A coroner has ruled that neglect played a part in the deaths of three Army reservists who collapsed during a 16-mile SAS test march.

Recording narrative verdicts at an inquest in Solihull, senior Birmingham coroner Louise Hunt said all three soldiers would have survived if Ministry of Defence regulations on heat illness had been followed.

Describing parts of the planning and conduct of the special forces march as inadequate or not fit for purpose, the coroner said inadequate supplies of water also contributed to one of the deaths.

Lance corporals Edward Maher and Craig Roberts were pronounced dead on the Brecon Beacons after suffering heatstroke in July 2013.

Corporal James Dunsby died at Birmingham's Queen Elizabeth Hospital from multiple organ failure more than two weeks later.

Criticising the "chaotic" response to the men's collapse and accusing special forces' commanders of a catalogue of serious mistakes, Ms Hunt said: "The risk assessment undertaken for this exercise was inadequate.

"There was a failure to implement an adequate medical plan to allow for treatment of any heat illness casualties."

A GPS tracker system in place at the time of the march - with a "slow man" function disabled - was not fit for purpose, the inquest also heard.

Claiming there had been a failure to learn from a previous fatality on an SAS test march in 2008, Ms Hunt added: "There was a culture of following what had gone before without giving any consideration to specific risks.

"The (special forces) signals regiment took their lead from, and was subservient to, the lead regular unit. They do not think for themselves."

Ms Hunt said those who organised the march failed to appreciate that candidates would push themselves to the limit with a "do or die" desire to succeed.

Ms Hunt also identified a lack of build-up marches for reservists as a contributory factor in the deaths.

In general comments on the preparation and conduct of the march, Ms Hunt criticised a risk assessment completed more than two weeks before the exercise for failing to incorporate weather conditions or to identify a heat stress index for the march.

The coroner also ruled that that if the reservists had been afforded "basic treatment of cooling, hydration, rest and removing kit" the men would have survived.

All three men died as a result of a "failure to properly organise and manage" the march on Saturday July 13 2013, the coroner said.

In respect of L/Cpl Roberts, originally from Penrhyn Bay in North Wales, the coroner found that he became static at about 2.55pm and was found by another soldier at about 3.37pm.

The failure to identify that the 24-year-old had stopped moving amounted to a gross failure, and the subsequent delay in providing treatment was ruled to constitute neglect.

L/Cpl Maher, from Winchester in Hampshire, veered off course and was stationary from 2.16pm, according to data from his tracker beacon.

Ms Hunt said soldiers monitoring the tracker in a command vehicle had only noticed that L/Cpl Maher was not moving at 4.10pm.

As a result, the 31-year-old former regular soldier with the Royal Green Jackets had signs of rigor mortis by the time he was reached at 4.45pm.

In her narrative verdict, Miss Hunt said of L/Cpl Maher: "There was a gross failure to identify that Edward became static and was off course at 2.16pm.

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

The coroner ruled that Cpl Dunsby, from Trowbridge in Wiltshire, had probably shown signs of heat illness at a checkpoint on Pen Y Fan at 2.51pm.

The Afghanistan veteran, a former member of the Royal Tasmania Regiment in Australia, was taken to hospital with a body temperature of 41C (105.8F) after collapsing in the final stages of the march.

The inquest heard that the 31-year-old reservist went "static" at 3.17pm but march commanders failed to realise he had stopped marching until 4.35pm.

Medical help only reached the Solihull-born soldier at 4.58pm.

Ms Hunt said she would file a report with a view to preventing similar deaths.

"I am extremely concerned that the new tracker system doesn't resolve the problem of the 'slow man' and static function," she told barristers and family members of those who died.

"I'm particularly concerned that it was only after my request to view (the new system) that that came to light."

The coroner - who heard that numerous soldiers had no knowledge of formal procedures for preventing heat injury - also expressed concern at the system in place for disseminating information between regiments and the lack of a simple, straightforward system for recording heat illness cases.

In her final remarks at the inquest, the coroner paid tribute to each soldier in turn, describing Cpl Dunsby as a talented sportsman, academic and soldier.

L/Cpl Maher had dedicated his life to others through his service in the Army and charity work, while L/Cpl Roberts was known for his eccentric tastes in literature, sense of humour and determination.

The family of L/Cpl Roberts declined to comment as they left the hearing but said they would issue a statement at a later date.

After the inquest, Cpl Dunsby's widow called for a change in culture at the Ministry of Defence.

Bryher Dunsby said her "chivalrous, loyal" husband would have been "hugely disappointed" by the behaviour of the MoD, "for which he had fought and to which he ultimately lost his life".

She added: "No part of the armed forces can be beyond scrutiny or above the law, but unless and until those at the top acknowledge and accept responsibility for the failings of their organisation, cultures will not change and the mistakes of the past will be repeated.

"So, looking forward to the future, it is my ardent wish and plea that as an institution the MoD has the maturity to look at its failings and to want to improve.

"I so dearly hope that pride and ego will not continue to blind individuals from implementing the changes which so evidently must be made."

The MoD offered an unreserved apology for the soldiers' deaths.

Speaking after the hearing, Brigadier John Donnelly, the Army's personnel director, said: "I would like to apologise for the deaths of James Dunsby, Craig Roberts and Edward Maher, three fine soldiers.

"I would like to offer my sincere condolences to their families and friends who have shown great dignity during what has been a very difficult period.

"We are truly sorry for all the mistakes the coroner identified today."

Changes to the way the test march is run have already been made following input from the Health and Safety Executive (HSE), he said.

The senior Army officer added the coroner's findings would be carefully studied to make sure there is no repeat of the tragedy.

Brig Donnelly also announced a "service inquiry" would be carried out after all civil investigations had finished.

He added: "It is necessary to train our soldiers to the high standards to meet the security challenges that we face both in this country and overseas and to do this requires our individuals to push themselves and take some risk.

"However we must ensure those risks are carefully managed. In this case we did not do this and accept responsibility."

In a joint statement, the HSE and Dyfed-Powys Police said: "We undertook a joint investigation into this incident and HSE's investigation into circumstances surrounding the deaths of these soldiers continues.

"Our thoughts are very much with the families of Craig Roberts, James Dunsby and Edward Maher, who have shown strength and dignity throughout the inquest process."