Following a five-day inquest, a coroner sitting at Preston has found that confused orders and failures in communication meant that opportunities were missed to save the life of a young soldier.
Steven Murray, aged 23, was a new soldier in training at Catterick. He attended a training weekend at Halton. During one evening he suffered a severe head injury following a playfight with a fellow recruit. This subsequently led to his death. During the course of the evening no medical assistance was summoned. The Coroner found that there were a number of confusing and contradictory orders relating to medical care and that, further, certain soldiers had failed to escalate the issue up the chain of command. He returned a narrative verdict finding that:
"the principal contributing factors to [Steven's] death were inadequacy of orders as to the sources and provision of medical care, insufficient communication by the NCOs of a loss of consciousness when escalating matters up the chain of command and of failure of recruits to escalate developments ... up the chain of command."