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
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