Marine Simeon Ferrante (Hansard, 25 November 1991)

§ Mr. Jonathan Sayeed (Bristol, East)

On 14 August 1989 Royal Marine Simeon Ferrante died from head injuries he received during parachute training at RAF Brize Norton. No one meant him to die, no one wanted him to die. It was an accident, but not necessarily an unavoidable accident. Accidents do happen and often no one individual is to blame. Bad luck, a coincidence of events, momentary inattention, an act of God—any or none of these could be the cause. In the armed services, where training must necessarily be tough and realistic, accidents sometimes result in severe injury or death. This is why in peacetime safety procedures have to be stringent.

Simeon Ferrante was a green beret Marine and all that that signifies. Young, fit, courageous and keen, he was proud, as a reservist, to have attained the accolade of the distinctive head gear. That pride he shared with his close-knit family and many friends, and when he was selected for parachute training by the royals he could not contain his excitement. On 7 August 1989, his first jump went badly. He landed heavily, and, explaining to his colleagues that he had hit his head on landing, he showed clear signs of cranial injury—lassitude, nausea, headaches, vomiting and lack of concentration. They were all noticed by the students and RAF staff on the course. He attended the sick bay, something that, as many of those present who have served in the armed forces will know, in that young male society is sometimes felt to be an admission of weakness, and therefore undertaken only in extremis.

Marine Ferrante was seen by a newly qualified RAF doctor, who was one week into his first tour of duty with the RAF. That doctor has said that Simeon did not say that he had sustained a head injury on that day, and I have no reason to doubt his word; and whether his diagnosis and treatment—a viral infection and painkillers—are open to question, I am not qualified to judge. Perhaps a more probing investigation would have saved Simeon's life—I do not know.

What is also noteworthy is that the RAF instructors took no action over the following two days when Marine Ferrante continued to show the same clear symptoms. Perhaps they did not understand the significance of those symptoms—which would indicate a gap in the training of the trainers—or perhaps they were satisfied that the medical staff were handling it. I do not know, I have no access to their evidence at the board of inquiry. What I do know is that if Simeon Ferrante showed the symptoms that the—as far as I am aware—uncontested evidence says he did, he should not have been allowed to continue jump training. But continue he did, and on the third jump, on 10 August 1989, he again landed heavily, swiftly lapsed into a coma and died.

Mr. and Mrs. Ferrante understood that their son's death was the result of that last jump, and a tragic, unavoidable accident. They mourned the waste of a life, but raised no queries, for neither the services nor the Ministry had mentioned the earlier heavy landing. This they found out by chance. Then they started to ask questions. What else was being kept from them? Was 753 Simeon's death avoidable? What lessons could be learnt that might save others from the same grief that they were experiencing?

There were queries about safety equipment, the speed of response of the emergency services and medical training for parachute training instructors. There were doubts about the content and quality of evidence offered to the inquest, and real and understandable anger at the inconsiderate attitude of the RAF. The questions were many but the answers inadequate. I regret to say that Simeon's parents found the MOD unhelpful. They had to go to court to force the Ministry to provide answers. They may have to institute compensation proceedings, not for the money—it is clear that the balance of any award after costs will go to the Royal Marine Benevolent Fund—but in order to gain access to the facts.

Their experiences have led them to distrust the Ministry and that is partly the Ministry's fault, for the understandable climate of secrecy within the MOD is allowed to intrude into areas where it should have no place.

Of course, there are good reasons why the proceedings of boards of inquiry are classified, and I can think of three now. First, the proceedings may contain militarily sensitive information, but I suggest that that is not so in this case. Secondly, the privacy of proceedings encourages frank testimony, and that is always helpful. Thirdly, the facts that are disclosed at a board of inquiry may at some future date give rise to disciplinary action. However, their secrecy also creates problems. It is the MOD which decides what is disclosed, and by being at times unnecessarily secretive it gives the impression that it has something to hide even when it has not. It feeds the suspicion that secrecy is abused to cover up mistakes rather than keep secrets. That may be an entirely unworthy suspicion, but it is an understandable one, and one which does nothing but damage.

The families and the friends of those who are killed or injured need the reassurance of frankness to enable them to come to terms with their tragedy. Service men and their families would like the certainty of knowing that the faults that endangered their lives cannot be hidden under the cloak of secrecy and then ignored. There needs to be another way—a clearly independent way—of determining what should be disclosed when a board of inquiry is convened to investigate why a death or injury occurred in peacetime.

I shall suggest just one way in which that could be done. It could be by the appointment of a senior independent judge. He would comment on the terms of reference when a board was set up to examine a peacetime death or injury. He would be empowered to decide in what form and how much, and to whom, evidence from the board was disclosed. His aim would be the greatest possible frankness consistent with the nation's security and the rights of those who are involved in an inquiry. His recommendations could then be overruled only by a Minister, who in turn would be answerable to Parliament.

There may be a better way. It may be that tonight my right hon. Friend the Minister of State will suggest a better or different way. It is unlikely, however, that there could be a way more calculated to breed suspicion and thus damage the armed services than the one that we have now.

754 I believe that the Ferrante family has a right to the truth, even, or particularly, if it discloses negligence. The services have the right to expect that Ministers will not allow the fear of compensation costs to deter them from exposing those errors that make peacetime training unnecessarily hazardous. We all have the right to expect that those in the MOD or the services who deal with these sad cases have the compassion and sensitivity to put themselves in the position of the bereaved or that of the injured, and then to treat them as they themselves would wish to be treated.

We all understand that there are times when secrecy is essential. There are times, however, when it is unnecessary, unhelpful and cruel. The Ministry and my right hon. Friend are not unthinking, uncaring or unwilling to change. I hope that the case of Simeon Ferrante, tragically dead before his time, will be the spur that brings that change about.

§ The Minister of State for the Armed Forces (Mr. Archie Hamilton)

I am grateful to my hon. Friend the Member for Bristol, East (Mr. Sayeed) for bringing this case to the attention of the House, thereby affording me the opportunity to allay any fears that the Ministry of Defence is an uncaring and secretive Department.

Obviously there is nothing that can be said to the families that could alleviate their anguish at the tragic loss of their son. Nevertheless, I want to express to them publicly my sincere sympathy. I should now like to respond to certain of the major criticisms that have been levelled at my Department.

Simeon Ferrante enlisted in the Royal Marine Reserves on 12 November 1985, and joined a parachuting course for reservist soldiers and marines run by No. I Parachute Training School, RAF Brize Norton, from 30 July to 11 August 1989. He was parachuting at RAF Weston-on-the-Green on 10 August when he landed badly. He died four days later. On the day after the accident, a unit inquiry was convened at RAF Brize Norton and, following his death, a coroner's inquest was held, at which a verdict of accidental death was recorded.

Since then, my Department has received a considerable number of inquiries from the father and from hon. Members. There have been allegations of obsessive secrecy and that there may have been a cover-up over the circumstances surrounding the incident. There have been specific criticisms to which my hon. Friend referred, and to which I shall respond.

I will first cover Marine Ferrante's fitness to jump. It has been suggested that he had an accident on 7 August and should not have been allowed to jump on 10 August. It has been alleged that the Ministry of Defence refused to admit that Marine Ferrante had suffered a previous injury prior to that received on 10 August 1989. That is not so. My Department has never disputed the fact that Marine Ferrante was involved in two incidents, and that came out clearly at the coroner's inquest.

The records show that on 7 August, following a jump, Marine Ferrante vomited at the drop site and was referred to the medical attendant, who instructed him to see the doctor. There was no evidence to suggest that he had landed badly on that occasion. On questioning Marine Ferrante, the doctor was told that he had sustained a slight blow to the head on landing on 4 August 1989, which he 755 had not reported previously. The doctor carried out a full neurological examination but could find no evidence of injury, and concluded that he was suffering from a viral infection. Marine Ferrante was told to report back if there was no improvement in his condition or if it should worsen. I think that is important, because we were depending on Marine Ferrante to come back if his condition continued.

Parachute training instructions tell trainees that they should jump only if fit to do so. As an added safeguard, before leaving the aircraft, trainees have to confirm that they are ready and willing to jump; anyone who is not happy for any reason is not allowed to continue. The doctor had examined Marine Ferrante and found no reason to declare him unfit for duty, but had instructed him to report back to the medical centre if there was no improvement. There is no evidence that he reported back, and it must be presumed that he had regarded himself as being fit to jump on that fateful day.

I should mention that Marine Ferrante had jumped once already on 10 August, and it was following the second jump on that day that the accident occurred.

Having received the report of the RAF medical officer who examined Marine Ferrante prior to the jump of 10 August, the pathologist at the coroner's inquest commented that he understood that approximately five days before his acute head injury, Marine Ferrante had received another blow on the head—but there was no evidence of that at the post-mortem examination.

It has been claimed that the RAF were unhelpful and did not liaise with Mr. Ferrante or his family following the accident and subsequent death. Simeon Ferrante was a Royal Marine Reservist, and as such it is normal practice in an incident of that kind for the welfare support to the injured person and his family to be provided by the parent unit, rather than by the unit where the accident occurred. Obviously, the two services liaised closely, but the Marines took the lead in that regard, with the officers and senior NCOs of Martine Ferrante's parent unit, Royal Marines Reserve, Bristol, becoming actively involved from the outset by contacting the family to identify what support was needed.

Although a private funeral was held, there was a military attendance. The station commander at RAF Brize Norton wrote to the family expressing his condolences two days after Marine Ferrante had died. He subsequently received a letter from Mr. Ferrante, thanking him for the discreet and sympathetic manner in which he and the RAF had conducted themselves. Not unreasonably, the station commander at RAF Brize Norton concluded that Mr. Ferrante felt that everything had been done that could be done and that: the Royal Marines were providing the necessary follow-on support.

There followed a series of letters from Mr. Ferrante, seeking details of his son's death. Because the exchange of correspondence appeared not to be helpful to Mr. Ferrante, two senior RAF officers visited Mr. and Mrs. Ferrante in an attempt to answer all Mr. Ferrante's questions, and to allay any misgivings that he might have about the circumstances surrounding the accident. When the officers left Mr. Ferrante, they believed that they had answered his questions fully and satisfactorily; indeed, they subsequently received a telephone call of thanks and a letter from Mr. Ferrante. Mr. Ferrante, however, continued to ask the same questions.

756 An inquiry was convened on 11 August 1989 at RAF Brize Norton. Its terms of reference were wide ranging, and designed to establish the full facts. Among the more important considerations was the requirement to determine the cause of the accident and whether anyone had failed in his duties, and to make any appropriate recommendation.

The inquiry found that Marine Ferrante was injured in the course of the performance of his official duties. There was no question of any negligence on his part; he had exercised reasonable care throughout. The inquiry also found that the staff of No.1 Parachute Training School had taken reasonable care in training Marine Ferrante. After he had completed six parachute descents to a satisfactory standard, they were entitled to believe that Marine Ferrante was capable of safely undertaking his seventh training descent. The seventh descent was properly organised and controlled, and therefore the inquiry found that no member of staff had failed in his duty.

The inquiry made some recommendations for change —that a servicing schedule should be introduced for all types of parachutists' helmets, that at the start of all courses a check should be made by a safety equipment fitter of each trainee's helmet, that trainees should be instructed in the proper use and care of their helmets—including internal and external serviceability checks—and that standing orders should be reviewed to reflect current procedures for checking helmets.

The inquiry was completed on 18 September 1989. It was subsequently reopened following a request from the coroner's office that further witnesses be called, and that statements be taken from them to enable the inquiry to determine the date on which Marine Ferrante first received a blow to the head; to resolve any points of difference between existing evidence and the new statements taken from students on the same course as Marine Ferrante; and to clarify any points arising, amending previous findings if necessary.

All Marine Ferrante's fellow students were asked whether they had witnessed Marine Ferrante receiving any injury on either 4 or 7 August. Statements were taken from those who felt that they could contribute to the investigation. Those witnesses were called to the reopened inquiry. Having considered their statements along with the previous ones, the inquiry considered that its original finding should remain unchanged. It concluded that Marine Ferrante first sustained a blow to the head on 4 August 1989.

Mr. Ferrante was issued with a summary of the inquiry on 10 July 1990 and, following his successful application for a writ for pre-action discovery of documents, his solicitors have been sent the full report.

That brings me to one of the crucial areas in which my Department has been criticised—that of excessive secrecy in the refusal to give Mr. Ferrante a full copy of the inquiry report. It may help if I say a few words about the status and purpose of board of inquiry reports.

The Royal Air Force derives its authority for holding boards of inquiry from the Air Force Act 1955, statutory rules made thereunder and Queen's regulations for the RAF. Boards of inquiry may inquire into all manner of things. Generally, their primary purpose is to investigate and report on the facts about the matter referred to them by the convening authority, and to make recommendations aimed at preventing a recurrence of an accident.

757 It is of overriding importance, particularly in cases of injury or death, to establish the facts as quickly as possible. Lives may depend on it. It is essential, therefore, that witnesses appearing before a board of inquiry should give their evidence in a full and frank manner. One must remember that some of the witnesses will be young, or of very junior rank; they may be required to give their evidence in difficult circumstances; they may have to criticise the actions of fellow service men, their close comrades even, or of their senior officers; or they may themselves have made mistakes which contributed to an incident, about which, for the good of the services, we would want them to be completely open and frank. Board of inquiry procedures have, therefore, been designed to do everything possible to encourage witnesses to come forward and to be absolutely candid when giving their evidence to this end.

Boards of inquiry are conducted as internal investigations. They are not held in public. Section 135(5) of the Air Force Act 1955 provides that evidence given by a witness may not be used against him in any subsequent disciplinary proceedings. The report of the board of inquiry is regarded as confidential to the service and the Department and, unless the courts order otherwise, only those within the service and the Department who need to see it in the course of their duties will see it.

Equally I must emphasise that it is not the wish of the services to deny those with a genuine and valid interest their right to know what happened in a particular incident. My hon. Friend's constituent clearly had such a right in this case. It is, therefore, my Department's practice to make available on request a narrative summary of the Department's investigations, which contains all the material facts. As I have explained, this procedure was followed in Mr. Ferrante's case. In addition, my Department endeavoured to answer the large number of supplementary questions raised by Mr. Ferrante both through direct correspondence and under cover of correspondence from my hon. Friend. Mr. Ferrante has remained dissatisfied with what I consider to be the very positive response of my Department, and to this end Mr. Ferrante has, in contemplation of taking legal proceedings, obtained an order from the courts for discovery of documents. It would not be appropriate for me to comment on these proceedings. I am, however, satisfied that my Department, through the good offices of the Treasury Solicitor, has made every effort to comply with the terms of the order.

An inquest into the death of Marine Ferrante was opened and adjourned on 15 August 1989. The inquest was reopened on 6 June 1990 and returned a verdict of accidental death. It has been alleged by Mr. Ferrante that his son suffered a previous head injury which contributed to his death, but, in view of the lack of reliable evidence, the coroner left this point open. It would not be appropriate for me to comment on the findings of the inquest. Mr. Ferrante is not content with this conclusion and wishes to have the inquest reopened. While my Department has no reason to dispute the findings of Her Majesty's coroner for Oxford, it would not object to a reopened inquest if that was considered to be necessary.

At the inquest, there was some discussion of the condition of the helmets used by trainee parachutists at 758 RAF Brize Norton. Following the death of Marine Ferrante, an RAF safety fitter, responsible for examination and servicing of RAF flying helmets rather than the Army parachute helmets used on this course, inspected the Army helmets and considered a large number to be in a poor condition. However, an expert from the stores and clothing research and development establishment told the inquest that the defects were "normal wear" and were not of significance with respect to the impact performance of the helmets. Furthermore, the evidence of the pathologist was that for the particular injury sustained by Marine Ferrante there is no form of helmet than can help. It has also been alleged that accident and emergency services provision at Weston-on-the-Green were inadequate and that a specialist ambulance should have been summoned from Frenchay hospital, Bristol. There is always an ambulance with a medical attendant present whenever parachuting is taking place. I have to say that the service ambulance in which Marine Ferrante was taken to the John Radcliffe hospital was equipped to the standard of a crash ambulance on the fire line of an RAF operational flying station. It contained resuscitation equipment and was equipped with a blue light, which was activated in transporting Marine Ferrante to the nearest hospital. The hospital was advised in advance to expect him and I have no doubt provided the highest standard of care, for which it is rightly renowned.

Another area of concern to Mr. Ferrante is whether training is given to parachute instructors so that they will recognise concussion or other forms of illness that could impair the safety of trainee parachutists and what first aid training is given. All parachute jumping instructors obtain a first-aid certificate during basic training as a physical training instructor. That includes the recognition of concussion. There is no requirement for training to be given in the recognition of any forms of illness, as trainees have immediate access to fully qualified medical officers the moment they feel unwell. During all forms of parachute training, there is a medical attendant and ambulance available at all times. There is always an individual responsibility to report sick if the trainee considers that he is unfit to continue training. That is laid down in Queen's regulations.

Following the inquest, the Ministry wrote to Mr. Ferrante on 17 August 1990 suggesting that he seek legal advice in respect of submitting a claim against the Ministry. I can assure the House that my Department will not attempt to avoid responsibility should negligence be established.

I should like to deal with the difficulty that my Department experienced in corresponding with Mr. Ferrante. In the period immediately following this tragic accident, Mr. Ferrante wrote a large number of letters to RAF officers. The recipients of the letters recognised the right of Mr. Ferrante to be given as much information as possible about his son's death, and gave him detailed replies. However, it is not our practice, for the reasons I have described, to disclose verbatim proceedings of boards of inquiry, although we are always prepared to provide an accurate summary to the next of kin.

Mr. Ferrante was visited by two RAF officers, who sought to explain the situation. Following that meeting, the correspondence continued and was addressed to a wide range of RAF officers and officials throughout my 759 Department. The House will understand the dilemma facing those responsible for corresponding with Mr. Ferrante. On the one hand, they wished to give a grieving father the information that he needed to come to terms with the death of his son, and on the other they wished to avoid perpetuating the correspondence. Once all the facts that could have been given had been given, there was little more to be said. My officials considered this matter most carefully and decided in October 1990 to advise Mr. Ferrante that no further letters from him would be answered. That decision was not taken lightly and of course it did not extend to correspondence from hon. Members from whom 12 inquiries have been received and answered. Correspondence has also continued with Mr. Ferrante's legal advisers.

Mr. Ferrante's legal advisers wrote to the Department in February this year intimating that a claim would be 760 made. That was followed by an order for discovery of certain documentation that would allow them to advise their client whether any proceedings brought by him would have reasonable prospects of success.

I have attempted to explain as fully as possible the background to the public unease surrounding the death of Marine Simeon Ferrante. I have stated that my Department will not try to avoid responsibility should anybody be blamed for this tragic accident. Clearly, in addressing the question of liability, we will need to consider the claim which, I understand, Mr. Ferrante will be presenting. As I have said, we await a statement of claim which, when received, will be considered by my Department in consultation with legal advisers.