Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0131, written 6 Mar 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Mar 2025 |
|---|---|
| Reference | 2025-0131 |
| Deceased | John McLoughlin |
| Coroner | Gareth Jones |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 British Airline Pilots’ Association (BALPA) 2 Civil Aviation Authority (CAA) 1 CORONER I am Gareth JONES, Assistant Coroner for the coroner area of West Sussex, Brighton and Hove 2 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. 3 INVESTIGATION and INQUEST On 21 July 2023 I commenced an investigation into the death of John Peter MCLOUGHLIN aged 44. The investigation concluded at the end of the inquest on 06 March 2025. The conclusion of the inquest was that: John Peter McLoughlin was a Pilot employed by West Atlantic UK. He was on a training course which he found stressful and highly pressurised. He had a fear of failing the course. He was staying at a Hotel in Brighton. On the 19th of July 2023, he hung himself in the bathroom . There was no third party involvement. The room was closed and he was alone. He had removed his wedding ring. He was not under the influence of drink or drugs and there was no evidence of mental illness. death. I find that he did this act which ended his life and did so with the intention of ending his life. . This caused his 4 CIRCUMSTANCES OF THE DEATH John Peter McLoughlin was a Pilot employed by West Atlantic UK. He was on a training course which he found stressful and highly pressurised. He had a fear of failing the course. He was staying at a Hotel in Brighton. On the 19th of July 2023, he hung himself in the bathroom . There was no third party involvement. The room was closed and he was alone. He had removed his wedding ring. He was not under the influence of drink or drugs and there was no evidence of mental illness. death. I find that he did this act which ended his life and did so with the intention of ending his life. . This caused his 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) John was an experienced Pilot. He was on a training course run by Quadrant which he found stressful and with which he struggled. On the course, mental health issues were discussed. The support offered was through Peer Support who allow pilots to talk to Regulation 28 – After Inquest Template Updated 15/10//2024 TG another pilot who is a trained mental health first aider, but they are not medically trained. Although HM Coroner is of the view that there is great merit in talking through difficulties with those in the same industry, I have concerns that Peer Support is not adequate support for those who are suffering severe mental health difficulties and suicidal thoughts. It appears that there is not enough support in the industry as a whole for pilots whose problems escalate beyond the usual stresses and pressures of the job. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by May 01, 2025. 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. 9 Dated: 06/03/2025 Gareth JONES Assistant Coroner for West Sussex, Brighton and Hove Regulation 28 – After Inquest Template Updated 15/10//2024 TG Regulation 28 – After Inquest Template Updated 15/10//2024 TG
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only GARETH JONES – HM ASSISTANT CORONER FOR WEST SUSSEX, BRIGHTON AND HOVE INVESTIGATION INTO THE DEATH OF MR JOHN PETER MCLOUGHLIN CIVIL AVIATION AUTHORITY RESPONSE TO A REPORT ON ACTION TO PREVENT OTHER DEATHS PURSUANT TO REGULATIONS 28 & 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Introduction The UK Civil Aviation Authority (‘CAA’) would first like to express its sincere condolences to the family and friends of Mr McLoughlin. The CAA is a public corporation, established by Parliament in 1972 as an independent specialist aviation regulator. The CAA works so that: the aviation industry meets the highest safety standards, • • consumers have choice, value for money, are protected and treated fairly when they fly, • through efficient use of airspace, the environmental impact of aviation on local communities is effectively managed and CO2 emissions are reduced, the aviation industry manages security risks effectively. • The CAA has carefully considered the Regulation 28 Report to prevent future deaths issued by the Assistant Coroner for West Sussex, Brighton and Hove (‘the Report’), including the following concerns that are considered relevant to the CAA’s role and functions: John was an experienced Pilot. He was on a training course run by Quadrant which he found stressful and with which he struggled. On the course, mental health issues were discussed. The support offered was through Peer Support who allow pilots to talk to another pilot who is a trained mental health first aider, but they are not medically trained. Although HM Coroner is of the view that there is great merit in talking through difficulties with those in the same industry, I have concerns that Peer Support is not adequate support for those who are suffering severe mental health difficulties and suicidal thoughts. It appears that there is not enough support in the industry as a whole for pilots whose problems escalate beyond the usual stresses and pressures of the job. The CAA was not an Interested Person at this inquest. As such, it did not have access to the evidence. When preparing this response, with a view to implementing future action, the CAA has relied on the information contained in the Report, regulatory information held by the CAA and the professional opinions of CAA subject matter experts. OFFICIAL - Named Parties Only OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only Regulatory Framework The CAA has considered the legal framework for the regulation of pilot training, in particular, the requirements contained within UK Regulations (EU) No. 965/2012 laying down the technical requirements and administrative procedures related to air operations (‘the Ops Regulation’) and (EU) No. 1178/2011 laying down technical requirements and administrative procedures related to civil aviation aircrew (‘the Aircrew Regulation’). Peer Support The Ops Regulation Annex IV Part CAT.GEN.MPA.215 [Support Programme] requires operators (usually commercial airlines) to make available and ensure, enable and facilitate access to a proactive and non-punitive support programme for flight crew. This support programme assists flight crew to recognise, cope with and overcome any problem which could negatively affect their ability to safely exercise the privileges of their licence. In practice, peer support programmes are how aircraft operators comply with these regulations. Peer support programmes in the aviation industry involve the upskilling of pilots in a similar manner to mental health first aiders, in order to break down barriers and stigma for flight crew accessing mental health care. However, this is only one element of support programmes supporting the health and wellbeing of flight crew, alongside regular check-ins with aero- medical examiners and support from healthcare professionals and General Practitioners. Peer support is intended as early intervention rather than crisis intervention, such as for an individual considering self-harm. The CAA does accept that peer supporters may not always be adequate support for those who are suffering severe mental health difficulties and suicidal thoughts. Best practise would encourage peer supporters to be upskilled in suicide awareness and how to manage such an intervention. In this situation a peer support program should signpost pilots with significant mental health issues to professional healthcare providers and have the support of clinical psychologists in making these decisions. The use of mental health professionals is not identified as a specific requirement in the Ops Regulation; however, best practise is already highlighted by the CAA when inspectors audit operators’ compliance with CAT.GEN.MPA.215. The CAA has received positive feedback from operators about the effectiveness of peer support since its introduction, and evidence from existing programmes, both in the UK and overseas, suggests effective peer support can satisfactorily address around 85-95% of pilot wellbeing questions, without the need to seek further help or assistance.1 To support organisations with pilot peer assistance, the CAA launched a dedicated Pilot Peer training course through its subsidiary, CAA International. The course provides delegates with the skills, knowledge and behaviours, as a peer, to become confident in delivering pilot peer assistance to flight crew under an operator’s support programme. The course has been run annually since 2023 and can be run on a bespoke, ad-hoc basis when requested. More information about this course can be found here. Mental Health Assessment for Pilots The Aircrew Regulation Annex IV Part MED.B.055 [Requirements for Pilot Medical Certificates] provides that a comprehensive mental health assessment shall form part of the initial Class 1 aero-medical examination. The CAA publishes extensive guidance for aero-medical examiners 1 RAeS Flightcrew Mental Health Conference May 2019. Capt. D Fielding. OFFICIAL - Named Parties Only OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only on how mental health is assessed as Guidance Material and Acceptable Means of Compliance for this part of the regulation: available here. This mechanism means commercial pilots have a further layer of protection through their aero-medical examiner who conducts periodic medical reviews (at least annually). Pilots undergo a review of their health, including screening for mental health issues, for which examiners have professional training. Pilots who are identified as suffering with psychological stress or mental health issues are triaged by the aero-medical examiner and may be referred for psychological or psychiatric evaluation and further support. We note in particular the requirement for pilots undertaking their initial training to have a medical examination before they can fly solo. Pilots with known mental health issues remain under the care of their general practitioner and can access professional mental health care through this route. In this case they may be required to undertake additional surveillance by their aero-medical examiner or the CAA medical department who have their own team of psychiatrists. Another resource that is made publicly available by the CAA is a recording of a workshop that was overseen by Astral Aviation Consulting in November 2024 on human factors and pilot mental health: available here. This workshop was hosted by an aviation psychologist and human factors specialist. Astral Aviation Consulting are the current contracted provider of General Aviation Safety Promotions for the CAA’s General Aviation Unit. Next Steps The CAA does consider there is already an aviation safety regulation structure in place that is designed to mitigate some of the concerns identified by the Assistant Coroner. This structure, which includes direct regulation of operational peer support programmes for pilots in accordance with the requirements in the Ops Regulation and mental health assessments for pilots under the Aircrew Regulation, is enhanced by the publication of information and guidance by the CAA which is focussed on operators and aero-medical examiners recognising mental health concerns for pilots, those who are in training and those who are actively engaged in flight operations, and how to deal with them. However, the CAA does recognise there is scope to further encourage operators and Approved Training Organisations to further enhance their internal processes in this area. The CAA will therefore instruct Flight Operations and Approved Training Organisation Inspectors, through its programme of audit activity, to encourage operators and Approved Training Organisations to continue improving their mental health support to pilots by: • upskilling the practical knowledge of peer supporters as a matter of best practise; and • supporting the escalation of individual concerns to mental health professionals when appropriate, including the use of trained expert intervention. Further, the CAA will, on an ongoing basis, direct its inspectors to encourage operators and Approved Training Organisations to highlight to pilots the importance of their mental health and to ensure they are aware of the resources that are available to them, particularly during times of stress, such as during flight training and examinations. These measures will make these organisations fully aware of the roles they play in supporting pilots at risk. OFFICIAL - Named Parties Only OFFICIAL - Named Parties Only. This information is intended for HM Assistant Coroner, CAA and Interested Persons only The CAA’s General Aviation Unit is also in the process reviewing the content in its Pilot Health Safety Sense Leaflet, due to be published at the end of Summer 2025. A section will now be included within this leaflet on the topic of Pilot Mental Health related to pre-flight preparation for non-commercial operations. Dated: 30th April 2025 Flight Operations Manager Civil Aviation Authority OFFICIAL - Named Parties Only
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