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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 had been 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. |
| Coroner Louise Hunt ruled L/Cpl Edward Maher, L/Cpl Craig Roberts and Cpl James Dunsby died as a result of neglect. | Coroner Louise Hunt ruled L/Cpl Edward Maher, L/Cpl Craig Roberts and Cpl James Dunsby died as a result of neglect. |
| All three suffered the effects of hyperthermia. The Brecon Beacons march was held on one of 2013's hottest days. | All three suffered the effects of hyperthermia. The Brecon Beacons march was held on one of 2013's hottest days. |
| Ms Hunt said a failure of basic medical care contributed to their deaths. | 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Defence's (MoD) code of practice, the march would have been cancelled after two men - not among those who died - were withdrawn from the exercise shortly after midday due to heat sickness.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Defence's (MoD) code of practice, the march would have been cancelled after two men - not among those who died - were withdrawn from the exercise shortly after midday due to heat sickness.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 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. | 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, 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. | 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 July 2013 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 July 2013 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 L/Cpl Maher's death, the hearing was told. | A lack of water contributed to L/Cpl 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 with 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 with heat illness and some staff were unaware some were ill. |
| 'Complacent attitude' | 'Complacent attitude' |
| 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 the first victim, Cpl Roberts, was found convulsing 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 Penrhyn Bay, Conwy, and L/Cpl Maher, of Winchester, had attempted SAS selection. | |
| In a statement after the hearing, the family of L/Cpl Maher paid tribute to the "humanity and skill" of the police and SAS family liaison officers who supported them through the "most difficult two years of our lives". | In a statement after the hearing, the family of L/Cpl Maher paid tribute to the "humanity and skill" of the police and SAS family liaison officers who supported them through the "most difficult two years of our lives". |
| They said while they supported the work of the special forces to produce "magnificent soldiers", training methods "must be fit for purpose" with differences between training and operational activities. | They said while they supported the work of the special forces to produce "magnificent soldiers", training methods "must be fit for purpose" with differences between training and operational activities. |
| "Our son was not on active service in July 2013; he was undergoing selection training on a Welsh hillside, and it is unacceptable that he paid for that training with his life," the statement added. | "Our son was not on active service in July 2013; he was undergoing selection training on a Welsh hillside, and it is unacceptable that he paid for that training with his life," the statement added. |
| Cpl Dunsby's widow, Bryher Dunsby, said at times during the inquest the MoD had displayed "no responsibility, no accountability and no humility" in acknowledging the "vast catalogue of errors which were so clearly made". | Cpl Dunsby's widow, Bryher Dunsby, said at times during the inquest the MoD had displayed "no responsibility, no accountability and no humility" in acknowledging the "vast catalogue of errors which were so clearly made". |
| "No part of the armed forces can be beyond scrutiny or above the law but unless and until those at the top acknowledge and accept responsibility for the failing of their organisations cultures will not change and mistakes will be repeated," she added. | "No part of the armed forces can be beyond scrutiny or above the law but unless and until those at the top acknowledge and accept responsibility for the failing of their organisations cultures will not change and mistakes will be repeated," she added. |
| After the hearing, Health and Safety Executive said its investigation into the circumstances surrounding the reservists' deaths was continuing. | After the hearing, Health and Safety Executive said its investigation into the circumstances surrounding the reservists' deaths was continuing. |
| Heat exhaustion and heatstroke are two potentially serious conditions that can occur if you get too hot. | Heat exhaustion and heatstroke are two potentially serious conditions that can occur if you get too hot. |
| They usually happens during a heatwave or in a hot climate, but can also occur when doing very strenuous physical exercise. | They usually happens during a heatwave or in a hot climate, but can also occur when doing very strenuous physical exercise. |
| Source: NHS Choices website | Source: NHS Choices website |