Lance corporals Edward Maher and Craig Roberts were pronounced dead on the Brecon Beacons after suffering heatstroke in July 2013.
Afghanistan veteran Corporal James Dunsby died at Birmingham’s Queen Elizabeth Hospital from multiple organ failure more than two weeks later.
Recording narrative verdicts at an inquest in Solihull yesterday, senior Birmingham coroner Louise Hunt said all three soldiers would have survived if Ministry of Defence regulations on heat illness had been followed. Describing parts of the planning and conduct of the special forces march as inadequate or not fit for purpose, the coroner said inadequate supplies of water also contributed to one of the deaths.
After the inquest, Cpl Dunsby’s widow called for a change in culture at the Ministry of Defence.
Bryher Dunsby said her “chivalrous, loyal” husband would have been “hugely disappointed” by the behaviour of the MoD, “for which he had fought and to which he ultimately lost his life”.
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 failings of their organisation, cultures will not change and the 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.”
In a statement, Lance Cpl’s Maher’s family said it was “unacceptable” that he paid for training with his life.
Concluding the inquest, Ms Hunt criticised the “chaotic” response to the men’s collapse and accused special forces’ commanders of a catalogue of serious mistakes.
A risk assessment undertaken for the exercise was “inadequate” and a GPS tracker system in place at the time of the march - with a “slow man” function disabled - was not fit for purpose.
In the case of Lance Cpl Maher, who was 31 and from Winchester, soldiers monitoring the tracker took almost two hours to notice he had stopped moving. In respect of 24-year-old Lance Cpl Roberts, who was from North Wales, the failure to identify that he had stopped moving amounted to a gross failure, and the subsequent delay in providing treatment was ruled to constitute neglect, said Ms Hunt.
Medics only reached Cpl Dunsby, who was 31 and from Trowbridge, two hours after he had probably shown signs of heat illness at a checkpoint on Pen Y Fan.
Claiming there had been a failure to learn from a previous fatality on an SAS test march in 2008, Ms Hunt added: “There was a culture of following what had gone before without giving any consideration to specific risks. The (special forces) signals regiment took their lead from, and was subservient to, the lead regular unit. They do not think for themselves.”
In her final remarks, the coroner paid tribute to each soldier in turn, describing Cpl Dunsby as a talented sportsman, academic and soldier. Lance Cpl Maher had dedicated his life to others, while Lance Cpl Roberts was known for his eccentric tastes in literature, sense of humour and determination.
The MoD offered an unreserved apology for the soldiers’ deaths. Speaking after the hearing, Brigadier John Donnelly, the Army’s personnel director, also announced a “service inquiry” would be carried out after all civil investigations had finished.
Here are the timings of key events during the ill-fated SAS test march on Saturday July 13 2013.
6.46-6.56am: Reservists Edward Maher, Craig Roberts and James Dunsby set off from Checkpoint 1 near Beacons Reservoir. Each soldier is set a target time of eight hours and 48 minutes to cover more than 16 miles (26km).
12.14pm: Soldier 2J is withdrawn from the march. According to a heat illness expert, directing staff should have conducted a Wet Bulb Globe Test temperature reading and considered calling off the march.
12.46pm: A medical assessment leads to Soldier 2P, who is so confused he cannot recall his civilian trade, being medically withdrawn.
2.16pm to 3.20pm: All three soldiers who later died are believed to have collapsed or to have “gone static”, according to their GPS tracker beacons. Tracker data suggests Cpl Dunsby had covered around two miles (3.2km) in 30 minutes after passing through a checkpoint at the summit of Pen y Fan.
3.31pm: Soldier 1D, who is taking part in the SAS march, finds L/Cpl Roberts less than 0.6 miles (1km) from the finishing point and presses his “man down” button. Repeated attempts are made to revive L/Cpl Roberts but he is pronounced dead at 5.10pm despite the best efforts of soldiers and paramedics.
4pm: The hourly temperature measurement in the nearby village of Libanus peaks at 27.1C (80.8F).
4.26pm: Reservist 4E, who is hallucinating due to the effects of heat, is withdrawn from the march after diverting to the wrong checkpoint because it was manned by a medic.
4.45pm: L/Cpl Maher is found lifeless on a hillside, still clutching a bottle of water and a half-eaten chocolate bar. GPS timings show he had stopped moving up to two and a half hours before a medic arrived to help him.
4.52pm: March directing staff reach Cpl Dunsby and trigger his emergency tracker alarm. GPS data suggests he may have been stationary and requiring medical help for up to 90 minutes. He was handed over to an ambulance crew at 5.34pm and died in hospital on July 30.
8pm: The training officer of the lead SAS unit - who had been at a different march - is told there have been two fatalities. Cpl Dunsby is critically ill in hospital and four other reservists are also being treated in hospital.