Coroner at inquest into deaths of three army reservists who collapsed on exercise in Brecon Beacons cites ‘systemic failures’ in narrative conclusion

This article is more than 5 years old

This article is more than 5 years old

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.

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.

“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.

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.

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:

The risk assessment was “inadequate and not fit for purpose”. She said there was a failure to incorporate the weather conditions into the risk assessment and a failure to understand the significance of the weather forecast and its implications for heat illness.

There was no “dynamic risk assessment”. There was a “failure to consider actual water requirements for the specific task”.

There was a “general lack of understanding of heat illness and the risks posed to candidates”.

There was inadequate training for staff in charge of the test.

There was a failure to implement an adequate medical plan.

The tracker system [designed to show if the men had stopped] was “not fit for purpose”.

There was a “culture of following what had gone before without giving any consideration to specific risks”.

There was a “failure to appreciate that candidates would push themselves to their limit and have an “overwhelming desire to succeed – do or die”.

The reservists did not do build-up marches.

There were “systemic failures … in the planning, training and organisation of this endurance event”.

How three army reservists died on an SAS march - visual guide Read more

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.

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.

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.”

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.



Facebook Twitter Pinterest James Dunsby’s widow, Bryher Dunsby, speaks to reporters after the hearing

Speaking afterwards, James Dunsby’s widow, Bryher Dunsby, said: ‘The events that took place two years ago yesterday and the process that we have all subsequently been through and the findings that were announced today could never alter the truth that James loved the army.

“There are times during the course of this inquest when the Ministry of Defence has lost sight of the importance of their very own values and standards.

“They displayed no responsibility, no accountability, and no humility for their role in creating the culture which lead to the events on the 13 July 2013.

“Even an ounce of this would have gone such a long way in acknowledging the vast catalogue of errors which were so clearly made.

“Those qualities and values were surely the very least that should have been displayed to honour the memory of three of their own.

“James would have been so hugely disappointed by the behaviour of an organisation for which he had fought for and for which he ultimately lost his life.

“The evidence in this inquest has revealed a list of countless and quite honestly embarrassing failings which anyone with pride in our armed forces would find to be shocking and unacceptable. The choices that were available have all been made. The words to be spoken have all been said.

“If only we were unable to unpick the stitches of time to go back and make better decisions. Sadly this is not how life works.

“No part of the armed forces can be below scrutiny or above the law but unless and until those at the top acknowledge and accept responsibility for the failings of their organisation, cultures will not change and mistakes of the past will be repeated.

“So, looking forward to the future, it is my ardent wish and plea that as an institution the MoD has the maturity to look at its failings and to want to improve. I so dearly hope that pride and ego will not continue to blind ingiduclals from implemenitng the changes which so evidently must be made.

“My challenge to the Ministry of Defence is not to allow those most tragic events to be in vain and that with the opportunity to change to equipment, training and procedure they appropriately honour the memories of three extraordinary young men.”

She concluded: “Please find a moment this evening to remember Craig Roberts, Ed Maher and James Dunsby.”

Brigadier John Donnelly, director personal services army, said: “We are truly sorry for all the mistakes the coroner identified today. We have already made a number of changes to the exercise in terms of the way it is run. But we will study the coroner’s conclusion very carefully and make sure that everything possible is done to prevent a reoccurrence of an incident such as this. We will also hold our own service inquiry as soon as all the civil investigations have finished.

“It is necessary to train our soldier to the highest standards to meet the security challenges we face in this country and oversees and to do this requires our individuals to push themselves and take some risk. However we must ensure those risks are carefully managed. In this case we did not do this and accept responsibility.”





















