A CORONER has ruled out manslaughter through gross negligence over the deaths of three soldiers on an SAS selection march on the Brecon Beacons.

An inquest this morning heard west Midlands coroner Louise Hunt outline a “catalogue of very serious mistakes” made by many involved in the planning and execution of  the march in July 2013 that saw three candidates suffer fatal heat illness and several others stricken by the same condition.

Returning a narrative conclusion, Coroner Hunt said that with the right basic treatment the men would have survived, but she did not believe that failings in the management and supervision of the march amounted to manslaughter through gross negligence.

It was, she said, 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 there were “systemic failures” by soldiers on the ground and those “much higher up” contributing to a catalogue of “very serious mistakes”.

Coroner Hunt also identified issues with the way the march was planned and the preparation given to the three men, all reservists.

The resulting rescue operation was, she said, “at times chaotic”.

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.

Expert evidence put to the inquest suggested that the march should have been stopped.

 Other evidence exposed those involved in overseeing the exercise as having not read Ministry of Defence guidelines on dealing with heat illness.

Reservists Roberts, 24, Maher and Dunsby, both 31, collapsed during the exercise on 13 July 2013.

Together, they were trying out for selection to the SAS reserve.

Seventy-eight soldiers took part in the march on and around Pen y Fan in full kit carrying rucksacks weighing at least 49lbs (22kg).

They were to complete the march within eight hours and 48 minutes in  temperatures that soared towards 30C.

In reaching a narrative conclusion coroner hunt said she considered the risk assessment for the exercise was “not adequate” in failing 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,” she said.

In her view, 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, Coroner Hunt said that that fitness was different to conditioning and that all those who died had been “very fit”.

She found 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 with the response, at times, chaotic and hampered further by wrong grid references - as evidenced in related 999 calls.

But neglect, she said,  narrative verdict, she said neglect played a part in the death of the soldiers.

There was, she said neglect over the deaths and a “gross failure” that directing staff did not at first notice that the men had collapsed, delaying the emergency medical response.

“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.

But she did not believe the failings amounted to manslaughter through gross negligence.

 Dyfed-Powys Police and the Health and Safety Executive have issued a joint statement "acknowledging" the narrative verdict.

It reads: "Dyfed-Powys Police and Health and Safety Executive undertook a joint investigation into this incident and HSE’s investigation into circumstances surrounding the deaths of these soldiers continues.

Our thoughts are very much with the families of Craig Roberts, James Dunsby and Edward Maher, who have shown strength and dignity throughout the inquest process."