A coroner has told the Army she has “grave concerns” about its “ability to learn from previous mistakes” after an inquest into the death of a soldier who collapsed during a test march on a hot day.
Senior Birmingham coroner Louise Hunt concluded there had been “very serious” failings at all levels as she concluded a hearing into the death of Corporal Joshua Hoole.
Cpl Hoole, described as “fit, capable and determined”, died within an hour of collapsing 400m from the end of an annual fitness test (AFT) at Brecon in Wales on July 19 2016.
The death of the 26-year-old, from Ecclefechan, near Lockerbie, Dumfries and Galloway, came three years after three Army reservists suffered fatal heat illness during an SAS selection march in the Brecon Beacons.
He had previously deployed to Afghanistan and was serving with 1 Rifles.
An inquest into Cpl Hoole’s death heard that soldiers were aware it was to be “the hottest day of the year” and the march time at Dering Lines was brought forward as a result.
Of the 41 soldiers taking part in the march, 18 dropped out, collapsed or were withdrawn – a rate of 42%.
The drop-outs included two with suspected heat injuries before Cpl Hoole collapsed.
At a 2015 inquest into the SAS selection march deaths, Ms Hunt concluded there had been a lack of awareness about key health and safety documents, including one called JSP 539.
Highlighting the Army’s “continuing” failure in that field at Cpl Hoole’s inquest on Friday, she said: “There was a very serious failure on the part of the Army to ensure the Rifles’ training team were familiar with improvements in JSP 539 and how they applied to the AFT.”
She added: “There was a report to prevent future deaths issued in July 2015 following inquests which specifically raised concerns about lack of awareness of JSP 539.
“I consider the continuing lack of awareness and failure to follow up to be a very serious failing which directly impacted on the safety of the AFT.
“The failure of the Army to learn from previous mistakes is a very concerning matter for me.”
Relatives of those reservists who died on the SAS selection march were also in court, alongside Cpl Hoole’s parents.
Announcing that she would be sending a report to prevent future deaths to the Defence Secretary, Ms Hunt said: “This is the biggest concern that I have.
“It leaves me very worried about the Army’s ability to learn from previous mistakes.
“It is a matter of grave concern for me I am raising the same concerns.”
“I really want to give a message to the Army,” she added.
“They need to think about how to learn from things that have happened because I also know there are others here feeling this very hard, knowing perhaps the only comfort they had from their inquest was something might change, and we’re sitting here and it hasn’t changed.
“Quite simply it has to change.
She added that there was “also a failure on the part of individuals” not to consider the possibility of heat injuries during the march.
Ms Hunt said: “It should be noted three soldiers died from heat-related illness on the (SAS selection) march in the Brecons in July 2013.”
She concluded that the march should “not have taken place” in such heat, but there had been a “very serious failure” to check a key temperature gauge before the AFT – and in any case it was giving “erroneous” readings.
Ms Hunt said: “I am able to conclude, had the AFT not gone ahead or been stopped any time before 8.28am, before Josh’s collapse, on balance he would not have died when he did.”
However, she added that Cpl Hoole had an “underlying vulnerability, not previously identified, to a sudden cardiac event”.
She concluded cause of death was a “combination of factors” recorded as sudden arrhythmogenic cardiac death associated with high cardiovascular workload due to exercise, heat stress and adrenaline burst from individual drive.
Earlier, she ruled out conclusions of unlawful killing, telling Cpl Hoole’s family she had heard no evidence “beyond all reasonable doubt” to make that finding.