A coroner strongly criticises a string of failures by the Ministry of Defence after the deaths of three reservists on an SAS selection course in the Brecon Beacons two years ago.
A coroner has highlighted a string of failures by the Ministry of Defence (MoD) that contributed to the deaths of three army reservists on an SAS selection run in 2013.
The three men, carrying rifles and heavy rucksacks, collapsed during a 16-mile SAS test march on the Brecon Beacons on what proved to be the hottest day of the year.
The senior coroner for Birmingham and Solihull, Louise Hunt, said neglect played a part in the deaths of the three reservists, criticising delays in providing medical treatment, which she found contributed to their deaths after the exercise.
“There would have been an obvious need for this attention and there was a delay in providing effective medical treatment, in not identifying they were static, which contributed to their deaths,” she said.
She also found that GPS trackers used to monitor the soldiers was not fit for purpose, which the hearing heard had been known by the MoD since 2009.
She further criticised a lack of build-up marches and ruled that checkpoint staff had missed signs of heat illness in one of those who died.
Ms Hunt said a risk assessment completed more than two weeks before the exercise was inadequate.
“It failed to address the increased risk of heat illness based on the weather forecast,” she added. “It failed to have a clear plan for how to get to and treat any heat injury casualties that occurred.”
He would have made a fine leader of men James Dunsby’s father
She ruled that the lack of build-up marches in the week before the march had contributed to the deaths, stressing that fitness was different to conditioning and that all those who died had been “very fit”.
Lance Corporal Edward Maher, from Winchester, and Lance Corporal Craig Roberts, originally from Penrhyn Bay in North Wales, were pronounced dead on the hills.
Corporal James Dunsby, from Trowbridge in Wiltshire, died at Birmingham’s Queen Elizabeth Hospital from multiple organ failure more than two weeks after the march.
Read more: SAS deaths inquest hears soldiers 'could have been saved'
A 20-day inquest in Solihull, West Midlands, in June was told that all three soldiers fell victim to heat stroke on 13 July 2013.
Up to seven other men on the selection march for the reserve special forces units were also treated for heat effects, including four who were taken to hospital.
Ms Hunt concluded said that while a lack of water did not contribute to the deaths of Cpl Dunsby or L/Cpl Roberts, it did play a role in the death of L/Cpl Maher.
She said that if the reservists had been given “basic treatment of cooling, hydration, rest and removing kit” the men “would have survived”.
In particular with Cpl Dunsby, she found on the balance of probability he would have been showing signs of heat illness at the last checkpoint before he succumbed, and this “should have been noticed” by his commanders.
Ms Hunt agreed with the conlusion of Professor George Havineth: “It would have made a big difference if James (Dunsby) had been admitted to hospital earlier.”
David Dunsby, the father of Cpl James Dunsby, told Channel 4 News before the inquest’s ruling: “I’ve never wanted anything out of this except the truth. It was never going to bring James back, it was never going to bring Craig or Edward back.”
Recalling his son, Mr Dunsby said he was “a decent man, well loved”.
“He would have made a fine leader of men,” he added. “I like to think that when he did pass away he knew everybody was there, everybody who loved him.”
The inquest heard that 37 reservists took part in the march alongside 41 regular soldiers trying to gain entry to a special forces signals regiment.
The inquest heard evidence from staff on the march, candidates and senior officers, including the former head of UK Special Forces.
It was told that Cpl Dunsby collapsed near a main road amid “heatwave” conditions.
Read more: SAS deaths inquest - 'too much paperwork' to stop march
The main finding of an MoD land accident investigation, completed within weeks of the tragedy, was that reservists were “less well physically conditioned” than regulars in the build-up to test week.
Among other contributory factors was a change of route caused by sheep-herding.
The first “test week” march undertaken by 37 reservists was originally earmarked for a 14.3-mile route in the Elan Valley.
But the movement of livestock in Mid Wales on 13 July meant the march was switched to a longer 16.4-mile course in the Brecon Beacons.
The army investigation said that the change – given the required speed of 1.9mph – extended the march by an extra hour, during which James Dunsby, Craig Roberts and Edward Maher succumbed to heat stroke.
The report further questioned why march directing staff – members of a Special Forces Signals Regiment – assumed they would be able to communicate by mobile phone in an area with intermittent network coverage.
Colonel William Bowles, the head of the land accident inquiry team, suggested that a reliance on GPS trackers to identify casualties had “built in” a treatment time delay.
Other areas which did not meet best practice included the failure to provide water for all legs of the march, and a “less than complete” and non-specific risk assessment.
A heat illness expert told the hearing there was a “good chance” that at least two of the soldiers who died did not exhibit clearly recognisable signs of heat exhaustion at march checkpoints.
Asked by coroner Louise Hunt whether the determination of the SAS hopefuls placed an onus on march directing staff to exercise extra vigilance, Col Bowles said:
“They have to be aware of that fact but at the same time they are obviously required to make sure that the individual makes his own decisions.”