A Royal Navy officer collapsed and died just minutes into a 'feared' physical fitness test after staff failed to check his medical questionnaire - despite his complaints of chest pains and high blood pressure, a coroner said. Decorated Acting Petty Officer Ian Fleming died from a cardiac episode on the first day of a four-week leadership programme which he believed he had to take or his pay could be slashed.
The 53-year-old, who was a smoker and had heart disease, collapsed 'in the early stages' of a jogging exercise at HMS Collingwood, in Fareham, Hampshire, after the Navy 'missed opportunities' to prevent his death. The serviceman had been so 'anxious' about the ‘mentally and physically challenging' course that he had been 'suffering panic attacks', the inquest heard.
At the conclusion of the four-day inquest, area coroner Mrs Rosamund Rhodes-Kemp said: “The most striking aspect of the evidence from many witnesses was the fear engendered by the arduous training element which formed a significant, many felt excessive, part of the Senior Rates Leadership Course. For Ian Fleming, it was more than fear.
"It was obvious from the medical record and from the accounts of his wife and close colleague that contemplation of the course meant he suffered panic attacks and severe anxiety." The inquest heard APO Fleming, who had served tours in Iraq and Afghanistan and been awarded numerous medals, was so 'frightened' by the prospect of undergoing the programme that he had put it off five times.
The father of one, whose wife Michele gave evidence at the hearing, was scared about his 'loss of status' if he failed to complete the programme, facing possible loss of pay, accommodation, and rank. Mrs Rhodes-Kemp told the hearing, at Portsmouth Coroner's Court: "He had withdrawn from the course on multiple previous occasions.
"But we heard from evidence that he had run out of time for deferment. It was openly acknowledged by his work colleagues he was someone who engaged in little exercise.
"He was a long time smoker. At the time of the incident his unit had been under strain.
"In the days leading up to the course, we know from an email he sent to his chain of command. He had decided to withdraw and face the consequences of demotion, losing his pay and final pension.”
However, in a meeting with two senior officers, APO Fleming, from Plymouth, was persuaded to take the course. On the morning of November 16 2020, an issue with his paperwork then meant there was not ‘proper and thorough scrutiny’ of his medical circumstances.
Mrs Rhodes-Kemp continued: “The declaration of health questionnaire which was supposed to be checked was not checked for reasons unknown. His comments regarding chest pain and high blood pressure were not picked up.”
Before physical training commenced in the evening of November 16, APO Fleming had been seen to struggle while running to the muster point, waving the group on as he walked the rest of the route. Eyewitnesses became ‘concerned’ when he started ‘falling behind’ during a 700 metre run to the obstacle course.
During a warm up for Dogwatch training, APO Fleming slowed and fell down only four laps into a 'light jog' across the 50-metre width of an all-weather pitch. Mrs Rhodes-Kemp said: "He fell back from his peers and collapsed moments into the planned warm up.
“Despite everyone’s best efforts, it was not possible to save him." Consultant pathologist Dr Adnan Al-Badri later found that APO Fleming had a 'significantly enlarged' heart and was suffering from 'severe' ischemic heart disease when he died.
Mrs Rhodes-Kemp concluded that a number of factors meant a decision to exempt APO Fleming from physical training had been overlooked. She said: “There were missed opportunities to avoid his death.
"[These] may have led to his non-attendance of the course, and/or his exclusion from physical activity, thus avoiding his death." After the conclusion was read, APO Fleming’s mother, Audrey Wales, paid tribute to her ‘super son’, who had been born in in Ballymena, Northern Ireland, and was known within the Navy as 'Paddy'.
She said: “He was larger than life and so friendly. We heard what a good worker he was.
"As a son, he was so supportive." Mrs Rhodes-Kemp said it was clear from evidence that APO Fleming was well respected for his ‘first rate work’.
She said: “He was held in high regard by all that worked with him.” The family said they ‘agreed’ with the coroner’s findings.
Mrs Wales added: "The outcome of this inquest won’t bring back my son, but the heartbreak this has caused... I don’t want any other family to feel.”
A Service Inquiry was conducted. The final report including findings of the inquiry and its recommendations to improve defence safety were published in March of this year.
