scotland, Northern 
Ireland, Wales            

G.  NORTHERN EUROPEAN 
(WHITE)  

Austria, Belgium, Switzerland, 
Scandinavia                               

Ireland (Eire), France, Germany, 
Netherlands  
Australia, North America, 
Canada, South Africa, New 
Zealand 
Any other European family 
origins 

H.  DON'T KNOW 
Adoption 
Unknown for other reasons 

I.  BONE MARROW 
TRANSPLANT (FOR SICKLE 
CELL DISEASE) 

Have you had a bone marrow 
transplant?           

Has either parent had a bone 
marrow transplant – if yes to 
either parent - test  

Biological Mother 

Biological father 

Biological Mother 

Biological father 

Yes 
Biological Mother 

No 
Biological father 

Yes/No 

Yes/No 

Biological Mother - Grandmother  Biological Mother - Grandfather 

J.  ORIGIN  

A.    AFRICAN OR AFRICAN-
CARIBBEAN (BLACK)                                        
B.    SOUTH ASIAN (ASIAN) 
C.    SOUTHEAST ASIAN 
(ASIAN) 

D.    OTHER NON-EUROPEAN 
(OTHER) 

E.    SOUTHERN AND OTHER 
EUROPEAN (WHITE) 
F.    UNITED KINGDOM (WHITE) 
G.    NORTHERN EUROPEAN 
(WHITE) 
H.    DON’T KNOW 

B-3 
OFFICIAL – SENSITIVE  

 
 
  
 
 
  
  
 
  
 
 
  
  
  
  
  
  
  
  
 
 
 
  
 
 
 
 
 
  
 
  
 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 Biological Father - Grandmother 

Biological Father - Grandfather 

K.  ORIGIN 

A.    AFRICAN OR AFRICAN-
CARIBBEAN (BLACK)                                           
B.    SOUTH ASIAN (ASIAN) 
C.    SOUTHEAST ASIAN 
(ASIAN) 

D.    OTHER NON-EUROPEAN 
(OTHER) 

E.    SOUTHERN AND OTHER 
EUROPEAN (WHITE) 
F.    UNITED KINGDOM 
(WHITE) 
G.    NORTHERN EUROPEAN 
(WHITE) 
H.    DON’T KNOW 

Guidance for health care professionals. 

Please ask for the family origins going back at least 2 generations (or more if possible) – 

1. 
sections J and K.  Assessing risk as per below, i.e. origin groups A, B, D, E H and I require testing. 

Boxes A, B, D, E, H and I represent a high prevalence area/risk for sickle cell disease, and 

2. 
boxes C, F and G are associated with a low prevalence area/risk. 

If a Candidate has ticked any of the high prevalence boxes, it is recommended that a 

3. 
screening test for sickle cell is required to proceed in the process. 

If the candidate ticks a low prevalence box for both parents, then they can proceed to the 

4. 
RFT(E) in particular the 2 km run. 

If the candidate does not consent to the completion of the FOQ, the clinician is to sign and 

5. 
date this form. 

The form is to be signed by the clinician to confirm that they have informed the candidate 

6. 
the purpose of the questionnaire. 

B-4 
OFFICIAL – SENSITIVE  

 
 
  
 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 Annex C to 
PFDR RESPONSE 
Dated 30 Jan 20 

10 Jan 20 

ARMY HQ PHYSICAL DEVELOPMENT GUIDANCE TO ARITC 
REDUCING THE LIKELIHOOD OF EXERTIONAL COLLAPSE ASSOCIATED WITH SICKLE 
CELL TRAIT (ECAST) 

1.      Following a series of meetings on 07 Jan 20 at ATR(W), the following physical development 
guidance is provided by Professional Development Branch, Personnel Directorate, Army HQ. This 
document provides interim guidance for the delivery of the Soldier Development Course (SDC) to 
reduce the likelihood of ECAST during selection and training. Future consultation will be necessary 
with stakeholders to further refine the SDC content and to enhance the guidance and mitigations 
provided at this stage.  
ECAST Education 
2.      Educate both SCT+ candidates and Directing Staff on how to promote, prevent, detect and 
treat ECAST: 

a.      Promote: 

(1)     Health education, including a positive approach to PD activities and general 
lifestyle. 

(2)     Management of SCT+ through effective policy and guidance to staff and SCT+ 
personnel. 

b.      Prevent: 

(1)     Using universal mitigations and generic risk factors associated to exertional 
collapse.  Direction and Guidance is available in AGAI Vol 1 Ch 7. 

(2)     Through education and candidates and Staff in the management of progressive 
training and the basic use of the heartrate monitors and training zones. 

c.      Detect: 

(1)     During training.  Participants and Staff should be aware of the signs, these being: 

(a)     The SCT+ candidate may have been a front runner, or off to a strong start, 
but will be noted somewhere before the collapse as slowing down, falling behind 
and struggling.  

(b)     They begin to lose smooth coordination, they evolve into an awkward 
running posture and gait, with legs that may look wooden or wobbly.  

(c)     The SCT+ candidate may complain of progressive weakness, pain, 
cramping or shortness of breath. 

(d)     Distinct from the cramping of exercise associated muscle cramping, in 
ECAST, there is generally no visible muscle twitching and the muscles do not 
"lock up." The pain of muscle cramping is generally excruciating, whereas the 
predominate symptom of ECAST is weakness over pain. 

(e)     The ECAST casualty will initially be mentally clear, before the onset of 
confusion and loss of consciousness. 

C-1 
OFFICIAL – SENSITIVE  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (2)     View the US SCT awareness videos at https://www.hprc-
online.org/articles/sickle-cell-trait-awareness. 

d.      Treat: 

(1)     In the event of exertional collapse, the following immediate action drills are to be 
followed: 

(a)     STOP the activity. 

(b)     EVALUATE, ADMINISTER FIRST-AID as appropriate (ie. Check Airway, 
Breathing, Circulation and TREAT as required) and CALL emergency services if 
needed. 

(c)     ADMINISTER oxygen if available and appropriate. 

(d)     HYDRATE if tolerating liquids. 

(e)     INITIATE COOLING techniques as required. 

(f)     ENSURE appropriate medical follow-up of the individual. 

(g)     REVIEW others. Only restart activity when assessed as safe to do so. 

(h)     INFORM the Chain of Command as necessary. 

Controlled and Progressive Physical Training 
3.      Long-term prevention measures judged to reduce the likelihood of ECAST are to employ the 
use of training zones to support the positive effects of progressive and controlled physical 
conditioning. ARITC should review SDC MEL and allocate lessons to achieve the following: 

a.      At the beginning of the course conduct a sub-maximal aerobic test on the wattbike for 
all candidates.  A sub maximal aerobic test is a recognised method of establishing individual 
training zones whilst not taking the individual to maximum exertion.  

b.      Review training duration, intensity and frequency for all training activities including 
physical training, swimming, drill, fieldcraft and adventurous training. 

c.      Review medical plans and access to medical facilities including the access to oxygen.   

d.      Introduce pacing to assist SCT+ candidates to achieve their RFT (E) CEG run time 
whilst not at best effort (zone 5, 90-100% of maximum heart rate).  This is a pragmatic 
mitigation noting excessive motivation, highly likely on RFT (E), is an ECAST risk factor. 

e.      Ensure all exertional collapse risk factors (AGAI Vol 1 Ch 7) are reduced to ALARP. 

4.      Directing Staff to manage and monitor exertional levels of SCT+ candidates for all training 
activities: 

a.      As an additional mitigation tool (to the visible symptoms), monitor SCT+ candidate’s 
heartrate using issued heart rate monitor (HRM) watches. During training, use the alarm 
function on the issued heart rate monitor (HRM) watches to prevent SCT+ candidates from 
training in zone 522.  It must be noted the use of the HRM only forms one part of the overall 
assessment process and monitoring of participants. 

22 There is some fluctuation in heart rate zones depending on the activity. For example, take cycling and running at the same level of 
intensity: the cyclist’s heart rate is 5-10 beats slower than the runner’s heart rate. This is because cyclists don’t need to support their 
own bodyweight and their muscles can use most of the available oxygen for moving forward. Also, the number of working muscle 
groups used for cycling is smaller than for running.  

C-2 
OFFICIAL – SENSITIVE  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
                                                 
 Upper Thresholds 

Not to be used 

Only in Week 4 

Only in Weeks 2,3,4 

To be used 
throughout SDC 
To be used 
throughout SDC 

b.      ARITC Directing Staff to manage and monitor training/performance of participants and 
reduce the likelihood of ECAST to ALARP. 

c.      Participants to develop their fitness progressively and gradually in a controlled 
environment.  Analysis of the participants performance and HRM data should be used to 
review the SDC and to ensure the content remains optimised and intensity is progressive. 

d.      A key summative training objective on the SDC for SCT+ candidates is to achieve the 
RFT (E) minimum run time whilst remaining within the prescribed personal training zone (ie 
below 90% of maximum heart rate).  

e.      Wake Up exercises should not be used for SDC SCT+ candidates. 

Future Staffing Requirements 
5.      Recommended future tasks include:   

a.      Army HQ will continue to review SCT+ academic literature. ARITC to refine training 
and mitigations as necessary. 

b.      Establish failure and retest policy. ARITC with Army HQ in support. 

c.      Develop protocols to conduct the sub-maximal aerobic test on a treadmill.  ARITC with 
Army HQ in support. 

d.      Refine and optimise future SDC content by: 

(1)     Evaluating course feedback through internal validations from both staff and 
candidates. ARITC 

(2)     Evaluating candidates’ performance and development. ARITC 

(3)     Analysing HRM training zone data from candidates. Ensuring a progressive 
training pathway is achieved during the 4-week SDC course. ARITC 

C-3 
OFFICIAL – SENSITIVE  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Annex D to 
PFDR RESPONSE 
Dated 30 Jan 20 

APPENDIX 9 

FORM FOR NOTIFYING MEDICAL/ FUNCTIONAL RESTRICTIONS TO UNIT 

Guidance for MO. The form should provide sufficient information for the Unit to manage the individual’s 
career for the period until the review date. The individual should be given a copy and asked to read the 
paragraph below and sign at section 8. A second signed copy should be sent to the unit. It is the unit’s 
responsibility to hold the signed copy. There is no requirement to retain a signed copy on DMICP. If the 
individual refused to consent to the distribution of the App 9, you are still required to complete the DMICP 
JMES template and inform the CO of safety critical duties (weapon handling, driving etc). This is a public 
safety duty that surpasses that of confidentiality. 

Guidance for Unit. The unit are responsible for ensuring promulgation to OC, line manager, RCMO and 
the appropriate APC Career Manager as required. This form allows the Unit to conduct a risk assessment 
on the individual’s role. The form remains valid until the review date only. It is signed by the individual to 
ensure they are aware of the restrictions advised. If overdue review the unit should assume the individual 
is restricted all activities previously indicated and arrange a review. THIS APP MUST BE UPLOADED 
ONTO PAPMIS. 

Guidance for Individual. You must read this form and comply with its direction - it explains to your Unit 
any medical/ functional restrictions you have been given. The form will be used at Unit Health Committee 
meetings, will be held by your unit and a copy will be passed to your APC Career Manager. The APC 
Occupational Health Branch may access your medical record to provide further functional advice if 
requested. You have been given the opportunity to ask questions regarding the form and the Medical / 
Assessment Board proceedings, on-going treatment and likely outcome. You will need to sign section 8 to 
say you have been given a copy consent to its use and will abide by its direction.  

No:  

Unit: 

Rank
:  

JME
S: 

Date of board:  
MDS:  
MES temp/perm:  
MES:  A  L  M  E 

Name:  

Board 
Type:  

Review 
date: 

*Anticipated Outcome:  (e.g. return to MFD) 
*Anticipated Timeline / Stability:  

* Where appropriate these fields can be populated with relevant information in order to support 
employment decisions/discussions at UHC in addition to the PAPMIS record (which is key). The 
information is for guidance only and is subject to change.  

1. 
MND (L5-
L6) 

DEPLOYABILITY/EMPLOYABILITY ON OPERATIONS 

Not  Not deployable on operations 

MLD (L2-
L4) 

Limite
d 

MFD (L1) 

Full 

PJHQ CAT 1: personnel whose duties remain within the confines of designated 
main operating bases 
PJHQ CAT 2: personnel whose duties may require periodic deployment outside 
defensive locations 
PJHQ CAT2+: personnel whose duties may require routine deployment outside 
defensive locations  

D-1 
OFFICIAL – SENSITIVE  

 
 
 
 
 
 
 
 
 
 
  
 
             
 
 
              
 
 
 
 
 
 PJHQ CAT 3: personnel whose duties encompass the full spectrum of 
operations in theatre. CAT2+ by exception 

Deployability Category 
[SP]’s Deployability Category is:  
Functional Capacity on Operations 

Take cover/prone position - Yes  
Run a short distance (100m) - Yes  
Carry own bergan to transport - Yes  
Wear Operational Body Armour - Yes  
Stand 2 hours in PPE with weapon - Yes 
- 
- 

Overall risk assessment for deployment: 

Deployment Risk 

Incapacitation (Low Risk)  
Worsening condition (Low Risk)  
Primary care requirement (Low Risk)  
Rehabilitation requirement (Low Risk)  
Secondary care requirement (Low Risk)  
Emergency aeromed (Low Risk)  
Interference with treatment (Low Risk)  
Overall risk assessment for deployment (Low 
Risk) 

Comments:  Deployability/Employability on Operations – User comments 

DEPLOYABILITY/ EMPLOYABILITY ON EXERCISES/TRAINING SUPPORT 

2. 
DEPLOYMENTS 

Weight-personal kit & equipment  
Weight - personal kit & equipment - No specified limit  
-  

Infantry activities (Including digging) 
3100: Infantry activities - No specified restriction  
-  

Travel on foot across rough terrain  
3101: Travel on foot across rough terrain - No 
specified restriction  
Comments: - exercise cat 5  

Full trade exercise activities 
Full trade exercise activities - No specified 
restriction 
-  
Living in field conditions 
3200: Living in field conditions - No specified 
restriction  
-  
Move tactically and adopting fire positions 
3102: Move tactically and adopting fire positions 
- No specified restriction  

3. 

Trade restrictions 

Noise Restrictions  

SPECIFIC LIMITATIONS - complete if appropriate 
- trade cat 5  
Noise Restrictions - No specified restriction - as per 
HCP -  
5100: Climatic - No specified restriction -  
Other Restrictions - No specified restriction -  
Does not require ongoing primary health care  

Climatic Restrictions  
Other restrictions  
Requires ongoing primary health care 
Comments: - limitations cat 5  

4. 
Level 3 
PT 
Level 2 
PT 

Level 1 
PT 

FUNCTIONAL CAPACITY  
Unit mainstream or operational specific PT Programme (conditioning PT).  
Will have passed RFT(S)/AFT. 
Personnel with reduced physical ability, not quite ready to conduct mainstream PT 
(reconditioning PT).  
Will have completed the SCR to a satisfactory standard but not RFT(S)/AFT. 
Personnel who are medically exempt, un-acclimatised, on weight management programme, 
or who have not reached a satisfactory SCR, RFT(S)/AFT level. Requires rehabilitation 
and/or reconditioning before advancement.   

D-2 
OFFICIAL – SENSITIVE  

 
 
 
 
 
 Recommended Physical Training Level 
NB: PT prescriptions and PT Levels 1-3 detail can 
be found in AGAI 7. This relates to medical fitness to 
participate in physical training and medical fitness to 
attempt the fitness assessments/tests (i.e. physical 
fitness is not a factor that can prevent medical 
upgrading). 

Recommended PT Level: Level 3 PT  

Rehabilitation: 

Individual has been given a PT prescription  

Rehabilitation programme - risk of prolonged 
recovery if rehab interrupted - No  

Functional Activities  
Walking  
6007: Walking - No specified 
restriction  
-  
Standing  
6004: Standing - No specified 
restriction 
-  
Sitting  
6003: Sitting - No specified 
restriction 
-  
Lifting  
6200: Lifting - No specified 
restriction  
-  
Comments: - functional active cat 5  

Working Hours  
1210: Working Hours - No 
specified restriction  
-  
Workplace 
1213: Workplace - No specified 
restriction  
-  
Marching / drill  
6006: Marching/drill - No specified 
restriction  
-  
Guard duties 
9200: Guard duties - No specified 
restriction  
-  

Boots  
9301: Boots - No specified 
restriction  
-  
Clothing 
9300: Clothing - No specified 
restriction  
-  
Combat Body Armour  
Combat Body Armour - No 
specified restriction  
-  
Helmet  
Helmet - No specified 
restriction  
-  

SAFETY CRITICAL TASKS 

5. 
Driving  
1403: Driving - No specified 
restriction  
-  
Passenger 
1212: Passenger - No specified 
restriction  
-  
Comments: - safety cat 5  

Weapons 
9004: Weapons - No specified 
restriction  
-  
Ranges  
9003: Ranges - No specified 
restriction  
-  

Working at Heights  
1203: Working at Heights - 
No specified restriction  
-  
Workplace Assessment 
Workplace Assessment - No 
specified restriction  
-  

6. 

MEDICAL REVIEW  

Medical review required before commencing MST/ 
Deployment  
Approval by an ROHT required before commencing MST/ 
Deployment 
Comments: - med rev 5   

5500: Medical review before 
MST/Deployment - No  
ROHT approval required before 
commencing MST/Deployment - No  

7.  
Name: 

COMPLETED BY 

Rank and Appointment: 

Date: 

Signature: 

INDIVIDUAL’S ACKNOWLEDGEMENT OF RECEIPT  (Sign before giving to line 

8. 
manager) 

Name: 

Rank 

Signature: 

D-3 
OFFICIAL – SENSITIVE  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Annex E to 
PFDR RESPONSE 
Dated 30 Jan 20 

ARMY RECRUITING AND INITIAL TRAINING COMMAND HANDBOOK – TRAINING 
QUALITY MANUAL 
This document forms part of the ARITC Handbook and is intended for use in HQ ARITC and 
its Operating Groups only 

Title: 

ARITC Sickle Cell Trait (SCT) Information and Awareness 

Subject Area:    Deliver 

Applies:   

13 Dec 19 

Issued: 

13 Dec 19 

Last Reviewed:    10 Jan 20 (v1.1 with amendment) 

Contact: 

Maj (MAA) C M Roberts RAPTC 

Email: 

ARITC-PD-SO2 

Telephone: 

Military 

94344 5758 

Civilian 

01980 615758 

SICKLE CELL TRAIT (SCT) INFORMATION AND AWARENESS – FOREWORD 

Noting recent events, particularly those related to recruiting, assessment and testing, there is a 
requirement within the organisation to recognise how SCT may affect soldiers within our duty of 
care. 

The notes below are designed to present a wider understanding of SCT and inform our training 
staff on how to recognise those who within our care may be subject to a strain of sickle cell 
inheritance. 

SCT is a genetic condition that is generally benign; however, under physical exertion, 
complications can occur.  Unfortunately, many people do not know that they are affected, and 
symptoms can easily be confused with more common conditions, making it difficult to recognise 
immediately.  Exertional Collapse Associated with Sickle Cell Trait (ECAST) in our recruits can be 
minimised through screening23, education and appropriate acclimatisation to activity.  The detail 
below offers information and awareness for the prevention and management of our candidates and 
recruits. 

DOps  
ARITC 

S 

23. This process is currently under review by Occ Med, with further direction to follow. 

E-1 
OFFICIAL – SENSITIVE  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
    
                                                 
 SICKLE CELL TRAIT (SCT) INFORMATION AND AWARENESS 

References: 

Strength and Conditioning Journal – Sickle Cell Trait: a review and recommendation for 

A. 
training. (Vol 34 – Issue 3 – p 28-32). 
B. 
JSP 950 Lft 6-7-7 (V1.6 Aug 19). 
C.  Regulation 28 report dated 6 Dec 19. 
D.  Prevention of exercise-related collapse; Ser M34/19UM32246 dated 4 Oct 19. 

SICKLE CELL TRAIT (SCT) PHYSIOLOGY 

1.  What is it?  SCT is a condition acquired through inheritance and is related to family origin 
rather than geographic origin.  It is the inheritance of one gene for normal haemoglobin and one 
gene from sickle haemoglobin.   

Those Affected.  The sickle cell gene has survived in evolution as a natural way for the body 

2. 
to fight malaria.  It is present in 1:4 West Africans and 1:10 Caribbeans.  The trait can also appear 
in those with Mediterranean, Middle Eastern and Indian family origins. 

3. 
US Armed Forces Study.  (Ref A refers).  The US Armed Forces have linked SCT to 
exertional collapse during basic training.  Their conclusion is that Exertional Collapse Associated 
with Sickle Cell Trait (ECAST) is associated with intense conditioning at a level to which the 
individual is not accustomed. 

Physical Observations.  During intense maximal activity, a decrease in oxygen levels can 
5. 
cause some blood cells to deform (from the normal round shape to a sickle shape).  These sickle 
cells can block small blood vessels in the muscles leading to muscle breakdown (known as 
‘rhabdomyolysis’).  The breakdown products of damaged muscle can block the kidneys (causing 
kidney failure), with other toxic substances creating a ‘metabolic crisis’ that can include heart 
failure and death.  The harder and faster the individual works, the greater the chance that sickling 
will occur.  The Army recognises that a best effort run is a focus of risk.  US Army experience is 
that risk is greatest in early training, but does not completely disappear later on in Service. 
However, that risk can be significantly reduced by conditioning, education and by taking sensible 
precautions to mitigate the external risk factors of ECAST as much as practicably possible.  Heat, 
cold, dehydration, high altitude and carrying a heavy load are some of the factors that can increase 
risk.  

DIFFERENTIAL JUDGEMENT 

ECAST vs Heat Illness.  ECAST and heat illness can have similar symptoms and heat can 

6. 
amplify the risk of ECAST.  Heat management within the organisation is well measured and 
understood by our instructors.  An individual with ECAST will complain of muscle pain and 
weakness; they may have been a front runner before dropping off the pace, slowing, and being 
seen to wobble or have an odd running gait, before collapsing.  Heat illness will be associated with 
feeling hot and is associated with muscle cramps.  These are indicators as there are few absolutes 
in medicine.   

Signs and Symptoms of ECAST.  Additional signs of ECAST are abdominal pain, chest 

7. 
tightness and difficulty breathing.  None of these symptoms are exclusive to ECAST, but in a 
known SCT-positive individual then ECAST should be immediately considered.  A casualty will 
often be conscious when they first collapse with ECAST so they can state the symptoms: however, 
deterioration is often rapid, and they must be regarded as a life-threatening emergency requiring 
immediate transport to hospital. 

E-2 
OFFICIAL – SENSITIVE  

 
 
 
 
 
 
 
 
 
 Table 1 - Common Conditions Leading to Non-Traumatic Collapse 

Sickle Cell Trait (SCT) 
Onset 

Many SCT carriers 
are not aware of 
their condition 

Usually no gradual 
warning or ill 
feeling 

Sickling can occur 
in as little as 2-3 
mins of vigorous 
activity 

Signs and 
symptoms 

Casualty is usually 
able to 
communicate after 
collapsing 

Muscles look and 
feel normal, but 
the individual says 
they are painful 
and feel weak 

Sickling pain 
(usually in the 
legs, buttocks, and 
low back) is often 
milder than heat 
cramps (this is 
unlikely to be a 
helpful sign at 
point of collapse) 

Mild sickling can 
improve after only 
10-15 mins of rest, 
oxygen and fluids. 
Do not delay 
transfer on the 
assumption the 
casualty will 
improve 
Pain in upper left 
quadrant of the 
abdomen, or in the 
chest due to blood 
vessels blocked in 
the spleen. May 
have severe 
difficulty breathing 

EXTERNAL RISK FACTORS 

8. 

A number of factors are believed to contribute to the onset of ECAST:   

a. 

b. 

c. 

d. 

e. 

Dehydration. 

Those who have previously suffered minor episode of ECAST. 

Exercising with a cold or when feverish (including within 24 hours of vaccination). 

Lack of appropriate acclimatisation. High ambient temperature and humidity. 

Certain medications (such as statins for cholesterol). 

Dietary supplements containing stimulants, to include various types of energy shots or 

f. 
drinks. 

g. 

Exercise at altitude. 

Risk Mitigation.  These risk factors are to be mitigated as much as reasonably practicable, 

8. 
particularly during the first four weeks of Basic Training, with a focus on hydration, the avoidance of 
supplements and stimulant, underlying health and climatic conditions.  

INTERIM GUIDELINES FOR CMTs/INSTRUCTORS 

9. 
ECAST.  An episode of ECAST should be treated as a life-threatening emergency.  In all 
instances where ECAST is suspected a 999 call must be initiated.  For the CMT/first responder the 
following are immediate actions to be taken: 

a. 

Administer high flow oxygen. 

Check, record and monitor vital signs including heart rate, respiratory rate, SpO2, ECG 

b. 
(where available) and level of consciousness. 

E-3 
OFFICIAL – SENSITIVE  

 
 
 
 
 
 
 
 
 
 
 
 
 
 If there is suspected associated heat illness, the first aid treatment guidelines as 

c. 
detailed in JSP 539, Section 1, Annex B is at the following 

E-4 
OFFICIAL – SENSITIVE  

 Annex F to 
PFDR RESPONSE 
Dated 30 Jan 20 

Army General and Administrative Instructions Volume 1 Chapter 7  
 Physical Training  

Risk of Exertional Collapse  
An individual who is poorly performing or demonstrates distress during, or immediately after 
physical exercise, may be at risk of exertional collapse, and potentially death. Poor performance 
and distress must be recognised early to enable timely intervention, including immediate cessation 
of the physical activity. Priority must be given to treating the individual. A dynamic risk assessment 
should consider whether others participating in the same activity are also at risk and whether the 
activity can safely resume.    
Risk factors associated with exercise-related collapse can be personal, environmental, or external. 
In addition, excessive motivation is equally important to recognise as a risk factor, as an individual 
can push themselves during physical activity and ignore the onset of physical signs and symptoms 
of distress.  
The risk can be mitigated through physical conditioning, good hydration, acclimatisation, avoiding 
potentially harmful supplements or medications (as directed by the medical chain), and recognising 
and addressing risk factors.  Recognised risk factors are listed below, noting this is not an 
exhaustive list. 

a.      Personal risk factors include: 

• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 

Dehydration 
Recent or current illness (include raised temperature) 
Recent vaccination (within 24 hours) 
Poor baseline conditioning/fitness level 
Excess body fat 
Prior poor fitness test performance 
Prior exercise related collapse 
Accumulated fatigue 
An underlying cardiac condition 
Asthma 
Sickle Cell Trait (SCT) 

b.      Environmental and external risk factors include: 

• 
• 
• 
• 
• 

Lack of appropriate environmental acclimatisation 
Exercise at altitude 
High ambient temperature and humidity, and cold weather 
Certain medications 
Dietary supplements containing stimulants, including energy shots or drinks 

Additional attention should be given to individuals with Sickle Cell Trait (SCT). Clinical evidence 
suggests that these individuals may be more prone to injury (or death) with physical exertion.  
In the event of exertional collapse, the following immediate action drills are to be followed: 

c.      STOP the activity. 

d.      EVALUATE, ADMINISTER FIRST-AID as appropriate (ie. Check Airway, Breathing, 
Circulation and TREAT as required) and CALL emergency services if needed. 

e.      ADMINISTER oxygen if available and appropriate. 

f.      HYDRATE if tolerating liquids. 

F-1 
OFFICIAL – SENSITIVE  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 g.      INITIATE COOLING techniques as required. 

h.      ENSURE appropriate medical follow-up of the individual. 

i.      REVIEW others. Only restart activity when assessed as safe to do so. 

j.     

INFORM the Chain of Command as necessary. 

F-2 
OFFICIAL – SENSITIVE  

 
 Annex G to 
PFDR RESPONSE 
Dated 30 Jan 20 

Source: Army Communications 

Date: 
ABN: 

24 Jan 20 
(Leave blank; serial number inserted by Internal Comms) 

NEW RELEASE OF AGAI VOL 1 CH 7 PHYSICAL TRAINING – DATED JAN 20 

Issue. The purpose of this ABN is to notify the Chain of Command of the recent release of 

1. 
AGAI Volume 1 Chapter 7 dated Jan 20. This version supersedes all previous versions of this 
AGAI. 

2. 

3. 

4. 

Target Audience. Distributed to all regular and reserve units. 

Staff Branch for ABN Digest. G7.   

Extract for Routine Orders. The following is to be repeated on Unit Routine Orders: 

NEW RELEASE OF AGAI VOLUME 1 CHAPTER 7  

  A revised AGAI Vol 1 Ch 7 Physical Training (AEL120) was republished in Jan 20.  AGAI Vol 1 
Ch 7 provides the Army’s direction and guidance on the management and delivery of physical 
training.  

  Amendments contained within the revised version include: 

  Risk of Exertional Collapse 

  Training and Testing Risk  

  Revised Risk Assessment process (IAW ACSO 3216).  To incorporate WBGT readings 
using QT34 eqpt. 

  Officer In Charge criteria 

  Use of Generic Risk Assessments (RA) 

  Clarification on fitness equipment induction 

  The revised AGAI Vol 1 Ch 7 is accessible via AKX. 

This Army Briefing Note, along with all others, can be viewed on MODNET or on a personal 
device via Defence Connect or by scanning this QR Code: 

ABNs on Defence Connect 

5. 

Key Points. The following key points should be noted:   

G-1 
OFFICIAL – SENSITIVE  

 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 AGAI Vol 1 Ch 7 is the Army’s overarching publication on Physical Training. All Physical 

a. 
Training must be conducted in accordance with the direction and guidance contained within. 

b. 

The various updates to the revised AGAI Vol 1 Ch 7 include: 

(1)  Risk of Exertional Collapse. Personal and environmental factors associated 
with exertional collapse are provided, including immediate action drills. 

(2)  Testing and Training Risk Management. All mandated physical testing and 
assessment are to be conducted in accordance with the direction issued by Army HQ 
in MATT 2. No deviation can be authorised by the CoC or event OIC without Army HQ 
endorsement. For Physical Training, commanders have the freedom to create and 
design innovative physical training activities which either support the APTS or 
supplement other training objectives. 

(3)  Revised Risk Assessment process (IAW ACSO 3216). WBGT readings must 
be incorporated in the RA for MATT 2 testing when there may be an elevated risk of 
heat illness. The QuesTemp 34 is the ratified method of measuring heat stress by the 
MOD and is an accountable item. 

(4)  Officer in Charge (OIC). Must be nominated prior to any physical training.  That 
individual is to have sufficient military experience and judgement to be responsible for 
the safety of individuals during the activity.  Hence, they are to be at least a Corporal 
(only in exceptional circumstances where senior rank is unavailable), but typically a 
Captain/Sergeant or above.   

(5)  Generic Risk Assessment. Generic RAs are to be produced for MATT 2 testing 
and where similar activities are undertaken or repeated. They are to be used as part of 
the forward planning of the activity or event. On the day of the activity or event, the RA 
must be reviewed and amended as appropriate to be site and conditions specific. As 
and when the situation or conditions change a dynamic review of the RA is to take 
place. 

(6)  Clarification on fitness equipment induction. Where standard fitness eqpt is in 
place there is no requirement for SP to receive specific eqpt induction from a qualified 
in-date PTI before using item which they are familiar with. 

c. 

All previous versions of AGAI Vol 1 Ch 7 are to be removed from use and circulation. 

6. 

 Point of Contact. Maj Geraint Field (Army Prof Dev PD PT SO2) 94393 6765. 

G-2 
OFFICIAL – SENSITIVE

Response from Secretary of State for Defence and Capita (PDF)

SECRETARY OF STATE 
MINISTRY OF DEFENCE 
FLOOR 5, ZONE D, MAIN BUILDING 
WHITEHALL  LONDON  SW1A 2HB 

4.7.3.1  

19 December 2022 

Dear Mrs Hunt, 

HM SENIOR CORONER’S REGULATION 28 REPORT TO PREVENT FUTURE 
DEATHS 

Thank you for writing us about this important matter. 

We  write  in  response  to  your  Prevention  of  Future  Deaths  reports  delivered  under 
paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 
of the Coroners (Investigations) Regulations 2013, in respect of the Inquest held into the 
deaths  of  Mr  Kamil  Iddrisu  and  Mr  Youngson  Nkhoma  which  concluded  on  18  October 
2022. 

In  your  Prevention  of  Future  Deaths  reports  dated  24  October  2022,  you  set  out  the 
circumstances giving rise to your concern.  Please find enclosed at Annex A our response 
to your concerns. 

We  hope  that  our  response  has  confirmed  that  the  Ministry  of  Defence  and  Capita  has 
learned  and  will  continue  to  learn  lessons  from  the  tragic  death  of  Mr  Iddrisu  and  Mr 
Nkhoma.    This  response  we  hope,  has  provided  you  with  sufficient  assurance  that  the 
necessary corrective action has been taken in response to your Regulation 28 reports. We 
hope  too  that  families  of  Mr  Iddrisu  and  Mr  Nkhoma  will  draw  some  comfort  from  the 
knowledge that your report has prompted action. As ever, our thoughts remain with them, 
and with all those friends and colleagues who continue to feel their loss so acutely. 

Secretary of State for Defence 

Chief Executive Capita plc 

Mrs Louise Hunt 
Senior Coroner for Birmingham and Solihull Areas 
50 Newton Street  
Birmingham  
B4 6NE 

 
                           
                        
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 Annex A 

RESPONSE TO HM SENIOR CORONER’S REGULATION 28 REPORT TO 
PREVENT FUTURE DEATHS 

Matters of Concern 1 Sickle cell trait screening process and identifying 
Sickle Cell Trait in candidates:  

1a 

 The Inquest heard evidence that since these tragedies there had been 

twelve (thirteen as one incident includes two people) near misses where the 

process that had been put in place following these tragedies had not been 

followed. This resulted in three candidates at High Risk for Sickle Cell Trait 

according to their Family Origins Questionnaire undertaking the 2km run. 

One of these had self-identified to a Group Leader prior to the exercise but 

was directed to complete the Role Fitness Test (Entry) run element in any 

case. This raises a concern about the screening process may not be safe 

and effective.  

Following a post-inquest review of Sickle Cell Trait risk management by six sigma 

qualified professionals, additional process control measures have been established to 

prevent high risk or unknown Family Origin Questionnaire candidates from attending an 

Assessment Centre. Individuals will not be loaded onto the course prior to being screened 

through the Family Origin Questionnaire or receiving their Sickle Cell Trait blood test 

results. This measure has been put into place to ensure that there is no prospect of such a 

candidate attempting the Role Fitness Test (Entry).  If the candidate’s Sickle Cell Trait 

status is positive or is not known prior to the Role Fitness Test (Entry), they will not 

participate in the Role Fitness Test (Entry) Multi-Stage Fitness Test.  Post-inquest, 

Recruiting Group has also completed a pipeline review of all candidates to identify any 

individuals who have not completed a Family Origin Questionnaire and the above process 

has been applied to such candidates so that they are prevented from attending an 

Assessment Centre prior to screening being completed.   

 In addition, a thorough review has now been completed of each of the twelve incidents 

identified following Recruiting Group’s Business Assurance Review. In all cases, the 

medical screening component worked as intended. However, in nine instances, a post-

screening control measure failed due to an administrative error; Defence Recruitment 

System record was not updated, or an error was made in completing/recording pre-service 

screening medical outcomes. However, other measures such as manual checks of an 

individual’s Sickle Cell Trait status worked as intended, so there was no risk of harm to the 

candidates involved.  

In three cases, other measures failed, these are therefore classified as ‘near miss’ incidents. 

Two of these took place at a facility administered by the Army, and additional controls have 

now been introduced, including enhanced staff training and awareness of Sickle Cell Trait 

and exertional collapse, and procedural changes that ensure that Sickle Cell Trait candidates 

are clearly identifiable.  One case took place at a Recruiting Group Assessment Centre 

(Pirbright), and specific enhancements have been introduced at this site, including an 

amendment to the Assessment Centre loading process that prevents high-risk Family Origin 

Questionnaire candidates from attending an Assessment Centre until blood test results are 

known, therefore removing the potential for at-risk candidates to undertake the run.  

Reporting processes have also been enhanced; any similar future incident will be 

investigated promptly and jointly by the medical and health and safety teams. These 

include automated notification of Recruiting Group’s Chief Medical Officer and Head of 

Health and Safety, to enable them to trigger an investigation by a newly established Joint 

Lessons Learnt Panel. This panel includes senior Recruiting Group and Army colleagues 

in operational, clinical, and health and safety leadership roles. The Panel has an enduring 

remit to review all reported accidents and near misses within 96 hours and make 

appropriate recommendations, although in practice incidents are reviewed within 48 hours. 

The panel also directs a suitably qualified individual or body (such as Recruiting Group’s 

Clinical Oversight Board) to conduct a more detailed Learning Account investigation. 

Once finalised, the Learning Account is reviewed monthly to ensure progress is made in 

implementing all recommendations. Learning Account reports are disseminated to Joint 

 Lessons Learned Board members who have the opportunity to challenge/comment.  The 

recommendations are added to an action tracker and assigned an owner and completion 

date, and progress is reviewed at the monthly Corporate Governance Review Board 

meeting. 

From an Army perspective, the Sickle Cell Trait screening process for all streams of 

candidates continues to be reviewed and refined on a regular basis (and informed where 

necessary, by the outcomes of any Joint Lessons Learnt Panel, Clinical Oversight Board or 

Learning Account recommendations) within the four Soldier Assessment Centres and the 

Army Officer Selection Board.  Similarly, Recruiting Group and Army Recruiting and 

Initial Training Command have reviewed the Sickle Cell Trait risk-management process 

and associated Risk Assessments for moving a candidate from the initial stages of 

recruiting activity through to the Pre-Service Medical Assessment and Role Fitness Test 

(Entry).    

To further reinforce these control measures, scenario-based simulation training 

exercises are conducted (and recorded) by each soldier Assessment Centre each 

quarter. All Assessment Staff attend scenario-based training that test understanding 

of Standard Operating Instructions/emergency response procedure for a variety of 

incident types. These exercises test understanding of Standard Operating 

Instructions, and emergency plans, including individual responsibilities. In addition, 

all new members of staff receive comprehensive Sickle Cell Trait related education 

and awareness during their induction training. This is based on developing 

awareness and an understanding of Sickle Cell Trait and the end-to-end risk 

management of candidates, through adherence to Standard Operating Instructions 

and familiarity with emergency response plans. Accordingly, the Sickle Cell Trait 

screening process is now deemed to be as safe and as effective as it can 

practicably be and will be subject to twice-yearly scrutiny by both the Recruiting 

Group assurance team, and Army-directed assurers.     

 
 1b  

The inquest was told that the Royal Air force and Navy are not 

screening any candidates for Sickle Cell Trait. The Army are. Both services 

are recruiting from the Commonwealth. Medical evidence at the inquest 

confirmed screening was the only way to safely identify candidates at risk. 

This raises a concern that the recruitment process is not safe and effective.  

Updated policy (Defence Instructions and Notice (DIN 2022DIN06-021) was issued on 04 

November 2022, that mandates that all military recruits or potential military recruits, 

across the Army, Royal Navy and Royal Air Force, be screened for Sickle Cell Trait. The 

screening process for identifying Sickle Cell Trait is split into two stages: 

•  Stage 1 – screening questionnaire: All recruits (regardless of origin and application 

stream) are required to complete an adapted Family Origin Questionnaire. 

•  Stage 2 – blood tests: Those identified as at-risk in the Family Origin Questionnaire 

proceed to blood testing to determine if they are Sickle Cell Trait positive or 

negative. 

Where recruits and/or potential recruits are identified by the screening process as having 

Sickle Cell Trait, the new policy mandates that this must be considered in the risk 

assessment for all intense exertional activities and suitable control measures must be 

applied based on input from medical professionals. The new process is to be implemented 

by the Royal Air Force and Royal Navy Commands no later than 1 January 2023. Army 

Recruiting and Initial Training Command and Recruiting Group have engaged with the 

Royal Navy and Royal Air Force to exchange best practice in respect of Sickle Cell Trait 

screening processes and risk management. 

The Royal Navy and the Royal Air Force have adopted the two-stage screening as part of 

their recruitment processes. It will initially be an in-house solution until a contract can be 

let in early 2023. The screening will be completed by all candidates irrespective of origin 

and application stream (Officer, Regular, Reserve). Candidates who are identified with 

Sickle Cell Trait from the Family Origin Questionnaire, will be blood tested prior to the 

 Pre-Joining Fitness Testing and can attempt a supervised, sub-maximal pre-joining 

physical test instead if they are found to be Sickle Cell Trait positive. Any candidates 

identified with Sickle Cell Trait are strongly encouraged to wear a wrist band during the 

pre-joining phase and in the first four weeks of initial training to identify them to staff as 

being at increased risk of exertional collapse. As a safeguard, if the candidate chooses to 

not wear a wristband (e.g. they do not want their medical status to be made public), 

Physical Training Instructors will know which candidate has Sickle Cell Trait which 

would allow for sufficient supervision of them.   All entry streams undertake a minimum, 

four-week Graduated Training programme incorporating Universal Training Precautions. 

The Royal Navy and the Royal Air Force have updated and communicated their policies 

and processes to improve understanding of Sickle Cell Trait amongst their personnel. This 

includes Defence direction for screening and reporting all suspected or confirmed cases of 

heat illness and exertional collapse in their policies. 

Matters of Concern 2 Training and Education 

2a 

The near miss incidents lead to a concern that staff involved in the 

selection process and Role Fitness Test (Entry) assessments are still not 

aware of the risk associated with Sickle Cell Trait given that in one case the 

person was directed to undertake the run despite knowing he was at high 

risk of developing exertional rhabdomyolysis associated with Sickle Cell 

Trait.   

In respect of the near miss incidents referred to, Director Operations, Headquarters Army 

Recruiting and Initial Training Command has issued Army guidance to all staff (‘A 

Commander’s Guide to Exertional Collapse’ and ‘Sickle Cell Trait The Facts’) to all 

personnel within Recruiting Group on 21 October 2022 and, following a process review, 

additional guidance on the management of Sickle Cell Trait candidates at Assessment 

Centres has been published (Standard Operating Instruction 26 dated 21 October 2022) – 

which every individual has been required to sign to say they have read and understood.  In 

 addition, scenario-based simulation training exercises are conducted by each soldier 

Assessment Centre every quarter and new members of staff receive comprehensive Sickle 

Cell Trait related education and awareness during their induction training. All Assessment 

Centre staff participate in quarterly scenario-based simulation exercises – including 

Physical Training Instructors.  Further, staff receive regular updates to policies and 

procedures through formal briefing notes, cascaded communications and through various 

management forums.  The Recruiting Group assurance framework, which includes checks 

by local line managers and compliance assessments by the Business Assurance Team, then 

verifies that amended policies and procedures are being adhered to and that they are 

effective in reducing the residual risk to as low as reasonably practicable.  This method is 

consistent with the Army’s Safety Risk Management approach which is based on five 

principles as laid down in Army Command Standing Order 1200 – The Army Safety and 

Environmental Management System. This replaced Army Command Standing Order 3216, 

which was extant at the time of the incidents, on 1 January 2021.  

To support the understanding of this approach there is structured training and an education 

package starting with awareness for practitioners and professionals (Safety Risk 

Management instructors) who will gain a recorded competency qualification. Additionally, 

the Army requires any Ministry of Defence person (Military or Civilian) responsible for 

conducting a risk assessment to also be suitably competent (trained, experienced and 

current), again with an associated competency qualification at both practitioner and 

instructor level. This risk assessment competency is valid for five years. 

2b  

The lack of screening in the Navy and Royal Air Force leads to a further concern 

about the level of understanding regarding the risks associated with Sickle Cell Trait – 

the evidence at the inquest said this risk was unpredictable.   

As covered under Matters of Concern 1b, a new Defence policy has been issued (Defence 

Instructions and Notices (DIN 2022DIN06-021 dated 4 November 2022) that directs that 

all military recruits or potential military recruits, across the Army, Royal Navy and Royal 

Air Force, are to be screened for Sickle Cell Trait. 

 2c  

The inquest heard evidence that there is no standardised way to identify Sickle 

Cell Trait candidates who are going through the selection process as the different 

services were considering using different colours wrist bands in different services. The 

raises a concern about the ability to identify those candidates who have Sickle Cell Trait.   

The Army have shared their wristband design with the Royal Air Force and the Royal 

Navy.  The Royal Air Force and the Royal Navy have decided to adopt the Army’s 

approach to and design of wristbands in their entirety. This is covered under Matters of 

Concern 1b. 

Recruiting Group will clearly comply with Defence direction to utilise coloured wristbands 

to identify Sickle Cell Trait Candidates but, as an additional control measure, also intends 

to use coloured bibs to ensure that high risk candidates are easily identifiable from a 

distance for all Assessment Centre staff during the assessment process. The wristbands and 

bibs will be issued by the Doctor to the candidate following the Pre-Service Medical 

Assessment.  This process should be in place by early 2023. 

2d  

There should be a review of the wording used and rationale for including 

questions for candidates regarding ‘cola coloured urine’ in the Pre-Medical Screening 

Assessment. Dr Gupta, an expert hematologist at the inquest, informed the court that 

this is not always a sign of Sickle Cell Trait as an individual can get cola urine from 

hepatitis. This raises a concern about the level of understanding of the significant of 

"cola coloured urine" and what it might indicate. 

The Joint Service Publication 950 which includes this wording will be reviewed through 

the Medical Employment Standards Military Judgement Panel in early 2023.   

A history of cola coloured urine is an indicator for several health conditions, some of 

which are significant and include muscle and kidney damage. It can also be due to 

medication (several can cause darkening of the urine), or even diet (eating large amounts 

of fava beans, rhubarb or aloe can cause dark brown urine). The rationale for 

asking this question, and the need for any additional explanation will be reviewed 

 through the Medical Employment Standards Military Judgement Panel. The Subject Matter 

Expert leading the panel, on behalf of Surgeon General, will be the Defence Consultant 

Advisor Occupational Medicine, supported by Surgeon General’s Medical Policy team and 

the relevant Defence and single Service experts. 

Matters of Concern 3 Reporting and investigation 

3a  

The inquest heard how Capita have set up a Clinical Oversight Board to review 

any incidents. First this board did not appear to have reviewed or audited any of the 

near misses referred to above and second it does not include a representative from the 

Army. This raises concerns about the lack of joined up thinking for an incident between 

Capita and the Army and the safety of the new process. 

The Recruiting Group Clinical Oversight Board was established on 19 May 2022.  Nine of 

the twelve identified Sickle Cell Trait related near misses occurred before this date.  The 

Clinical Oversight Board did not examine three incidents following its establishment 

because, while Incident Reports were filed in all cases, they were not disseminated to key 

stakeholders at the time due to Incident Reports not going to functional leads such as the 

Chief Medical Officer and Health and Safety Manager.  That has changed – the Chief 

Medical Officer, Deputy Chief Medical Officer and Health and Safety Executive Manager 

now directly receive all Incident Reports and initiate the Joint Lessons Learnt Panel 

process and subsequent review by the Clinical Oversight Board.  

The Clinical Oversight Board’s Terms of Reference have been reviewed and approved by 

all relevant stakeholders and subject matter experts following the inquest. Standing 

membership now extends to military Occupational Health colleagues from Headquarters 

Army Recruiting and Initial Training Command.  In addition, all twelve near miss cases 

have been examined by the Clinical Oversight Board (as detailed in response to Matter of 

Concern 1a). Appropriate action has been completed or is in progress with a defined 

completion date.   

 Since the inquest, the Joint Lessons Learnt Panel which is co-chaired by the Capita 

Director Quality & Compliance and Assistant Director Recruiting (Colonel) has met four 

times to review incidents and near misses that resulted in, or had the potential to result in, 

death or serious injury/illness.  The Panel has convened virtually to review the Incident 

Report and any related Capita Accident, Safety, property and Environmental Reporting or 

Defence Unified Reporting and Lessons System accident report with the aim of identifying 

primary causal and aggravating factors and determining whether any immediate action is 

required to prevent a reoccurrence. The Joint Lessons Learnt Panel has subsequently 

directed suitably qualified personnel to conduct a more thorough Learning Account 

investigation and make appropriate recommendations.  Three Learning Accounts have 

been generated since the inquest, all of which were completed within ten days of being 

initiated.  Recommendations have been assigned to action owners with completion dates 

and progress is reviewed monthly by the Clinical Oversight Board.  

This governance and assurance activity supplements the monitoring of all accident reports 

submitted via the Defence Unified Reporting and Lessons System and Capita Accident, 

Safety, Property and Environmental Reporting systems.  Both the dedicated Army 

Recruiting and Initial Training Command Safety, Health and Environment staff officer and 

the Recruiting Group Health and Safety Executive Manager now have permissions on 

Defence Unified Reporting and Lessons System to undertake their monitoring, analysis 

and reporting responsibilities, enabling joined-up thinking in relation to all safety matters.  

Enhancements to the Capita Accident, Safety, Property and Environmental Reporting 

accident reporting system (described in the response to Matter of Concern 3d below) will 

also trigger an investigation for all Tier 1 (Fatalities) and Tier 2 (Reporting of Injuries, 

Diseases and Dangerous Occurrence Regulations reportable/lost time/significant near 

miss) incidents. This will also contribute to joint organisational learning.   

3b 

Reporting of incidents: the majority of the twelve near misses were not 

investigated at the time they occurred which indicates the present process is not safe and 

effective.  

 As detailed in response to Matter of Concern 3c, Incident Reports (see Annex B) were 

raised for each near miss incident at the time, but these reports were not correctly elevated 

and reviewed because they were not distributed to the necessary stakeholders.  As detailed 

above, all Incident Reports are now directed to a wider stakeholder community within 

Recruiting Group, both military and civilian, including the Chief Medical Officer, Deputy 

Chief Medical Officer and the Health and Safety Executive Manager.  In addition, the 

Health and Safety Executive Manager now has visibility of, and direct access to, the 

Defence Unified Reporting and Lessons System.  Both the Army and Recruiting Group 

have now reviewed each of the twelve ‘near misses’ to identify root causes, trends and 

lessons. 

Since the time of the incidents the Army has introduced a new reporting system, the 

Defence Unified Reporting and Lessons System (see Annex C). This went live on 10 

January 2022 replacing the Incident Notification System which was in use in 2019 at the 

time of the incidents. The system is a data driven platform with auto-notifications built in 

allowing for automated notification to interested parties in real time. To this end, if a 

Defence Accident Investigation Branch notification threshold is crossed, the Defence 

Unified Reporting and Lessons System informs the reporter who is then able to activate a 

direct notification to Defence Accident Investigation Branch. As part of lessons learnt 

from this incident, the Defence Accident Investigation Branch have recently consolidated 

their various phone numbers for individual Services into a single number for all varieties 

of incidents and for all Services.  The Defence Unified Reporting and Lessons System will 

be Defence wide by mid-2024, is funded for the next ten years and is designed to 

continually evolve to maintain its currency and utility. 

3c  

There is no system to audit whether incidents are being correctly processed and 

investigated.  

As detailed in the response to Matter of Concern 3a above, all actual and ‘near miss’ 

incidents are reviewed at the monthly Clinical Oversight Board. Audit takes place at the 

quarterly Joint Health and Safety Executive Manager’s Conference, the quarterly Joint 

 Assurance Group (attended by both Capita and Army staff) and via appropriate Army 

Permanent President Service Inquiries and Army Personnel Services Group oversight 

mechanisms.  This is further supplemented by Ministry of Defence oversight of Defence 

Unified Reporting and Lessons System reporting through the single Service Safety 

Centres, the Defence Accident Investigation Branch, the Defence Safety Agency; and, 

separately, through Capita Health and Safety Executive oversight of Capita Accident, 

Safety, Property and Environmental Reporting and via reporting at Capita Divisional and 

Group level. In addition, the Chief Executive Officer Recruiting Group has directed an 

external audit of Sickle Cell Trait risk management procedures by Capita Group Internal 

Audit during the second half of 2023. 

In addition, Defence operates an assurance model for Health Safety & Environmental 

Protection to ensure that its policies are being implemented and reviewed and actions 

taken. 

•  The first level of assurance is carried out by the Commands, the Royal Navy, Royal 

Air Force and Army – they conduct assurance on themselves at regular intervals 

and annually. As part of this it will be expected that they will examine and assure 

themselves that Sickle Cell Trait screening policies are being complied with. 

•  The second level of assurance is carried out by personnel from the Health Safety & 

Environmental Protection Directorate on the Commands’ annual self-assessment 

and against the Defence Safety Management System Framework as detailed in 

Joint Service Publication 815 Part 1. It is expected that any failure to assure 

compliance on Sickle Cell Trait screening will be identified and brought to the 

Commands’ attention for action to rectify. 

3d  

The reporting system continues to use two parallel reporting forms for Capita 

Accident, Safety, Property and Environmental Reporting, and the Army Defence Unified 

Reporting and Lessons System. These are on separate Information Technology systems. 

This raises a concern that there is no “one version of the truth”. The inquest heard 

evidence that Capita were unclear if they had resolved the issue in their Capita Accident, 

 Safety, Property and Environmental Reporting, system associated with the drop-down 

menu options and the fact that non-work-related incidents close investigations 

automatically.  

Immediate action has been taken to ensure that all colleagues within Recruiting Group are 

clear that deaths, incidents that result in serious injury or illness and all suspected or 

confirmed cases of exertional collapse are reported to the Defence Accident Investigation 

Branch without delay by the person closest to the incident.  This direction will be 

replicated in Recruiting Group incident reporting policy and in a revised mandatory e-

learning training module by 31 January 2023. 

Both partners within Recruiting Group (Army and Capita) have organisational obligations 

that necessitate the ongoing use of two accident reporting systems.  Recognising the risk of 

a lack of coherence between these two systems, Recruiting Group, in consultation with 

Army Recruiting and Initial Training Command, has implemented a number of changes to 

maintain consistency. The Capita Health and Safety Executive Manager now has access to 

the Defence Unified Reporting and Lessons System so he can ensure consistency between 

this system and Capita Accident, Safety, Property and Environmental Reports.  He also 

maintains an accident reporting register (a new post-inquest measure) that details all 

reports received – this is presented to the Corporate Governance Board each month.  

Within the Assessment Centre, as a further safeguard, the same individual, the Assessment 

Centre Sergeant Major, completes both of the reports mentioned above. These changes 

ensure that reportable incidents and near misses are elevated, captured, analysed, and 

addressed by both partners (Ministry of Defence and Capita) leading to a joint response to 

identify and mitigate any residual risk of a reoccurrence.      

In addition, the Recruiting Group Health and Safety Executive Manager now has a 

Defence Unified Reporting and Lessons System account and can see all submitted reports 

in addition to those raised on Capita Accident, Safety, Property and Environmental 

Reporting.  Recruiting Group have implemented a monthly accident reporting tracker, 

which captures all Recruiting Group accident reporting, links to the corresponding Incident 

 Reports, and is reviewed monthly by Recruiting Group’s Corporate Governance Review 

Board (chaired by the Recruiting Group Chief Executive Officer).  Recruiting Group has 

also developed a mandatory e-learning package for all personnel covering incident and 

accident reporting procedures which is currently being reviewed in light of the inquest 

findings. 

Following the inquest, the Capita Group is reviewing the functionality of the Capita 

Accident, Safety, Property and Environmental Reporting system to report ‘non-work 

related’ incidents to ensure that they are appropriately classified and elevated for 

investigation.   The incident reporting process within Capita Accident, Safety, Property 

and Environmental Reporting automatically logs all Fatalities / Deaths as a Tier 1 Event 

which then triggers a formal investigation by the Divisional Health and Safety Executive 

Director. A revised Capita Accident, Safety, Property and Environmental Reporting 

platform rollout is scheduled by early 2023.   

The Defence Unified Reporting and Lessons System makes reporting more straightforward 

for all those Ministry of Defence staff with Defence Connect access and to ensure Capita 

has similar capability, the Recruiting Group Health and Safety Manager has the Defence 

Unified Reporting and Lessons System permissions and has access to report, review 

reporting and investigations, and analyse the data and trends that Recruiting Group would 

find insightful.   

3e  

It was unclear from the evidence whether the Recruiting Group has a clear 

identifiable person to take responsibility for the review health and safety incidents and to 

ensure adequate investigation is undertaken. Specifically, it was still not clear that any 

oversight of the medical incidents fell within the remit of the Capita Head of Health and 

Safety.   

Recognising the important relationship between ‘health’ and ‘safety’ in understanding and 

responding to any incident, the Chief Medical Officer of Recruiting Group is responsible 

for the medical aspects of service delivery and for clinical governance as part of the 

contract, and the Health and Safety Executive Manager is responsible for all Health and 

 Safety Environmental matters.  Both individuals work together and now receive all 

Incident Reports and are members of the Joint Lessons Learnt Panel.  As such, both are 

accountable for investigating incidents and producing Learning Account reports and 

associated recommendations (as directed by the Joint Lessons Learnt Panel Chair) which 

are presented to the monthly Recruiting Group Corporate Governance Review Board 

(Capita) and to the quarterly Joint Assurance Group (Capita and Army).  To be clear, the 

Joint Lessons Learnt Panel process directs one Learning Account investigation lead by the 

most appropriate individual but supported, as necessary, by additional subject matter 

experts. 

3f  

It was unclear from the evidence whether the Recruiting Group act as one entity 

regarding health and safety issues with a clear line of responsibility for global risk 

assessment (and promoting information gathering & investigation) of incidents of any 

nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any 

medical risk, which is supported by the lack of investigation of the near misses.  

Recruiting Group acts as one entity for health and safety issues through joint (Army and 

Capita) forums including a Joint Risk Management Board, the Joint Lessons Learned 

Panel, Clinical Oversight Board, quarterly Joint Health, Safety and Environment reviews 

and the quarterly Joint Assurance Group.  Policies and procedures are reviewed and 

approved by both partners to ensure clarity and coherence.  This joint governance 

framework supports a proactive and coherent approach to risk management and a more 

robust, timely and effective response to reported incidents and organisational learning.   

Since the inquest, eleven accident reports have been raised on Defence Unified Reporting 

and Lessons System and replicated on Capita Accident, Safety, Property and 

Environmental Reporting.  For coherence, the originator of both reports is the same person 

within each Assessment Centre and the Recruiting Group Health and Safety Executive 

Manager is now alerted to and can see both reports.  Once logged, the reports are captured 

in a monthly Health and Safety Executive tracker that is presented to Chief Executive 

Officer Recruiting Group.  Any inconsistencies in reporting between the two systems can 

 therefore be identified quickly and addressed.  In addition, the Health and Safety Executive 

Manager is able to record whether the Defence Accident Investigation Branch has been 

alerted to any incident, recording when notified, how and by whom and is asked to raise 

and escalate any omissions immediately.  The accident reporting tracker is used to ensure 

that all cases are subsequently reviewed by the Clinical Oversight Board.  

The Army has a single methodology to Safety Risk Management based on activity using a 

holistic approach including factors such as Health and Safety, Environmental and Medical. 

The activity risk assessment should include all the identified hazards to the participants. 

The Army’s approach to Safety Risk Management is contained in Army Command 

Standing Order 1200 with associated training, education and qualification as described 

above.  This is now supported by Standing Operating Instruction 26, which governs the 

management of Sickle Cell Trait candidates at Assessment Centres. This is also supported 

by Standing Operating Instruction 20, which governs the management of candidates who 

become unwell at an Assessment Centre. 

Matters of Concern 4 Medical response 

4a 

 Inquest heard how Lichfield had specialist medical staff on site in the medical 

training unit but there was no system for getting urgent medical attention on the base if 

needed. There was no mechanism to put a tannoy out for a medical emergency, but the 

Inquest heard evidence that this could be done for a cake sale.  

The tannoy system was installed at Defence Medical Services Whittington when the site 

was redeveloped, and it came fully operational in April 2014. It is used for any type of 

emergency, and it can be used as part of a site awareness programme to advertise other 

events/activities if the Head of Establishment deems it appropriate, however its primary 

purpose is for emergency announcements.   

The Defence Medical Services Whittington site was further developed during 2021 

following the closure of the Defence Infrastructure Organisation in Sutton Coldfield and 

the staff based there were transferred to Whittington. During the building works for the 

 new Defence Infrastructure Organisation Headquarters the tannoy system unfortunately 

suffered some damage. The tannoy system went through a complete overhaul in 2021 and 

the early part of 2022. The system was fully functional by May 2022.  If an emergency 

tannoy announcement is required, the request would be sent to the Guard Commander 

either via Head of Establishment Second in Command, the Adjutant or Regimental 

Sergeant Major. Any member of staff can also ring the Guardroom to state an 

emergency.  A site wide broadcast is then made.  Additional works are being undertaken to 

increase the number of external speakers around the site to ensure any announcement is 

heard, no matter where personnel are on the site. 

Although the site is primarily occupied by Defence Medical Services, not everyone who 

works within the Defence Medical Services are medically trained personnel.   The tannoy 

system can be used to summon a response in the case of an emergency but should not be 

used in lieu of the medical emergency Standing Operating Instruction. 

Following the inquest, Recruiting Group has issued revised guidance (Standing Operating 

Instructions 20), which details how to respond if a candidate becomes unwell during an 

Assessment Centre event.  The document details that Recruiting Group Doctors (Capita 

staff) should assist in an emergency as a ‘Good Samaritan’ drawing upon paragraph 26 of 

the General Medical Council’s ‘Good Medical Practice’ guidance which states that ‘You 

must offer help if emergencies arise in clinical settings or in the community, taking 

account of your own safety, your competence and the availability of other options for 

care’. The Recruiting Group Business Assurance team’s audit and compliance of 

Assessment Centres includes an examination of individual and collective training records, 

the continuous professional development records of the Physical Training Instructors and 

the conduct of emergency response exercises. 

4b 

All the services should consider whether there should be a generic policy for the 

treatment of exertional collapse (of any cause) as per United States Army where during 

training there is a clear medical plan with availability of essential medical treatment (e.g. 

oxygen and fluids) before hospitalization.  

 There is joint clinical policy in place for exertional collapse including Joint Service 

Publication 950 Leaflet 2-4-4: Exertional Heat Illness: Acute Treatment (v1.3 February 

2022).  

This policy leaflet applies to all Defence Medical Services personnel and contains medical 

management guidelines for first responders that include treatment measures to be taken in 

the specific event of exertional heat illness.  The policy also identifies the responsibilities 

of all Defence Medical Services personnel to both be trained in the prevention and 

management of heat illness and the provision of relevant advice to the Chain of Command 

(appropriate to their level of competency and responsibility).   

This policy is generic for other causes of exertional collapse and will be reviewed annually 

by the relevant Subject Matter Experts to ensure coherence with Exertional Collapse 

Associated with Sickle Cell Trait management guidance.  

Work is under way with the Defence Medical Academy to ensure Defence Medic training 

(our most likely first responders) incorporates exertional collapse scenarios to ensure early 

differential diagnosis, particularly where this requires any specific interventions (for 

example, cooling with heat illness).   

The policy enables establishment processes and procedures in the 

recruiting/selection/training where Defence clinical personnel provide support to 

emergency healthcare cover. It does not and cannot direct civilian healthcare providers, 

nor replace their well-rehearsed establishment processes and procedures in the delivery of 

an emergency response.

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