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SAS selection deaths: Coroner delivers neglect conclusion SAS selection deaths: Coroner delivers neglect conclusion
(35 minutes later)
Three reservists who died on an SAS selection march would have survived if the hike was stopped when other soldiers fell ill, a coroner has said. Three reservists who died on an SAS selection march would have survived if the hike had been stopped when other soldiers fell ill, a coroner has said.
L/Cpl Edward Maher died as a result of hyperthermia during the Brecon Beacons march on one of the hottest days of the year in July 2013. Coroner Louise Hunt ruled L/Cpl Edward Maher, L/Cpl Craig Roberts and Cpl James Dunsby died as a result of neglect.
L/Cpl Craig Roberts and Cpl James Dunsby also collapsed and later died from the effects of overheating. All three suffered the effects of hyperthermia. The Brecon Beacons march was held on one of 2013's hottest days.
The coroner reached a conclusion of neglect. Ms Hunt said a failure of basic medical care contributed to their deaths.
The inquest in Solihull, West Midlands, had heard that had organisers strictly followed the Ministry of Defence's (MoD) code of practice, the march would have been cancelled after two men - not among those who died - were withdrawn from the exercise shortly after midday due to heat sickness.The inquest in Solihull, West Midlands, had heard that had organisers strictly followed the Ministry of Defence's (MoD) code of practice, the march would have been cancelled after two men - not among those who died - were withdrawn from the exercise shortly after midday due to heat sickness.
Controversially, Army personnel had told the coroner they were not aware of the contents of the MoD guidelines and had been told not to bother reading them.Controversially, Army personnel had told the coroner they were not aware of the contents of the MoD guidelines and had been told not to bother reading them.
The hearing has heard Cpl Dunsby, of Bath, would have been suffering signs of heat illness when he passed the penultimate check point but staff missed it. The hearing had heard Cpl Dunsby, of Bath, would have been suffering signs of heat illness when he passed the penultimate check point but staff missed it.
Delivering her conclusion on Tuesday, coroner Louise Hunt said: "Those running this march were fundamentally under-briefed. They did not fully understand the risk of heat illness, and the emergency plan was inadequate. Delivering her conclusion on Tuesday, the coroner said: "Those running this march were fundamentally under-briefed. They did not fully understand the risk of heat illness, and the emergency plan was inadequate.
"I consider the briefing to those running the march to be inadequate as it failed to include weather conditions, the risk of heat injury and the reporting of reasons for medical withdrawals should they occur."I consider the briefing to those running the march to be inadequate as it failed to include weather conditions, the risk of heat injury and the reporting of reasons for medical withdrawals should they occur.
"It also failed to include plans to evacuate any casualties," she said."It also failed to include plans to evacuate any casualties," she said.
Ms Hunt said the medical plan for the march was not good enough, water supplies were insufficient and the risk assessment did not identify the correct hospital for treatment.Ms Hunt said the medical plan for the march was not good enough, water supplies were insufficient and the risk assessment did not identify the correct hospital for treatment.
A lack of water contributed to Edward Maher's death, the hearing was told. A lack of water contributed to L/Cpl Edward Maher's death, the hearing was told.
There should have been closer liaison with emergency services to avoid multiple 999 calls and signal problems meant calls were cut off, leading to delays in getting to casualties, Ms Hunt said.There should have been closer liaison with emergency services to avoid multiple 999 calls and signal problems meant calls were cut off, leading to delays in getting to casualties, Ms Hunt said.
The coroner said there was a lack of understanding by the march's directing staff of soldiers withdrawing from heat illness and some staff were unaware some were ill.The coroner said there was a lack of understanding by the march's directing staff of soldiers withdrawing from heat illness and some staff were unaware some were ill.
'Complacent attitude''Complacent attitude'
She said had the MoD's own guidance on heat illness been followed, the march would have been called off by 12:40 BST - more than four hours before Cpl Roberts died on the mountain. She said that had the MoD's own guidance on heat illness been followed, the march would have been called off by 12:40 BST - more than four hours before Cpl Roberts died on the mountain.
GPS trackers used to monitor candidates were not fit for purpose - something the MoD had known since 2009, the hearing was told.GPS trackers used to monitor candidates were not fit for purpose - something the MoD had known since 2009, the hearing was told.
"No measures were put in place in this march to mitigate that risk. This is concerning because it appears lessons have not been learned," Ms Hunt said."No measures were put in place in this march to mitigate that risk. This is concerning because it appears lessons have not been learned," Ms Hunt said.
She added there was a lack of understanding of an "individuals will to succeed" and there was "complacent" attitude to risk.She added there was a lack of understanding of an "individuals will to succeed" and there was "complacent" attitude to risk.
The failure to recognise the three men had stopped moving via the GPS tracker was a gross failure, which amounted to neglect, she said.The failure to recognise the three men had stopped moving via the GPS tracker was a gross failure, which amounted to neglect, she said.
"In the case of each soldier there was a failure to provide basic medical care which contributed to their deaths.""In the case of each soldier there was a failure to provide basic medical care which contributed to their deaths."
Ms Hunt added the reservists were not adequately conditioned for the march, unlike regular soldiers, but all three were fit.Ms Hunt added the reservists were not adequately conditioned for the march, unlike regular soldiers, but all three were fit.
The test was the second time L/Cpl Roberts, from north Wales, and L/Cpl Maher, of Winchester, had attempted SAS selection.The test was the second time L/Cpl Roberts, from north Wales, and L/Cpl Maher, of Winchester, had attempted SAS selection.
The inquest into the three reservists' deaths sat for four weeks before adjourning for Ms Hunt to consider her conclusions.The inquest into the three reservists' deaths sat for four weeks before adjourning for Ms Hunt to consider her conclusions.
The closing submissions at the hearing raised the issue of whether the coroner could consider a verdict of unlawful killing.
Other issues of consideration include whether there was a gross failure on the part of the Ministry of Defence in ensuring the exercise was carried out safely.