Wayne Brown

PRIVATE AND CONFIDENTIAL 

For the Attention of Ms Louise Hunt 
Senior Coroner for Birmingham and Solihull Districts 

Chief Fire Officer 

11 July 2025 

Date: 
Ref no.: 
Email:   

Dear Senior Coroner Hunt,  

Inquest Touching the Death of Wayne Steven Brown (Date of death 24 January 2024) 
Response to Regulation 28 Prevention of Future Deaths Report 

On behalf of West Midlands Fire Service (“WMFS”), I acknowledge your Regulation 28 
Prevention of Future Deaths Report following the inquest into the sad death of Wayne Brown, 
the former Chief Fire Officer of WMFS.  This letter outlines WMFS’s response and planned 
actions.  

Your report raised two matters of concern.  

“1.   WMFS did not undertake any investigation after Mr Brown’s death and have no policy 
requiring them to do so.  Any opportunity to learn from a death such as a suicide related to 
work events including what welfare support was provided has not been addressed.  This 
creates a risk of future deaths and action should be taken”. 

“2.   Neither WMFS health and wellbeing policy nor the mental health policy make any 
provision for supporting senior staff members who are facing significant stressors and/or 
potential disciplinary investigations beyond the person approaching Occupational Health 
themselves.  The policy offers further support to lower ranks.  In addition, there was no formal 
mechanism for recording concerns about welfare that arise during either an informal or a fact-
finding investigation.  This creates a risk of future deaths and action should be taken.” 

Post-Incident Investigation and Learning 

To reiterate what was said at the inquest, following Mr Brown’s death, we sought the advice of 
external, specialist health and safety enforcement and compliance solicitors to provide legal 
advice, part of which involved investigating and assessing the evidence then available to 
advise upon: 

• 

Whether the mental health and wellbeing support available within WMFS met good 
practice within guidance published for all employers by the Health and Safety 
Executive. 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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• 

• 

Whether Mr Brown was aware of and accessed that support in the period prior to his 
death; and  
If he did access that support, to what effect?   

The review concluded that Mr Brown had been made aware of the support available and had 
been signposted to it and encouraged to access the support available multiple times in the 
period leading to his death, but sadly he had not accessed it in the relevant period.  

However, we acknowledge that the terms of reference of a review of this nature could be 
enhanced to ensure that learning is maximised and built into our policies and the outcomes 
from it better analysed to ensure that appropriate actions are built into our structures.  

We will therefore thoroughly review our crisis management and death-in-service protocols for 
deaths that occur in the workplace to ensure that they extend to situations where the death of 
a colleague is linked to their employment.  This will also include how we support other 
members of staff who might be affected. The review and the implementation of linked policies 
will be completed within 6 months of this response letter.  

Support for Senior Staff Facing Significant Stressors 

WMFS’s Health and Wellbeing policies apply to all members of staff and officers at all levels 
who may experience significant stressors within their roles.  The Employee Assistance 
Programme (EAP) provides internal support to anyone within the organisation, and signposts 
external assistance such as The Samaritans and GP assistance where appropriate.  

In addition, because of his seniority, Mr Brown was also offered funding for externally provided 
counselling, but this was not utilised and, as the record of inquest notes, tragically the risk of 
suicide was not identified by anyone.  

In addition to the policies disclosed, in accordance with the Orders made during the inquest 
process, WMFS also had a Disciplinary Procedure which is written in accordance with the 
ACAS Code of Practice and the National Joint Council for Local Authority Fire and Rescue 
Service’s.  Under this procedure, a Service Liaison Officer (SLO) is appointed for someone 
undergoing a disciplinary process.  As you will recall, the WMFS Monitoring Officer 
emphasised that matters were only at a preliminary stage during the discussions in the couple 
of days before Mr Brown died.  In preparation for a formal meeting, Mr Brown had already 
engaged the assistance of a representative from his representative body, and he would have 
then also been allocated a SLO.  

Notwithstanding the above, the Service is committed to enhancing available support. 
Therefore, we will carry out a review of the level and nature of support provided to senior 
officers undergoing a disciplinary process, including before and after any suspension, and 
make any enhancements identified in that process.  The review will  include:  

 
 
 
 
 
 
 
 
 
 
 
 
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Incorporating specific provisions within our Health and Wellbeing Policy and / or ‘The 
WMRFA / WMFA Constitution’ to address the unique support requirements of senior 
staff.  

•  Ensure mechanisms are in place to record and act upon welfare concerns raised 

during any informal or fact-finding processes. 

•  Exploration of additional third-party support options outside of internal Occupational 
Health, which we recognise may be more appropriate and accessible for senior 
officers. 

•  Review and strengthening of the process and risk assessments for personnel involved 

in disciplinary proceedings in line with best practice.  

We will complete this review and make the necessary changes within the next 6 months  

Sector-Wide Learning and Support 

We are committed to sharing the learning from this case to help improve support nationally.  

Therefore, alongside our own internal review, we have also agreed to be part of, and help fund, 
the national work that is being undertaken by the National Fire Chiefs’ Council (NFCC), 
alongside the Fire Fighters’ Charity (FFC), to establish a new emotional and wellbeing support 
provision specifically designed for senior officers. 

We also want to note the active ongoing work being undertaken by the NFCC that is 
considering how to best support senior managers in the fire service.  This includes peer-to-
peer mentoring, new CFO induction sessions, provision of a 24/7 helpline and liaising with 
central Government to consider changes in legislation.  WMFS will play an active role in this 
area.  

Our thoughts and condolences remain with Mr Brown’s family, friends and colleagues. 

Yours sincerely, 

Chief Fire Officer