Joshua Hoole

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 

     27 January 2020 

4.7.3.1  

Dear Senior Coroner, 

Thank you for your letter of 1 November 2019 in which you enclose a copy of your 
Regulation 28 Report following the Inquest into the death of Corporal Joshua Hoole.  

My  department  greatly  values  coronial  oversight  and  the  opportunity  to  improve 
safety.  The Ministry of Defence is committed to being a learning organisation and to 
supporting  service  personnel  and  their  families,  especially  so  where,  tragically,  a 
death occurs.  We acknowledge, however, that your report raises a serious concern 
that lessons have not been learnt from past tragedies.  In your report you raise 19 
matters of concern, under six headings, and I will address these in the paragraphs 
below. I have highlighted where corrective action has been completed, and I have 
been given assurance that where there is still more to do, robust plans are in place 
to deliver what is required.    

General 

1. Failure to learn lessons following the 2013 death of 3 soldiers whilst on a training 
exercise in the Brecon Beacons. 

Having recently spent time with the families of the three soldiers who died in Brecon 
in 2013, the Commander Field Army has been rigorous in addressing the failure to 
learn  lessons  from this  tragic  event.  Awareness  of  Joint  Service  Publication  539  - 
Heat  Illness  and  Cold  Injury:  Prevention  and  Management  (JSP  539),  by 
commanders has improved since 2013 and since Cpl Hoole’s death, but we continue 
to  do  more.    All  Commanding  Officers  (COs)  are  briefed  on  JSP  539  during  pre-
employment  training  and,  to  further  raise  its  profile,  actions  are  being  taken  to 
reinforce the importance of its content (See para 1a). A significant amount of work 
has  recently  been  completed  to  address  the  training  shortfall  in  the  matter  of  risk 
assessments.  Following a comprehensive Training Needs Analysis in October 2019, 
a  plan  is  now  in  place  to  meet  the  immediate  needs  and  to  build  safety  risk 
management training into career training for all soldiers and officers (See para 1(b)).  
Reporting of incidents has been simplified, and a clear guide for commanders will 
accompany  the  launch  of  the  new  procedures  in  April  2020  (See  para  1(c)).   The 
mandatory requirement to take Wet Bulb Globe Temperature (WBGT) readings, in 
accordance  with  JSP539  (where  there  is  an  elevated  risk  of  heat  illness)  before 
physical testing and loaded march training has now been included in policy, as has 
the need for it to inform a risk assessment (See para 1(d)). Below are more detailed 
answers to each of your listed concerns under this heading. 

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 a.  Commanding officers were unaware of the JSP539 and there was no clear system 
in  place  either  to  disseminate  information  or  to  check  those  commanding  had  the 
requisite knowledge.  

All  COs  attend  a  Commanding  Officers’  Designate  Course  as  part  of  their  pre-
employment training.  The importance of heat illness and the content of JSP 539 is 
included on this course.  JSP 539, the Commanders’ Guide to Heat Illness and Cold 
Injury, and the Heat Illness and Cold Injury Field Guide are all accessible on MODNet, 
the Army Knowledge Exchange and Defence Connect, which is accessed through 
the  Defence  Gateway.    To  improve  awareness  further,  work  has  been  initiated  to 
explore the utility of a CO’s electronic handbook which will seek to signpost COs to 
relevant policy documents.    

Army  Briefing  Notes  are  produced  and  promulgated  each  time  new  policy  is 
disseminated.  To assure dissemination of policy, the Audit and Inspection regime 
includes annual inspections to check units are using the most up-to-date policy. The 
question  set  for  the  annual  Physical  Development  audit  is  being  amended  to 
specifically include the key heat prevention publications of JSP 539, Army Command 
Standing Order 3216 - Management of Safety and Environmental Protection (ACSO 
3216), and AGAI Volume 1 Chapter 7 - Physical Training (AGAI Vol 1 Ch 7).  Director 
General  Defence  Medical  Services  (DG  DMS)  is  completing  the  re-writing  of  JSP 
539.    The  plan  is  to  separate  policy  on  how  to  prevent  heat  illness  (JSP  375  - 
Management of Health and Safety in Defence) and how to treat it (JSP 539) and this 
will be complete by December 2020; I have included more detail in the JSP section 
below (see para 3).  

In February 2020, the Commander Field Army will use his annual conference to brief 
all COs on heat illness and JSP 539.  He will also write to his Commanding Officers 
once  JSP  539  has  been  revised  to  emphasise  the  importance  of  management  of 
heat illness and other safety related issues. 

b.  Commanding officers had not been trained on completing risk assessments. 

You highlighted your concerns regarding Risk Assessments following the deaths in 
Brecon and this shortfall was readily apparent in the circumstances surrounding Cpl 
Hoole’s  death.    The  Army  has  now  addressed  this  matter  and  commissioned  a 
comprehensive Training Needs Analysis.  The report on Safety Risk Management 
was published in October 2019 and training for the Army will be rolled out in 3 phases: 

a.  Phase 1: Risk Assessment Training.  A Train the Trainer course has been 
developed by the Army Safety Centre and pilot courses have already been 
delivered to qualify Army Force Protection Advisors to deliver risk assessment 
training.  A mass training event will take place at Tidworth Garrison Theatre 
on 29 January 2020.  The event will train up to 120 Army personnel on how 
to deliver risk assessment training.  Under the direction of the Deputy Chief 
Safety (Army) the trainers will then deliver distributed training across the Army 
with  the  aim  of  training  the  majority  of  the  target  audience  (planning  and 
training staff, COs, directing staff, activity directors) by the end of March 2020.  
The trainers will continue to provide a rolling programme of risk assessment 
training throughout 2020 to catch those unavailable for the initial tranche. 

b.  Phase 2: Surge Safety Risk Management Training.  The delivery of surge 
training is a recommendation from the Training Needs Analysis report.  The 
means of delivery and the timeline to deliver are being scoped and a proposed 
delivery schedule will be completed by the end of February 2020. 

 
 
 
 
 
 
 
 c.  Phase 3:  Steady State Training.  The steady state will see Safety Risk 
Management  Training  embedded  into  career  courses  to  deliver  the  right 
training at the right point in a soldier’s and officer’s career with each course 
building on the last.  It is anticipated that it could take up to 2 years to fully 
integrate the training into career courses.  The surge training will remain in 
place until the steady state solution has been implemented. 

c.  The system for reporting heat illness cases was disjointed and cases were not 
reported giving incorrect data. 

The disjointed reporting system identified in your PFDR following the Brecon Inquest 
was  highlighted  as  an  unresolved  issue  by  the  Army  Inspector  in  his  Thematic 
Review of the Army’s Application of Heat Illness Policy (November 2018).  In 2019, 
a  major  reform  of  Health,  Safety  and  Environment  Protection  (HSEP)  policy  and 
governance  in  the  MOD  resulted  in  the  creation  of  the  Defence  Safety  and 
Environment Committee (DSEC), chaired by the MOD's Permanent Secretary.  More 
recently, the Deputy Chief of the General Staff (DCGS) raised the matter to the DSEC 
Working Group directing that the MOD conduct a detailed review of the Management 
Information to improve the  way it reports and records all incidents including those 
involving heat illness; this work is ongoing and will be updated at the next DSEC (23 
March 2020).  DCGS remains closely engaged with this work with the MOD’s Director 
of Health, Safety and Environment Protection and the Vice Chief of the Defence Staff. 

The MOD is therefore focussed on improving both  how  and  what data is reported 
and recorded, which will lead to better collation and interpretation, improved trend 
analysis, and better Management Information that can be presented to the DSEC for 
Departmental policy setting. 

Within  the  Army,  and  in  consultation  with  the  Royal  Navy  and  Royal  Air  Force  as 
users of the existing Incident Notification System (INS) there has been progress on 
improving the coordination of reporting. A common (tri-service) suite of reporting and 
investigation forms has been developed, and the rollout of these new forms will be 
accompanied by a Commander’s Guide to Reporting and Investigations; both will be 
issued by 1 April 2020.  Future work is now focussed on designing an app-based 
reporting  mechanism  utilising  the  Defence  Gateway  portal,  which  will  permit 
personnel to report using smart phones/tablets etc.  A timescale for this future work 
is not yet confirmed.  

d.    There  was  no  system  in  place  to  ensure  WBGT  readings  were  taken  before 
training exercises. 

Good  progress  has  been  made  by  the  Army  with  the  use  of  WBGT  monitors.   
A Defence Information Notice (2019DIN06-022) was published in September 2019, 
clarifying the use of WBGT monitors and providing clearer guidance on how to site 
the WBGT correctly, how to take readings before the start of an activity, and how 
these should inform the risk assessment.  Both Military Annual Training Test 2 (MATT 
2) guidance and Army General Administrative Instruction Volume 1 Chapter 7 (AGAI 
Vol 1 Ch 7) have been amended to include specific direction that the WBGT readings 
must form part of the Risk Assessment process.  A revised version of MATT 2 was 
published on 18 December 2019 and AGAI Vol 1 Ch 7 released in January 2020.  
The Institute of Naval Medicine’s Thermal Burden Project is due to deliver its findings 
by  31  January  2020.    This  will  generate  new  evidence-based  tables  to  assist 
Commanders  in  making  safe  decisions  for  work  processes  of  up  to  four  hours’ 
duration, where WGBT is used to define a maximum safe work/rest duration.  

 
 
 
 
 
 
 
 JSP 539 

2.  I heard evidence at the inquest that Commanders were unaware of the provision 
of JSP539 and how they should apply to an annual fitness test (AFT). Several said 
they have not been trained on the publication and those that had seen it confirmed 
they did not understand the full effects of it and had not been trained on it. 

It  is  the  instructions  contained  in  MATT  2  and  AGAI  Vol  1  Ch  7  that  provide 
commanders on the ground with the necessary information and guidance on how to 
safely conduct an AFT.  JSP 539 is the top level, overarching, publication and MATT 
2  and  AGAI  Vol  1  Ch  7  are  complementary  single  service  policy  documents  that 
provide additional information to commanders. MATT 2 and AGAI Vol 1 Ch 7 make 
specific  references  to  direction  and  guidance  contained  in  JSP  539.    In  order  to 
increase awareness of JSP 539, the Army is conducting a review of the Unit Fitness 
Training Officer course (training) and the Physical Development Audit (assurance) to 
ensure  that  both  include  an  increased  focus  on  JSP  539  and  WBGT  Monitor 
readings.  This review will be complete by 30 March 2020.  The training chapter in a 
new ACSO on Heat Illness Prevention contains the requirement to conduct education 
and briefings at all events where there is a risk of heat illness.  It is on final circulation 
before scheduled publication on 31 January 2020.   

3.  Evidence at the inquest confirmed that the version of JSP539 in place at the time 
was difficult to read and understand.  The latest version remains long and complex 
and difficult to understand.  There should be consideration to providing commanders 
with shortened advice on the key messages from the publication – an aide memoire 
or fact sheets for example – to allow them to understand at a glance the messages 
being given. 

A Field Guide was produced in October 2019 entitled ‘Heat Illness and Cold Injury’.  
This  provides  commanders  with  a  short  reference  guide  to  assist  in  the 
understanding  of  climatic  injuries.   A  comprehensive  review  of  JSP  539  has  been 
completed and the Joint Medical Group (JMG) discussed the document at the Heat 
Illness Working Group on 18 July 2019. Members of the JMG agreed that the JSP 
was long and not the easiest to read.  The decision was taken to disaggregate the 
document.  Advice and guidance on the prevention of heat injury  will  be removed 
and inserted as a new  chapter in JSP 375  - Management of Health and Safety in 
Defence, whilst the more clinically focussed medical care required for heat and cold 
injuries will remain in JSP 539.  This work will be completed by 31 December 2020. 
The  publication  of  the  Institute  of  Naval  Medicine’s  Thermal  Burden  Project  will 
further inform the next iteration of JSP 539 and the new chapter in JSP 375. 

4.    The  current  JSP539  states  at  Annex  A  page  2A  that  the  activity  should  be 
“paused” if there is a suspected case of heat illness. MATT 2 states the activity should 
be stopped. The publications need to be consistent with each other and the guide 
should be clearer. 

There is, in fact, no inconsistency. JSP 539 covers a much broader range of activities, 
including military operations, where it might not be necessary or appropriate to stop 
activity,  and  where  a  pause  would  be  appropriate  in  the  event  of  a  heat  illness 
incident.   To  cease  all activity  in  an  operational  context  would  likely  pose  a much 
greater threat to service personnel.  In the case of a physical training activity, such 
as an AFT, there is no similar operational imperative and so, at the first indication of 
a heat illness incident, the activity is to be ‘terminated’ as directed in MATT 2.  In the 
training context, as stated above, it is MATT 2 that should be followed by those in 
charge. 

 
 
 
 
 
 
 5.    The  current  JSP539  has  several  annex  “A’s”  which  could  be  confusing  if 
commanders reference the wrong annex.  

The disaggregation of JSP 539, and the creation of a separate chapter in JSP 375 
will provide the opportunity to remove any confusion over the labelling of annexes in 
JSP 539. 

6.  Individual risk factors were an important part of understanding how a soldier would 
react to a situation and how best to mitigate any associated risk.  At present there is 
no clear system in place to ensure those conducting activities have the necessary 
information  about  an  individual  to  enable  them  to  carry  out  an  appropriate  risk 
assessment. 

JSP 539 includes guidance on the individual factors to be considered in relation to 
heat.    The  new  ACSO  3222  Army  Heat  illness  Prevention,  will  provide  additional 
direction specific to Army requirements.  This will include a check list of individual 
factors for use by commanders prior to the activity, and specific reference to heat 
illness risk assessments (Annex C to ACSO 3222). 

7.  The current JSP 539 does not set out explicitly that it is the role of the medic on 
an activity to pass on medical information. 

The recently updated MATT 2 and AGAI Vol 1 Ch 7 now include direction that medics 
are to communicate medical details of incidents to the Officer in Charge of physical 
training events.  JSP 539 will also include this explicit instruction in its new amended 
iteration.  

8.  The AFT is being phased out and new tests have been introduced namely GCC 
(Ground Close Combat) and RFT (Role Fitness Test).  The current JSP 539 does 
not  provide  guidance  for  the  acceptable  work  rates  for  these  activities  yet  the 
activities have already been introduced.  JSP539 is therefore inconsistent with the 
new MATT2. 

Army Briefing Note (ABN) 076/19 gives interim direction and guidance with regards 
to  GCC  and  RFT  testing  thresholds  until  JSP  539  is  subsequently  updated.    The 
conclusion  of  the  Institute  of  Naval  Medicine’s  Thermal  Burden  Project  will  permit 
further detailed guidance and work rates to be established for a range of activities in 
a range of different dress states.  This will include specific guidance for the GCC and 
RFT.  

9.  The two cases of heat illness in the AFT were not formally reported in accordance 
with  JSP539.    There  needs  to  be  a  robust  system  in  place  to  ensure  cases  are 
properly referred and recorded.  

See response at para 1(c). 

Military Annual Training Test 2 

The  MATT  2  guidance  has  been  re-issued  to  include  your  helpful  suggested 
amendments.  The Physical Development Audit will include a new question set from 
January 2020 that will assure the correct application of the guidance in MATT 2 and 
will confirm that risk assessments for these activities are being produced to the right 
standard. Below are more specific answers to your concerns. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 10.  MATT 2 pages 1.1-1.3 fail to refer to JSP539 as a relevant publication.  
MATT 2 Policy has been amended to provide specific reference to JSP 539.  

11.  At pages 2.7/2.8 it does not mention the need to use a WBGT.   
MATT 2 has been amended and now directs that WBGT readings are to be taken 
and  recorded  as  part  of  the  Risk  Assessment  process  prior  to  all  testing  in 
accordance with JSP539 (where there is an elevated risk of heat illness).  

12.    Currently  MATT2  states  the  medic  on  a  fitness  test  is  to  be  MATT3  trained.  
Given  that  these  medics  only  receive  basic  training  as  per  MATT3,  consideration 
needs to be given to have a better qualified medic who can properly identify the signs 
and symptoms of Heat Illness.  The Inquest was told by those who were MATT3 or 
team medic trained did not feel confident to diagnose Heat Illness and deferred to 
the Combat Medical Technician (CMT). 

The  views  of  the  Defence  Consultant  Advisor  on  Pre-Hospital  Care  (DCA  PHEC) 
were sought on the current provision of MATT 3 trained First Aid NCOs to support 
AFTs.The DCA PHEC considers this to be sufficient but did stress that heat illness – 
recognising the symptoms and being able to treat any casualties  – must be given 
sufficient focus during annual MATT 3 training of those personnel.  I hope that this 
deals with your concern, albeit by a different route. He reiterated that MATT 2 must 
make clear that any physical activity is to be terminated once a heat illness casualty 
is suspected or identified.  

13.    MATT  2  states that  commanders  should  use  a  generic  risk  assessment  as  a 
starting point to risk assess a particular activity. However, there is no generic risk 
assessment within MATT 2. Fitness tests are usually run over pre-set courses so it 
would  be  sensible  to  have  generic  risk  assessments  for  each  venue  with  clear 
instructions that they need to be tailored to the day and time of the activity and the 
prevailing environmental factors.  

MATT 2 and AGAI Vol 1 Ch 7 have been amended to give clear direction that units 
are  to  produce  generic  risk  assessments  for  all  physical  testing  and  assessment 
activity.  Generic Risk Assessments will be used as part of the forward planning of 
the  activity.    However,  on  the  day  of  the  activity,  the  Risk  Assessment  must  be 
reviewed and amended as appropriate to the specific site and conditions. 

The Physical Development audit question set will be amended by 30 March 2020 to 
include a specific check on generic risk assessments, and units will be monitored for 
compliance. 

Training 

14.  Witnesses at the inquest stated they were unaware of publications and had not 
received adequate training on those publications they were aware of.  There needs 
to be a clear system of training for key tasks and updated publications.   There needs 
to be measures in place to ensure all commanders are provided with the necessary 
information and a mechanism for annual updates and monitoring of awareness and 
training. 

Headquarters  Royal  Army  Physical  Training  Corps,  as  the  Training  Requirements 
Authority is conducting a review of the content of the Unit Fitness Training Officer 
course.  This review will ensure that all relevant publications are included in the  

 
 
 
 
 
 
 
 
 
 course and that all attendees receive the required level of training.  This review will 
be complete by 30 March 2020.  In addition, the Physical Development Audit Self-
Assessment has been updated to include specific detail on JSP 539 and  

WBGT Monitors and their readings.  The Training Chapter in the new ACSO on Heat 
Illness  Prevention  contains  the  direction  to  conduct  briefings  and  education  at  all 
events where there is a risk of heat illness.  

In  addition,  I  have  directed  the  Minister  for  Defence  Personnel  and  Veterans  to 
review  the  current  education  provided  to  Training  Officers  to  ensure  that  they  are 
qualified  with  the  correct  knowledge,  skills  and  experience  to  carry  out  their 
responsibilities.  This review will be initiated soonest and the Defence Inquest Unit 
will update you on the progress in due course. 

Wet Bulb Globe Temperature Monitor 

An  Aide  Memoire  has  been  produced  for  use  of  the  QT34  WBGT  monitor  and 
instruction  labels  ensuring  the  correct  siting  of  the  monitor  have  been  distributed.  
This was completed in October 2019.  In support, on 7 October 2019, the Physical 
Development audit was updated to include the requirement to assure that the labels 
are  affixed  and  the  aide memoire  is  held  with  every  monitor.   The  audit  also  now 
assures  correct  siting  of  the  monitors.    The  QT34  YouTube  user  guide  has  been 
edited  to  include  direction  on  placing  the  monitor  in  direct  sunlight  and  is  now 
available  on  MODNet  giving  easy  access  to  all  Defence  users.    The  routine  and 
continual professional development courses for Army Physical Training Instructors 
includes a briefing on updated policy and guidance.  Attendance on these courses is 
required to ensure currency and competency and is recorded in Physical Training 
Instructors’ individual training log books. Below are more specific answers to your 
concerns: 

15.  It was established by the Coroner’s appointed expert that the WBGT at Dering 
Lines  was  in  the  wrong  place  on  the  19/07/16  leading  to  an  incorrect  reading.   
A PFDR was raised at the time to address this, however the inquest heard that the 
steps said to have taken place in the response have not been done. Not all WBGTs 
have warning/instruction stickers attached, and the YouTube instructional video does 
not specify that the WBGT should be in sunlight. In addition, the WBGT update does 
not specify it should be in sunlight.   
and 

16.    Each  venue  with  a  WBGT  needs  to  have  a  clear  policy  for  its  placement 
depending on the time of year and day. 

On 11 October 2019, a Safety Notice Via Email (Ref 00658) was distributed to all 
Safety  points  of  contact  across  Defence  directing  that  any  QT34  WBGT  monitors 
being used outdoors must not be shaded in any way from sunlight.  Stickers must be 
placed to this effect on every monitor and all must ensure that an up to date QT34 
User Aide Memoire published in September 2019 was to be kept with every monitor. 

Prior to 30 October 2019, a label and updated Aide Memoire was posted out for every 
registered  QT34  by  the  Operational  Infrastructure  (OI)  Delivery  Team.  On  
7 November 2019, the Physical Development Audit was updated to include a check 
that labels were affixed to, and Aide Memoires held with, every QT34, and that units 
reviewed the siting of the monitor.  Direction has also been included within the new 
ACSO 3216 - Heat Illness Prevention to be published on 31 January 2020.  

 
 
 
 
 
 
 
 
 
 The  Operational  Infrastructure  Delivery  Team  has  updated  all  Army  Equipment 
Support Publications (AESPs) and technical documentation to reflect this direction.  
Additionally, an article highlighting the changes has been written for publishing in the 
next edition of KiT magazine in March 2020.  (Published quarterly KiT Magazine is 
produced  on  behalf  of  Director  Land  Equipment  and  provides  updates  on 
management of equipment and vehicles). 
17.  The YouTube video does not play on MOD laptops.  

The User Guide video has now been edited to include direction that when used for 
taking outside WBGT readings, monitors are to be placed in direct sunlight.  The new 
video does now play on MODNet and an access link has been widely circulated.  It 
can be accessed through Defence Connect, Defence Net and the Army Knowledge 
Exchange (AKX).   

18.  No further training has been provided for gym staff. 

Refresher  training  for  staff  delivering  Physical  Training  is  provided  by  the  Army 
School of Physical Training and it is directed within the Annual Deficit Training (ADT) 
Directive.    The  ADT  Directive  mandates  Continual  Professional  Development 
activities  through  courses  and  distance  learning;  these  are  recorded  and  assured 
through Regional Command Physical Development PD branches.  

Physical Training Instructors (PTIs) now complete a personal PTI Log book of their 
training  and  delivery,  which  contains  detail  of  the  additional  training  they  have 
completed and the refresher training they have received as a result of any changes 
to current policy. 

Risk Assessment 

19.  The senior commanders at the inquest confirmed they had not received training 
on the production of risk assessments for the activities they were conducting.  There 
needs  to  be  a  robust  approach  to  training  and  management  of  risk  assessments 
ensuring  those  who  are  required  to  complete  them  have  the  necessary  skills  and 
training.  

I refer you to my response to concern para 1b above.  

I would like to thank you for clearly identifying serious failings – some of them very 
serious – at the end of the very thorough inquest which you conducted into the death 
of Corporal Joshua Hoole.  I acknowledge those failings and I regret them very much.  
The safety of service personnel is at the heart of what the Ministry of Defence does, 
and  I  am  determined  to  ensure  that  lessons  are  learned  from  the  tragic  death  of  
Cpl Hoole on 19 July 2016.   

THE RT HON BEN WALLACE MP