A senior coroner hearing the inquest of a soldier whocollapsed and diedduring a fitness test on a searingly hot day in the Brecon Beacons has strongly criticized the army for not learning from mistakes made during a previous tragedy whenthree men diedduring 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. ******
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. ******
The coroner said another soldier, who collapsed before Hoole died, should have been recognized 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.
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 calledJSP 539, which relates to climatic illness and was featured repeatedly during the SAS inquest.
The coroner said she had issued a report intended to prevent further deaths atthe 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 defense 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 20 C – 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.”
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.
After Hoole’s death, a defense 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 beenserious organizational failingsin 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.