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#OnThisDay in 2013, a Special Forces selection test in the Brecon Beacons is on the point of turning into a disaster. In unusually hot and still conditions, one candidate has just been medically withdrawn having experienced diarrhoea and vomiting
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#OnThisDay in 2013, a Special Forces selection test in the Brecon Beacons is on the point of turning into a disaster. In unusually hot and still conditions, one candidate has just been medically withdrawn having experienced diarrhoea and vomiting
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The Training Officer and Training Warrant Officer running the test had produced a risk assessment which said that the existing control measures against the risk of heat injury included compliance with all precautions in Land Forces Standing Order 3214
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The Training Officer and Training Warrant Officer running the test had produced a risk assessment which said that the existing control measures against the risk of heat injury included compliance with all precautions in Land Forces Standing Order 3214
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3/
The risk assessment had been created by copying and pasting the risk assessment of the so-called "lead regular unit". Neither the Training Officer nor Training Warrant Officer knew what Land Forces Standing Order 3214 actually said
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The risk assessment had been created by copying and pasting the risk assessment of the so-called "lead regular unit". Neither the Training Officer nor Training Warrant Officer knew what Land Forces Standing Order 3214 actually said
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Land Forces Standing Order 3214 required use of a Wet Bulb Globe Temperature meter to determine the risk of heat injury
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Land Forces Standing Order 3214 required use of a Wet Bulb Globe Temperature meter to determine the risk of heat injury
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Land Forces Standing Order 3214 also identified the need for changes in environmental conditions over the course of training to be anticipated, and for adjustments to be made to the intensity of activity
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Land Forces Standing Order 3214 also identified the need for changes in environmental conditions over the course of training to be anticipated, and for adjustments to be made to the intensity of activity
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The threshold WBGT values for activities were set out in an Annex to the Land Forces Standing Order. This indicated that no forced march activities were to be undertaken when the WBGT index exceeded 20
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The threshold WBGT values for activities were set out in an Annex to the Land Forces Standing Order. This indicated that no forced march activities were to be undertaken when the WBGT index exceeded 20
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7/
The Training Officer and Training Warrant Officer running the test, having not read the document their own risk assessment said they were complying with, knew nothing of the need to obtain WBGT readings and therefore had no WBGT meter available to them
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The Training Officer and Training Warrant Officer running the test, having not read the document their own risk assessment said they were complying with, knew nothing of the need to obtain WBGT readings and therefore had no WBGT meter available to them
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8/
At 1200, a WBGT reading was taken at Sennybridge Camp. The reading was 31.2°, far in excess of the permitted limit for forced march activities. Naturally, the Training Officer and Training Warrant Officer were oblivious to this reading ...
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At 1200, a WBGT reading was taken at Sennybridge Camp. The reading was 31.2°, far in excess of the permitted limit for forced march activities. Naturally, the Training Officer and Training Warrant Officer were oblivious to this reading ...
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9/
The guidance to mitigate the risk of heat injury which the Training Officer and Training Warrant Officer should have been following in 2013 was actually set out in Joint Services Publication (JSP) 539. Naturally, they had not read this document either.
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The guidance to mitigate the risk of heat injury which the Training Officer and Training Warrant Officer should have been following in 2013 was actually set out in Joint Services Publication (JSP) 539. Naturally, they had not read this document either.
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JSP 539 too required the use of WBGT readings to assist assessment of the risk of heat injury, and included upper threshold values for different types of activity
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JSP 539 too required the use of WBGT readings to assist assessment of the risk of heat injury, and included upper threshold values for different types of activity
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JSP 539 also contained an "immediate treatment algorithm". Note the requirement that ALL personnel should stop activity once any of them has shown symptoms of heat injury
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JSP 539 also contained an "immediate treatment algorithm". Note the requirement that ALL personnel should stop activity once any of them has shown symptoms of heat injury
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JSP 539 pointed out that a single case of heat illness was a sign that others might be at risk. While they had not read the document, both the Training Officer and Training Warrant Officer were aware of this principle
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JSP 539 pointed out that a single case of heat illness was a sign that others might be at risk. While they had not read the document, both the Training Officer and Training Warrant Officer were aware of this principle
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At 1214, a candidate was identified as suffering from heat illness and was medically withdrawn from the test exercise.
Both the Training Officer and Training Warrant Officer were informed of the withdrawal but neither enquired as to the reasons for it
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At 1214, a candidate was identified as suffering from heat illness and was medically withdrawn from the test exercise.
Both the Training Officer and Training Warrant Officer were informed of the withdrawal but neither enquired as to the reasons for it
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14/
At 1222, another candidate is held at a checkpoint suffering from clear symptoms of heat injury. After 20 minutes he is sent on his way, at the direction of the Training Warrant Officer
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At 1222, another candidate is held at a checkpoint suffering from clear symptoms of heat injury. After 20 minutes he is sent on his way, at the direction of the Training Warrant Officer
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15/
At 1246, another candidate is found in a delirious state by others. They activate the alarm on his personal tracker beacon
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At 1246, another candidate is found in a delirious state by others. They activate the alarm on his personal tracker beacon
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16/
A member of the directing staff is deployed from the same location as the command vehicle to assist the 1246 casualty. He brings the casualty back to the command vehicle's location
Still the penny doesn't drop with the Training Officer or Warrant Officer
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A member of the directing staff is deployed from the same location as the command vehicle to assist the 1246 casualty. He brings the casualty back to the command vehicle's location
Still the penny doesn't drop with the Training Officer or Warrant Officer
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17/
At 1314, Craig Roberts reaches Checkpoint 5. He has been on the move for 6 hours and 18 minutes but is now just 3.83km from the finish of the test
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At 1314, Craig Roberts reaches Checkpoint 5. He has been on the move for 6 hours and 18 minutes but is now just 3.83km from the finish of the test
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18/
At 1322, Edward Maher also reaches Checkpoint 5. Having started 10 minutes before Craig, he too has just 3.83km to go
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At 1322, Edward Maher also reaches Checkpoint 5. Having started 10 minutes before Craig, he too has just 3.83km to go
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19/
At 1426 yet another soldier, clearly suffering from heat injury, withdraws from the test.
The Training Officer and Warrant Officer are informed of the withdrawal but later claim not to have been aware of the reason for it. At best, they do not ask
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At 1426 yet another soldier, clearly suffering from heat injury, withdraws from the test.
The Training Officer and Warrant Officer are informed of the withdrawal but later claim not to have been aware of the reason for it. At best, they do not ask
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20/
At 1451, @RoyalYeomanry soldier James Dunsby reaches Checkpoint 2 on the summit of Pen y Fan. He has been moving (on the opposite route to Craig and Edward) for 7 hours and 59 minutes. He has just 3.86km to go
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At 1451, @RoyalYeomanry soldier James Dunsby reaches Checkpoint 2 on the summit of Pen y Fan. He has been moving (on the opposite route to Craig and Edward) for 7 hours and 59 minutes. He has just 3.86km to go
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The coroner later finds that James is displaying signs of heat illness, and should have been stopped, when he reaches Checkpoint 2. Instead, he is sent on his way and encouraged to speed up
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The coroner later finds that James is displaying signs of heat illness, and should have been stopped, when he reaches Checkpoint 2. Instead, he is sent on his way and encouraged to speed up
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22/
It is now 1517 on 13 July 2013.
Around 25 minutes after leaving Checkpoint 2 at the top of Pen y Fan, James Dunsby collapses. Heartbreakingly, and although he is wearing a tracker device and within 100 metres of the main path, no-one notices
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It is now 1517 on 13 July 2013.
Around 25 minutes after leaving Checkpoint 2 at the top of Pen y Fan, James Dunsby collapses. Heartbreakingly, and although he is wearing a tracker device and within 100 metres of the main path, no-one notices
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23/
At around 1531, Craig Roberts is found unconscious and face down in Cwm Crew (also known as "VW Valley"*) - almost within touching distance of the finish. The candidate finding him activates the alarm on Craig's tracker
*VW = Voluntary Withdrawal
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At around 1531, Craig Roberts is found unconscious and face down in Cwm Crew (also known as "VW Valley"*) - almost within touching distance of the finish. The candidate finding him activates the alarm on Craig's tracker
*VW = Voluntary Withdrawal
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24/
At 1537, the alert from the alarm on Craig's tracker is received in the command vehicle. A search party is despatched
James's tracker has now been static for 20 minutes. Still no-one notices
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At 1537, the alert from the alarm on Craig's tracker is received in the command vehicle. A search party is despatched
James's tracker has now been static for 20 minutes. Still no-one notices
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25/
At approximately 1600, the search party (which includes the Training Officer) reaches Craig. He is still unresponsive. Efforts to contact civilian emergency services are complicated by a lack of mobile coverage
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At approximately 1600, the search party (which includes the Training Officer) reaches Craig. He is still unresponsive. Efforts to contact civilian emergency services are complicated by a lack of mobile coverage
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26/
At around 1610, someone in the command vehicle finally notices that Edward Maher's tracker is static. Two of the directing staff at Checkpoint 5 (which Edward had left nearly 3 hours previously) are despatched to his location
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At around 1610, someone in the command vehicle finally notices that Edward Maher's tracker is static. Two of the directing staff at Checkpoint 5 (which Edward had left nearly 3 hours previously) are despatched to his location
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@RJArmyFitness @MilitaryBanter The other principal issue was insufficient acclimatisation to the conditions, for which the (Regular) CoC was responsible
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At 1635 someone in the command vehicle finally notices that James Dunsby’s tracker is static. Two soldiers are sent to assist him. But at this point the safety vehicle’s clutch, which has been slipping for days, gives out. They make their way on foot
To be continued …
At 1635 someone in the command vehicle finally notices that James Dunsby’s tracker is static. Two soldiers are sent to assist him. But at this point the safety vehicle’s clutch, which has been slipping for days, gives out. They make their way on foot
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28/
At about the same time, a civilian ambulance reaches the closest point on the road to Craig Roberts. The paramedics are unwilling to go further on foot until the Mountain Rescue Team arrives
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At about the same time, a civilian ambulance reaches the closest point on the road to Craig Roberts. The paramedics are unwilling to go further on foot until the Mountain Rescue Team arrives
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29/
Serendipitously, an off-duty member of the MRT passes by about 2 minutes later. He accompanies the paramedics to Craig at the same time as calling for an air ambulance
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Serendipitously, an off-duty member of the MRT passes by about 2 minutes later. He accompanies the paramedics to Craig at the same time as calling for an air ambulance
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30/
Side note: one of the additional control measures identified in the risk assessment was a unit helicopter to assist in searching for and recovering casualties. None had been arranged by the Training Officer or Warrant Officer
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Side note: one of the additional control measures identified in the risk assessment was a unit helicopter to assist in searching for and recovering casualties. None had been arranged by the Training Officer or Warrant Officer
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31/
At 1646, the civilian paramedics, accompanied by the MRT, reach Craig
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At 1646, the civilian paramedics, accompanied by the MRT, reach Craig
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32/
At 1653, civilian walkers come across another soldier (known as 1X) who has collapsed with heat illness. They activate the alarm on his tracker
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At 1653, civilian walkers come across another soldier (known as 1X) who has collapsed with heat illness. They activate the alarm on his tracker
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33/
At 1655, a member of the directing staff reaches Edward Maher. He is unresponsive
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At 1655, a member of the directing staff reaches Edward Maher. He is unresponsive
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Having been delayed by their broken Land Rover and by being sent to an incorrect grid reference, members of the directing staff reach James Dunsby at 1658, 1 hour & 41 minutes after he collapsed. He is unconscious but breathing.
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Having been delayed by their broken Land Rover and by being sent to an incorrect grid reference, members of the directing staff reach James Dunsby at 1658, 1 hour & 41 minutes after he collapsed. He is unconscious but breathing.
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35/
At about 1705, an air ambulance arrives to assist with the rescue efforts for Craig Roberts
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At about 1705, an air ambulance arrives to assist with the rescue efforts for Craig Roberts
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At about 1710, the paramedics treating Craig pronounce him dead. His family are later told, insensitively and no doubt flippantly, that the test exercise went ahead because cancelling it would have involved too much paperwork
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theguardian.com/uk-news/2015/j…
At about 1710, the paramedics treating Craig pronounce him dead. His family are later told, insensitively and no doubt flippantly, that the test exercise went ahead because cancelling it would have involved too much paperwork
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theguardian.com/uk-news/2015/j…
37/
The directing staff carry James Dunsby the short distance to the Pont Ar Daf car park, where they are met by the Mountain Rescue Team and a civilian ambulance at around 1715. James is still unconscious but breathing
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The directing staff carry James Dunsby the short distance to the Pont Ar Daf car park, where they are met by the Mountain Rescue Team and a civilian ambulance at around 1715. James is still unconscious but breathing
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At 1720, a SAR helicopter from Chivenor is despatched to assist Edward Maher
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At 1720, a SAR helicopter from Chivenor is despatched to assist Edward Maher
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At 1726, a second Sea King SAR helicopter is despatched from Chivenor to assist with the rescue efforts
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At 1726, a second Sea King SAR helicopter is despatched from Chivenor to assist with the rescue efforts
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40/
At 1734, the ambulance carrying both James Dunsby and yet another heat casualty leaves the Pont ar Daf car park, heading for Merthyr Tydfil
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At 1734, the ambulance carrying both James Dunsby and yet another heat casualty leaves the Pont ar Daf car park, heading for Merthyr Tydfil
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41/
At 1742, members of the directing staff reach Soldier 1X
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At 1742, members of the directing staff reach Soldier 1X
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It is quickly established that 1X is no longer able to walk. At 1746 the Sea King inbound to his location from Chivenor has to divert to refuel
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It is quickly established that 1X is no longer able to walk. At 1746 the Sea King inbound to his location from Chivenor has to divert to refuel
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At 1752, the ambulance carrying James Dunsby arrives at Prince Charles Hospital, Merthyr Tydfil. James will be admitted to the ITU
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At 1752, the ambulance carrying James Dunsby arrives at Prince Charles Hospital, Merthyr Tydfil. James will be admitted to the ITU
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At 1805, both a Sea King and an air ambulance arrive at Soldier 1X's location. Shortly afterwards, he is evacuated to Prince Charles Hospital in Merthyr Tydfil by the Sea King
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At 1805, both a Sea King and an air ambulance arrive at Soldier 1X's location. Shortly afterwards, he is evacuated to Prince Charles Hospital in Merthyr Tydfil by the Sea King
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45/
At 1827, the second Sea King reaches Edward Maher's location. It will take him to Prince Charles Hospital where he will formally be pronounced dead at approximately 2000
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At 1827, the second Sea King reaches Edward Maher's location. It will take him to Prince Charles Hospital where he will formally be pronounced dead at approximately 2000
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46/
James Dunsby will remain in the ITU at Prince Charles Hospital until 16 July, when he will be flown to Queen Elizabeth Hospital in Birmingham where he will remain until his death on 30 July
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James Dunsby will remain in the ITU at Prince Charles Hospital until 16 July, when he will be flown to Queen Elizabeth Hospital in Birmingham where he will remain until his death on 30 July
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47/
An inquest into the deaths of Edward, Craig and James will take place almost two years later, in 2015. It would be nice to report that the Army approached the inquest with appropriate humility and candour. But it did not
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An inquest into the deaths of Edward, Craig and James will take place almost two years later, in 2015. It would be nice to report that the Army approached the inquest with appropriate humility and candour. But it did not
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48/
Senior members of the SF community closed ranks - even to the extent of a CO pretending that JSP 539 did not apply to their activities when it featured in the generic risk assessment for his own unit's training, which he himself had signed
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Senior members of the SF community closed ranks - even to the extent of a CO pretending that JSP 539 did not apply to their activities when it featured in the generic risk assessment for his own unit's training, which he himself had signed
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And there was a notorious incident when the MOD was found to be rifling through the Coroner's bins
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dailymail.co.uk/news/article-3…
And there was a notorious incident when the MOD was found to be rifling through the Coroner's bins
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dailymail.co.uk/news/article-3…
50/
The Coroner gave a narrative verdict which was excoriating about the systemic failures, and the missed opportunities, which led to the tragedy
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bbc.co.uk/news/av/uk-335…
The Coroner gave a narrative verdict which was excoriating about the systemic failures, and the missed opportunities, which led to the tragedy
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bbc.co.uk/news/av/uk-335…
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Even today, there are those who do not understand just how deep seated and inexcusable the Army's failings were
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Even today, there are those who do not understand just how deep seated and inexcusable the Army's failings were
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There are signs the Army now accepts its responsibility for the tragic and unnecessary deaths. But the best way to prevent other families going through similar pain in the future is to keep these great men, and the awful events leading to their deaths, in mind.
END.
There are signs the Army now accepts its responsibility for the tragic and unnecessary deaths. But the best way to prevent other families going through similar pain in the future is to keep these great men, and the awful events leading to their deaths, in mind.
END.
@threadreaderapp unroll please
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