Gavin Williams death: Army 'failed to prevent beasting'
The Army's chain of command "failed to prevent" unlawful physical punishments known as beastings which led to a soldier's death, a coroner has found.
Pte Gavin Williams, 22, of Hengoed, Caerphilly, was forced to do intensive exercise for his drunken behaviour and disobedience.
He collapsed with heatstroke at Lucknow Barracks in Wiltshire in July 2006 and suffered heart failure.
Judge Alan Large recorded a narrative conclusion on Friday.
He said: "This punishment was part of a system of such unofficial punishments operating in the battalion which the chain of command had failed to identify or prevent."
Pte Williams's mother, Debra Williams, said in a statement read out after the hearing: "What happened to Gavin was wrong, plain and simple. He was killed by the way in which his fellow soldiers chose to punish him, unlawfully - to beast him.
"I know that the nature of that beasting was so inhuman, so degrading, that it cannot be tolerated in any civilised world."
Brig John Donnelly apologised on behalf of the Army and acknowledged there was "a culture of unofficial punishments" within the battalion at the time.
He said: "This is unacceptable and was unacceptable. We have already conducted our own inquiry into the incident and made a number of improvements to try to ensure that it does not happen again which the coroner has recognised."
Three soldiers who carried out the punishment on the hottest day of the year were previously cleared of manslaughter.
Sgt Russell Price, 45, Sgt Paul Blake, 37, and Cpl John Edwards, 42, were found not guilty at Winchester Crown Court in 2008.
The inquest at Salisbury Coroner's Court heard he was reprimanded for a series of drunken incidents, including spraying guests of a senior officer with a fire extinguisher and turning up drunk for duty.
He was ordered to carry out a march before the beasting - intensive exercise in a gym including running, press-ups and jumps - but collapsed.
Tests showed his body temperature was 41.7C when he died - the normal temperature is 37C. Traces of ecstasy were also found in his blood.
Judge Large, assistant coroner for Wiltshire and Swindon, said: " There was a level of ignorance about how [the official rule] should be used.
"Informal punishments were prohibited… however, there was considerable evidence that these punishments continued.
"Gavin's drill session was seen by many… [punishments] happened about once a week."
Judge Large said staff believed their actions were justified and permitted and would have been approved by the chain of command.
"I am satisfied that the unlawful system of punishment was known within in the battalion," he added.
He concluded the physical exertion, combined with the effects of Pte Williams's use of ecstasy, led to the onset of hyperthermia.
The coroner said staff had missed an opportunity to diagnose Pte Williams with heatstroke and, if that had happened earlier, "Gavin would have survived".
He also said Pte Williams's use of ecstasy "contributed a minimum to his death".
Judge Large added lessons learnt following Pte Williams' death include the fact that short exercises are now permissible "within sensible limits" and orders are being drafted to address issues of drug abuse among Army personnel.