The father of a soldier who died on an “unsafe” Army test march that should have never have taken place is bringing a civil action for corporate manslaughter against the Ministry of Defence (MoD).
Phillip Hoole announced the move after an inquest into the death of his son, Corporal Joshua Hoole, found “very serious” training and planning failings at every level, surrounding the exercise on a hot day in July 2016.
Concluding the inquest on Friday, senior Birmingham coroner Louise Hunt also told the Army she had “grave concerns” about its “ability to learn from previous mistakes”, after similar failings were identified following an SAS selection march in 2013.
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.
Reacting to the inquest’s narrative conclusion, Mr Hoole said: “I intend to take out a civil action against the MoD for corporate manslaughter.”
The death of 26-year-old Cpl Hoole, 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Of the 41 soldiers taking part in the march, 18 dropped out, collapsed or were withdrawn – a rate of 42%.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 who went down with suspected heat injuries, well before Cpl Hoole collapsed.
Rules governing the AFT meant that the exercise should have been stopped once heat illness was suspected and had they done so, the coroner found Cpl Hoole would have lived.
However, Ms Hunt identified failings, including “confusion” about who was in charge of the test march, leading to “wide gaps in management and assessment of the AFT, making it unsafe”.
The exercise’s directing staff were also “unfamiliar” with health and safety and risk assessment rules, had “poor” IT support and no budget of their own, operating a “black market economy”, begging instructors from other units, to bolster numbers.
Captain Colin Nufer, officer in charge of the course, told the inquest he took a “common sense” approach to health and safety.
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, 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.”
“Quite simply it has to change,” she added.
Ms Hunt that there was “also a failure on the part of individuals” not to consider the possibility of heat injuries during the march, knowing the weather would be hot.
She added: “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 AFT should “not have taken place” in such heat, but there had been a “very serious failure” to check a key temperature gauge before the march – and in any case it was giving “erroneous” readings.
Heat experts later calculated the temperature had already reached the limit of safe operation at 6.45am, before the march started.
Ms Hunt said: “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.
Afterwards, Bryher Dunsby, the widow of Cpl James Dunsby – who died on the SAS selection march, said the attitude to training and heat illness needed to change within the Army.
She said: “More of our service personnel will die in training if it not addressed.”
Brigadier Christopher Coles, head of the Army’s personnel services group, said: “The MoD has acknowledged that aspects of the policy in place which governed the training Corporal Hoole was undertaking could have been better, and was in areas inconsistent.
“While much work has already been done to address this, we will seek to ensure that it is refined and improved to help ensure a tragedy like Corporal Hoole’s death is not repeated.”