A coroner said there was insufficient consideration given to the need for water on a march which killed three soldiers including Lance Corporal Edward Maher of Winchester

In comments to the final day of an inquest in Solihull, Senior Birmingham Coroner Louise Hunt also ruled that checkpoint staff had missed signs of heat illness in one of those who died.

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

Corporal James Dunsby, from Trowbridge, died at Birmingham's Queen Elizabeth Hospital from multiple organ failure more than two weeks after the march.

In general comments on the preparation and conduct of the march, Ms Hunt said a risk assessment completed more than two weeks before the exercise was inadequate.

Senior Coroner Louise Hunt said: "Edward Maher died as a result of a failure to properly organise and manage the march on July 13, 2013.

"Had the march been stopped at 12.14pm or 12.46pm Edward would have been stopped at his last checkpoint at 13.22pm and would have survived.

"In addition, there was a gross failure to identify that Edward became static and was off course at 14.16pm.

"There was a further gross failure to notice that Edward was not on the ridge and was off course when checkpoint five (his last) was shut at about 3pm.

"This resulted in a further significant delay in identifying Edward and providing any treatment.

"There was a general delay in providing medical treatment and this contributed to his death.

"Inadequate water contributed to his death. His death was contributed to by neglect."

In a statement after the inquest, the family of Mr Maher said: "We support whole heartedly the unique work of all of the special forces. We also believe that their training methods must be fit for purpose in order to produce the magnificent soldiers who undertake a role that very few are willing or able to perform.

"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 coroner told the hearing: ''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.''

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, the coroner also decided.

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