Cpl Joshua Hoole Death: Coroner 'Very Worried' About Army's Ability To Learn From Mistakes

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's father Phillip Hoole, says he plans to take civil action against the Ministry of Defence (MOD) for corporate manslaughter.

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 19 July 2016.

The 26-year-old's death came three years after three Army reservists suffered fatal heat illness during an SAS selection march in the Brecon Beacons.

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.

In total, 18 out of the 41 soldiers taking part dropped out, collapsed or were withdrawn by the course directing staff, including Cpl Hoole.

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."

Watch: Cpl Hoole's father said the MOD failed to implement "meaningful changes".

Ms Hunt confirmed she would be sending a report to the Defence Secretary in order to prevent future deaths.

"It leaves me very worried about the Army's ability to learn from previous mistakes," she said.

"[The Army] 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 there was "also a failure on the part of individuals" not to consider the possibility of heat injuries during the march.

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.

Speaking after the inquest, Cpl Hoole's father Phillip Hoole, who successfully applied to have the hearing resumed, said he would bring a corporate manslaughter action against the Ministry of Defence.

Watch: Cpl Hoole had a "bright career" ahead of him.

Brigadier Christopher Coles, Head of the Army’s Personnel Services Branch, described Cpl Hoole as an "able, talented and dedicated and highly promising junior NCO, with a bright career ahead of him".

On behalf of the Army and MOD, Brig Coles gave his condolences to Cpl Hoole's family and friends.

An Army spokesperson said: "The death of Corporal Joshua Hoole was a tragedy and our thoughts remain with his family and friends.

"We shall carefully study and consider the recommendations which have come from this inquest and are grateful for the suggestions from Cpl Hoole’s family members on how heat illness can better be detected and managed."