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| SAS inquest: coroner highlights 'catalogue of very serious mistakes' | SAS inquest: coroner highlights 'catalogue of very serious mistakes' |
| (about 1 hour later) | |
| 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. | 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. |
| Coroner Louise Hunt told the inquest in Solihull, West Midlands, that with the right basic treatment the men would have survived. | Coroner Louise Hunt told the inquest in Solihull, West Midlands, that with the right basic treatment the men would have survived. |
| Delivering a narrative verdict, she said neglect played a part in the death of the soldiers. | Delivering a narrative verdict, she said neglect played a part in the death of the soldiers. |
| 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. | 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.” | “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”. | She said there were systemic failures by soldiers on the ground and those “much higher up”. |
| Related: SAS fatalities treated as matter-of-fact | |
| 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”. | 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. | But, giving a narrative conclusion, she said she did not believe the failings amounted to manslaughter through gross negligence. |
| The Ministry of Defence apologised for its failings but said that candidates had to undergo rigorous testing. | |
| 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. | 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. | 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. |
| The coroner concluded: | |
| Related: How three army reservists died on an SAS march - visual guide | |
| The coroner said she would be making about a dozen recommendations to the MoD to prevent further deaths. | |
| She said she remained concerned about the new tracker device being used on exercises and remained unconvinced that the MoD was learning from previous tragedies. She said she remained worried that the MoD still had not put in place clear guidance about how to deal with heat illness. | |
| In a statement the family of Maher said: “The SAS must distinguish between training and operational activities. Our son was not on active service in July 2013; he was undergoing selection on a Welsh hillside and it is unacceptable he paid for that training with his life.” | |
| 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. | 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 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 have a clear plan for how to get to and treat any heat injury casualties that occurred.” | “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.” |
| 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. | |
| 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 said. | |
| “The response was at times chaotic … giving wrong grid references, as evidenced by the 999 calls,” Hunt told the hearing. | |