NEGLECT played a part in the deaths of three Army reservists who collapsed during an SAS test march, a coroner has ruled, and that with the right basic treatment the men "would have survived".

In narrative verdicts recorded at an inquest into the deaths of Lance Corporal Craig Roberts, Lance Corporal Edward Maher and Corporal James Dunsby, senior Birmingham coroner Louise Hunt found delays in providing medical treatment contributed to their deaths after the exercise on the Brecon Beacons in 2013.

The inquest at Solihull has heard that lance corporals Edward Maher and Craig Roberts were both pronounced dead on the Brecon Beacons after suffering heatstroke on July 13, 2013.

Cpl Dunsby, 31, of Trowbridge, was a reservist with Swindon-based A Squadron The Royal Yeomanry who had fought in Helmand Province. He died at Birmingham's Queen Elizabeth Hospital from multiple organ failure more than two weeks after the march.

Today Ms Hunt said: "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 slammed the "chaotic" response after three Army reservists collapsed, saying that with the right basic treatment the men "would have survived" and a lack of build-up marches contributed to the deaths, ruling that checkpoint staff had missed signs of heat illness in one of those who died.

"The response was at times chaotic... giving wrong grid references, as evidenced by the 999 calls," Ms Hunt told the hearing.

In comments on the final day of an inquest in Solihull, the coroner said 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.

Ms Hunt said a risk assessment completed more than two weeks before the exercise was inadequate.

She said: "I consider that the risk assessment was not adequate for the march being undertaken.

"It failed 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."

As relatives of all three soldiers listened to her summary, Ms Hunt added that she considered the 37 reservists who took part in the 16-mile march were not adequately conditioned compared to regular soldiers.

Ruling that the lack of build-up marches in the week before the march had contributed to the deaths, Ms Hunt stressed that fitness was different to conditioning and that all those who died had been "very fit".

The coroner drew on the evidence of a heat injury expert who concluded that if each of the men been stopped at their last checkpoints they would have survived.

Ms Hunt said she accepted the determinations of Professor George Havineth who found that with "basic treatment" each of the three soldiers would have recovered.

She said that while a lack of water did not contribute to the deaths of Cpl Dunsby or L/Cpl Roberts, it did play a role in the death of L/Cpl Maher.

Ms Hunt added that if the reservists had been afforded "basic treatment of cooling, hydration, rest and removing kit" the men "would have survived".

In particular with Cpl Dunsby, she found on the balance of probability he would have been showing signs of heat illness at the last checkpoint before he succumbed, and this "should have been noticed" by his commanders.

Ms Hunt agreed with Prof Havineth's conclusion: "It would have made a big difference if James (Dunsby) had been admitted to hospital earlier."

In a statement issued after the inquest, L/Cpl's Maher's family said: "The SAS must distinguish between training and operational activities.

"Our son was not on active service in July 2013, he was undergoing selection training on a Welsh hillside, and it is unacceptable that he paid for that training with his life.

"The HSE (Health and Safety Executive) will now take the coroner's findings and work with the special forces to minimise the risks involved in the training and hopefully prevent any further tragedies. We wish them both well."

Dr Andrew Murrison, MP for South West Wiltshire, expressed serious concerns following the inquest verdict today into the deaths of three soldiers undergoing training in the Brecon Beacons.

“I am appalled at the avoidable deaths of these three fit young men," he said.

"Clearly there were some very serious shortcomings and I will be seeking early and detailed assurance from the MOD that steps have been taken to prevent a recurrence of this dreadful tragedy.”

Dr Murrison served for 18 years as a medical officer in the Royal Navy including in Iraq in 2003 and wrote two reports on military healthcare at the request of the coalition government.

Timeline of events on July 13, 2013

6.46-6.56am: Reservists Edward Maher, Craig Roberts and James Dunsby set off from Checkpoint 1 near Beacons Reservoir. Each soldier is set a target time of eight hours and 48 minutes to cover more than 16 miles (26km).

12.14pm: Soldier 2J is withdrawn from the march. According to a heat illness expert, directing staff should have conducted a Wet Bulb Globe Test temperature reading and considered calling off the march.

12.46pm: A medical assessment leads to Soldier 2P, who is so confused he cannot recall his civilian trade, being medically withdrawn.

2.16pm to 3.20pm: All three soldiers who later died are believed to have collapsed or to have "gone static", according to their GPS tracker beacons.

Tracker data suggests Cpl Dunsby had covered around two miles (3.2km) in 30 minutes after passing through a checkpoint at the summit of Pen y Fan.

3.31pm: Soldier 1D, who is taking part in the SAS march, finds L/Cpl Roberts less than 0.6 miles (1km) from the finishing point and presses his "man down" button. Repeated attempts are made to revive L/Cpl Roberts but he is pronounced dead at 5.10pm despite the best efforts of soldiers and paramedics.

4pm: The hourly temperature measurement in the nearby village of Libanus peaks at 27.1C (80.8F).

4.26pm: Reservist 4E, who is hallucinating due to the effects of heat, is withdrawn from the march after diverting to the wrong checkpoint because it was manned by a medic.

4.45pm: L/Cpl Maher is found lifeless on a hillside, still clutching a bottle of water and a half-eaten chocolate bar. GPS timings show he had stopped moving up to two and a half hours before a medic arrived to help him.

4.52pm: March directing staff reach Cpl Dunsby and trigger his emergency tracker alarm. GPS data suggests he may have been stationary and requiring medical help for up to 90 minutes.

5.34pm: Cpl Dunsby handed over to an ambulance crew. He died in hospital on July 30.

8pm: The training officer of the lead SAS unit - who had been at a different march - is told there have been two fatalities.

Cpl Dunsby is critically ill in hospital and four other reservists are also being treated in hospital.