Select Committee on Defence Written Evidence

Mechanisms for ensuring that lessons are learnt and implemented from complaints/incidents


  All units have formal and informal methods for ensuring that lessons are learned and implemented from complaints. The monthly welfare meeting will discuss outstanding cases and enable dissemination of information. The chain of command will also ensure discussion and dissemination of outstanding complaints at weekly conferences. The MS staff at HQ ITG and HQ ATRA will also ensure that lessons learnt from a specific case in a particular unit are disseminated to all units under their command.

  A Recruit Trainee Survey is in operation, managed outside the chain of command to ensure integrity is maintained. All trainees complete this questionnaire anonymously on completion of a stage of training. Results are fed back in report form to the establishments on a monthly basis. Quarterly, six monthly and annual reports are produced for higher headquarters.

  The results of Boards of Inquiry and accident investigations are widely circulated to ensure that the lessons learnt are disseminated widely. Such information is further reinforced at HQ ATRA/ITG study days and on visits by commanders and staff officers to units. Further direction is delivered in instructions from commanders.


  At unit level, local procedures include the feedback range from feedback on formal complaints through the chain of command, commanding officers' management meetings and course critiques and evaluations to more informal methods including staff surveys and open meetings.

  AT HQ level, HQ PTC (Group Captain Ground Training) holds regular meetings of training unit commanders to discuss wide duty of care issues and attends the tri-Service Training Best Practice Working Group.


  The circumstances attending the death from suicide, or serious injury from attempted suicide, of any person (including civilians) onboard one of HM Ships or, in establishments, or whilst on duty ashore in UK or abroad, are investigated immediately by a Board of Inquiry or Ship's Investigation (or Regimental Inquiry in the case of RM units) if a Board of Inquiry is impractical. The decision on the appropriate level of an inquiry is dependent upon the seriousness of the outcome, or intended outcome of an instance of Deliberate Self Harm. In the case of death or serious injury in a civilian setting (eg in a private vehicle or at home), an immediate Ship's Investigation will usually be convened to examine any Service aspects of the case.

  The purpose of a Board of Inquiry and Ship's Investigation is to examine the circumstances of an incident and, where appropriate, to make recommendations to the appropriate Higher Authority within the Naval Service which are aimed at preventing a recurrence of any incident. The responsibility for ensuring that lessons are learnt and implemented from any particular incident and BOI/Ship's Investigation will usually be convened to examine any Service aspects of the case.

  The regulations for handling cases of Deliberate Self Harm by officers and ratings in the Naval Service are contained in Article 0108 of the Personnel, Legal Administrative and General Orders and in Chapter 53 of the Queen's Regulations for the Royal Navy 5302.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2005
Prepared 14 March 2005