SAN DIEGO (CNS) - "Failures across multiple systems" contributed to the death of a 24-year-old Navy SEAL candidate during "Hell Week" at Naval Special Warfare Training Center in Coronado, according to an investigation released Thursday by the U.S. Navy.
The nearly 200-page report focuses on "systemic issues" surrounding the training program that Seaman Kyle Mullen undertook just prior to his death on Feb. 4, 2022. Mullen died at a hospital from bacterial pneumonia, according to the report.
Issues regarding instructors, medical oversight, and safety management "led to a number of candidates being at a high risk of serious injury," according to the investigation.
"At its core, the investigation finds that relentless and continuous self-assessment and self-correction within all departments of (Naval Special Warfare Command's Basic Training Command) is required," said Rear Adm. Peter Garvin in a statement.
"This investigation identifies risks that aggregated as the result of inadequate oversight, insufficient risk assessment, poor medical command and control, and undetected performance-enhancing drug use; and also offers actionable solutions to mitigate those risks going forward."
According to the investigation, Mullen's ailment progressed throughout "Hell Week" and was noticed by other candidates, instructors, and staff, yet he did not receive adequate medical intervention.
"Candidates were placed at significant risk by a medical system not trained, organized, integrated or drilled to ensure continuous effective medical monitoring or care," the report states.
"These failures were the result of absent or insufficient written guidance, ineffective oversight by both Basic Training Command and Naval Special Warfare Center medical and command leadership, and uninformed risk decisions made at the wrong level.
The Navy said in a statement that a number of policy improvements have been made in the wake of the death, including greater instructor oversight and training, and updated medical policies and standard operating procedures.
"In the wake of the tragic loss of Seaman Kyle Mullen, we have taken decisive steps to improve our policies and standard operating procedures. The insights gleaned from the NETC investigation will also further empower us to refine, enhance and elevate our naval commando training," said Rear Adm. Keith Davids, commander of Naval Special Warfare Command.
"We will honor Seaman Mullen's memory by ensuring that the legacy of our fallen teammate guides us towards the best training program possible for our future Navy SEALs."