A CORONER has ruled that neglect played a part in the deaths of three Army reservists who collapsed during a 16-mile SAS test march.

Recording narrative verdicts at an inquest in Solihull, 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.

Lance corporals Edward Maher and Craig Roberts were pronounced dead on the Brecon Beacons after suffering heatstroke in July 2013.

Corporal James Dunsby died at Birmingham's Queen Elizabeth Hospital from multiple organ failure more than two weeks later.

Criticising the "chaotic" response to the men's collapse and accusing special forces' commanders of a catalogue of serious mistakes, Ms Hunt said: "The risk assessment undertaken for this exercise was inadequate.

"There was a failure to implement an adequate medical plan to allow for treatment of any heat illness casualties."

A GPS tracker system in place at the time of the march - with a "slow man" function disabled - was not fit for purpose, the inquest also heard.

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."

Ms Hunt said those who organised the march failed to appreciate that candidates would push themselves to the limit with a "do or die" desire to succeed.

Ms Hunt also identified a lack of build-up marches for reservists as a contributory factor in the deaths.

In general comments on the preparation and conduct of the march, Ms Hunt criticised a risk assessment completed more than two weeks before the exercise for failing to incorporate weather conditions or to identify a heat stress index for the march.

The coroner also ruled that that if the reservists had been afforded "basic treatment of cooling, hydration, rest and removing kit" the men would have survived.

mf Page 2: 13:14 All three men died as a result of a "failure to properly organise and manage" the march on Saturday July 13 2013, the coroner said.

In respect of L/Cpl Roberts, originally from Penrhyn Bay in North Wales, the coroner found that he became static at about 2.55pm and was found by another soldier at about 3.37pm.

The failure to identify that the 24-year-old had stopped moving amounted to a gross failure, and the subsequent delay in providing treatment was ruled to constitute neglect.

L/Cpl Maher, from Winchester in Hampshire, veered off course and was stationary from 2.16pm, according to data from his tracker beacon.

Ms Hunt said soldiers monitoring the tracker in a command vehicle had only noticed that L/Cpl Maher was not moving at 4.10pm.

As a result, the 31-year-old former regular soldier with the Royal Green Jackets had signs of rigor mortis by the time he was reached at 4.45pm.

In her narrative verdict, Miss Hunt said of L/Cpl Maher: "There was a gross failure to identify that Edward became static and was off course at 2.16pm.

"There was a general delay in providing medical treatment and this contributed to his death. Inadequate water contributed to his death."

The coroner ruled that Cpl Dunsby, from Trowbridge in Wiltshire, had probably shown signs of heat illness at a checkpoint on Pen y Fan at 2.51pm.

The Afghanistan veteran, a former member of the Royal Tasmania Regiment in Australia, was taken to hospital with a body temperature of 41C (105.8F) after collapsing in the final stages of the march.

The inquest heard that the 31-year-old reservist went "static" at 3.17pm but march commanders failed to realise he had stopped marching until 4.35pm.

Medical help only reached the Solihull-born soldier at 4.58pm.