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Army did not learn from previous SAS test tragedies, inquest hears Army did not learn from previous SAS test tragedies, inquest hears
(about 2 hours later)
A senior coroner hearing the inquest of a soldier who collapsed and died during a fitness test on a searingly hot day in the Brecon Beacons has strongly criticised the army for not learning from mistakes made during a previous tragedy when three men died during an SAS trial. A senior coroner hearing the inquest of a soldier who died while taking part in a fitness test on a searingly hot day in the Brecon Beacons has strongly criticised the army for not learning from failings exposed when three men suffered fatal heat illness during an SAS trial.
Cpl Joshua Hoole, 26, collapsed near the end of an eight-mile course in south Wales in July 2016, three years after three army reservists suffered fatal heat illness in the same area while they took part in the SAS march on a very hot day. Cpl Joshua Hoole, 26, died near the end of an eight-mile course in south Wales in July 2016, three years after three super-fit army reservists collapsed in the same area in the SAS march.
Giving her conclusions, the coroner Louise Hunt said a string of “very serious failings” had meant the annual fitness test (AFT) in which Hoole was taking part was not safe. She said she believed the march should not have gone ahead because of the heat and concluded that the safety assessment carried out was not fit for purpose.Giving her conclusions, the coroner Louise Hunt said a string of “very serious failings” had meant the annual fitness test (AFT) in which Hoole was taking part was not safe. She said she believed the march should not have gone ahead because of the heat and concluded that the safety assessment carried out was not fit for purpose.
Hunt highlighted that of the 41 corporals and lance corporals taking part in the AFT only 24 completed it, with many complaining of the heat being magnified because it was held in by the hedges lining the lanes in which they were moving with full pack and rifle. One said it felt hotter than Afghanistan. Hunt added: “It leaves me very worried about the army’s ability to learn from previous mistakes. It’s a matter of grave concern. I want to give a message to the army that they need to think about how to learn. Quite simply, something has to change.”
Hunt’s comments were echoed by Hoole’s father, Phillip Hoole, who said the Ministry of Defence had failed to make meaningful changes since the SAS tragedy and accused it of “systemic organisational failure”. He said he intended to launch a civil action against the MoD for corporate manslaughter and called for the police to investigate.
“Many promises were made and undertakings given to implement change,” Hoole said. “It is my belief that the MoD failed in its duty of care to implement any meaningful changes.”
He was particularly angry at a report on his son’s death carried out by the Defence Safety Authority that he said had sought to rule out a link between Hoole’s death and heat. He claimed the report contained lies and inaccuracies.
Bryher Dunsby, whose husband James was one of the three who died in the SAS test, said she believed there had been an attempt to cover up what happened to Hoole.
She said: “The MoD are willing to defend themselves at all costs, regardless of truth or justice for the individual who has died and their families.”
Dunsby said she knew that special forces had updated and modernised their training and attitude to heat. “However, this clearly has not been transferred to the rest of the British army. This needs to happen as a priority: more of our service personnel will die in training if it is not addressed.”
Giving a narrative conclusion, Hunt highlighted that of the 41 corporals and lance corporals taking part in the AFT only 24 completed it, with many complaining of the heat being magnified because it was held in by the hedges lining the lanes in which they were moving with full pack and rifle. One said it felt hotter than Afghanistan.
The coroner said another soldier, who collapsed before Hoole died, should have been recognised as a casualty of the heat – which ought to have led to the AFT being halted. In fact, those in charge of the AFT thought he had an ankle injury. The soldier was told later in hospital he could have died if he had not stopped.The coroner said another soldier, who collapsed before Hoole died, should have been recognised as a casualty of the heat – which ought to have led to the AFT being halted. In fact, those in charge of the AFT thought he had an ankle injury. The soldier was told later in hospital he could have died if he had not stopped.
Officer in fatal march says he lacked health and safety trainingOfficer in fatal march says he lacked health and safety training
Hunt said there had been a “very serious failing” by the army to make sure the training team that ran the test was aware of a crucial document called JSP 539, which relates to climatic illness and was featured repeatedly during the SAS inquest. Hunt oversaw the SAS inquest in 2015 and issued a report intended to prevent further deaths at, specifically raising concerns about issues such as the lack of awareness about heat and risk assessments.
The coroner said she had issued a report intended to prevent further deaths at the conclusion of the SAS inquest in 2015, and specifically raised concern about issues including the lack of awareness about JSP 539 and risk assessments.
She said: “The failure of the army to learn from previous mistakes is a very concerning matter for me.” She said she would write another report on preventing further deaths to the defence secretary.She said: “The failure of the army to learn from previous mistakes is a very concerning matter for me.” She said she would write another report on preventing further deaths to the defence secretary.
Hunt added: “It leaves me very worried about the army’s ability to learn from previous mistakes. It’s a matter of grave concern to me that I’m raising the same concerns. I want to give a message to the army that they need to think about how to learn. Quite simply, something has to change.” The coroner said the AFT should not have gone ahead at all because when the trial began at about 7am the temperature would have been above 20C the point at which such exercises should not take place.
The coroner said the AFT should not have gone ahead at all because when the trial began at about 7am the temperature would have been above 20C the point at which such exercises should not take place. “The AFT should not have gone ahead,” she said. “Josh would not have died when he did if the AFT had not gone ahead.” Hunt concluded that “heat stress” was one of a number of factors that led to Hoole’s death, although she said it was not the sole factor and he also had an underlying heart condition.
She also said a crucial piece of kit called the wet bulb globe thermometer, which takes factors such as heat, humidity and wind into account when producing a reading, had been placed in the shade and so did not give an accurate reading. “The risk assessment for the AFT was not fit for purpose. It did not address the very real risk of heat illness,” she said. Brig Christopher Coles expressed regret but did not offer an apology to Hoole’s family. He said: “The MoD has acknowledged that aspects of the policy in place which governed the training Cpl Hoole was undertaking could have been in better and was in areas inconsistent. While much work has already been done to address this, we will seek to ensure it is refined and improved to help ensure a tragedy like Cpl Hoole’s death is not repeated.”
After Hoole’s death, a defence service inquiry report concluded that he died not because of the heat but due to an undiagnosed underlying medical condition. But his father, Phillip Hoole, rejected that conclusion and when he investigated the circumstances of the AFT came to believe there had been serious organisational failings in how the exercise was run. He successfully campaigned for a full and detailed inquest.
Hoole, who represented himself and his family, argued that the coroner should have concluded that his son had been the victim of unlawful killing and called for the Crown Prosecution Service to launch a corporate manslaughter investigation.
Recording a narrative conclusion, the coroner said she could not consider a verdict of unlawful killing. Hunt concluded that “heat stress” was one of a number of factors that led to Hoole’s death, although she said it was not the sole factor and he also had an underlying heart condition.
Relatives of two of the soldiers who died in the SAS trial in 2013 were in court in Birmingham to hear the coroner’s conclusions.
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