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SAS inquest: military response to emergency was chaotic, coroner says SAS inquest: coroner highlights 'catalogue of very serious mistakes'
(34 minutes later)
A coroner has described the response by the military to the emergency when three army reservists collapsed and died on an SAS exercise as “chaotic”. A coroner has said there were a “catalogue of very serious mistakes” made by many people involved in the planning and execution of an SAS test march in which three candidates suffered fatal heat illness.
She said the lack of buildup marches contributed to the deaths. Coroner Louise Hunt told the inquest in Solihull, West Midlands, that with the right basic treatment the men would have survived.
In comments to the final day of an inquest in Solihull, senior Birmingham coroner Louise Hunt also ruled that checkpoint staff had missed signs of heat illness in one of those who died. Related: How three army reservists died on an SAS march - visual guide
The inquest has heard that lance corporals Edward Maher and Craig Roberts were both pronounced dead on the Brecon Beacons after suffering heatstroke in July 2013. Delivering a narrative verdict, she said neglect played a part in the death of the soldiers.
Corporal James Dunsby died at Birmingham’s Queen Elizabeth hospital from multiple organ failure more than two weeks after the march. She said it was a “gross failure” that directing staff did not at first notice that the men had collapsed, which caused delays before medical attention reached them.
“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 there were systemic failures by soldiers on the ground and those “much higher up”.
Hunt flagged up problems with the way the march was planned and the preparation given to the three men, all reservists. She said the rescue operation once it had been noticed that the three had collapsed was “at times chaotic”.
But, giving a narrative conclusion, she said she did not believe the failings amounted to manslaughter through gross negligence.
Lance Corporals Craig Roberts, Edward Maher and Corporal James Dunsby collapsed in the heat during the 16-mile course used by the SAS for decades.
An expert had told the inquest that the march should have been halted before the three men collapsed after other candidates suffered heat illness. Several of those involved in overseeing the exercise said they had not read Ministry of Defence guidelines on dealing with heat illness.
Roberts, 24, Maher and Dunsby, both 31, collapsed during the exercise on 13 July 2013. All were reservists – part-time soldiers – who wanted to try out for the SAS reserve, which works alongside regular troops in some of the most dangerous war zones in the world.
They were among 78 men taking part in the march on and around Pen y Fan, the largest mountain in southern Britain, and were carrying rucksacks weighing at least 49lbs (22kg). Their target was to complete the march within eight hours and 48 minutes, but by early afternoon, as temperatures soared towards 30C, the trio collapsed.
In general comments on the preparation and conduct of the march, Hunt said a risk assessment completed more than two weeks before the exercise was inadequate.In general comments on the preparation and conduct of the march, Hunt said a risk assessment completed more than two weeks before the exercise was inadequate.
The coroner told the hearing: “I consider that the risk assessment was not adequate for the march being undertaken.The coroner told the hearing: “I consider that the risk assessment was not adequate for the march being undertaken.
“It failed to address the increased risk of heat illness based on the weather forecast. “It failed to address the increased risk of heat illness based on the weather forecast. It failed to have a clear plan for how to get to and treat any heat injury casualties that occurred.”
“It failed to have a clear plan for how to get to and treat any heat injury casualties that occurred.”
As relatives of all three soldiers listened to her summary, Hunt added that she considered the 37 reservists who took part in the 16-mile march were not adequately conditioned compared with regular soldiers.As relatives of all three soldiers listened to her summary, Hunt added that she considered the 37 reservists who took part in the 16-mile march were not adequately conditioned compared with regular soldiers.
Ruling that the lack of build-up marches in the week before the march had contributed to the deaths, Hunt stressed that fitness was different to conditioning and that all those who died had been “very fit”.Ruling that the lack of build-up marches in the week before the march had contributed to the deaths, Hunt stressed that fitness was different to conditioning and that all those who died had been “very fit”.
Communications in response to the casualties, which relied on mobile phones to dial 999, were not effective, and had contributed to a delay in reaching casualties, the coroner also decided.Communications in response to the casualties, which relied on mobile phones to dial 999, were not effective, and had contributed to a delay in reaching casualties, the coroner also decided.
“The response was at times chaotic ... giving wrong grid references, as evidenced by the 999 calls,” Hunt told the hearing.“The response was at times chaotic ... giving wrong grid references, as evidenced by the 999 calls,” Hunt told the hearing.
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