SN Kyle F. Mullen Command Investigation 25 May 23 This brief is designed to provide: ‘An overview of key elements of the Command Investigation, and actions taken@ Briefing Overview * Framing today's conversation + Command investigation (overview) * Details about SN Mullen (beyond Line of Duty brief) + Key Findings * Key Corrective Actions@ Today’s Discussion ‘The purpose of today’s discussion is to debrief the Command Investigation + 31 Aug 22: Vice Chief of Naval Operations directed RADM Garvin, the Commander of Naval Education and Training Command to conduct the investigation + 13Sep 22: RDML Reynolds directed by RADM Garvin to lead the investigative work + 18 Nov 22: RDML Reynolds completed his investigation + 24 Mar 23: RADM Garvin provided his endorsement We will not be able to discuss: + Results of the Medical Quality Assurance Review (completed Apr 23) + Accountability Actions: Will be briefed after final accountability determined Navy will provide: + Redacted copy of the command investigation (enclosures will be provided as soon as redactions complete) Nothing in the Command Investigation contradicts what was learned in the Line of Duty Investigation© Commands Involved + Commander, Naval Education and Training Command (NETC) * Recruit, train and deliver those who serve in the Navy + Oversees much of Navy training; does not provide oversight of NSWC/NSWCEN/8TC US Naval Special Warfare Command (NSWC) + Organize, train, man, equip, educate and sustain active component NSW forces and shore activities * Naval Special Warfare Center (NSWCEN) + Develop, plan and conduct training of Navy Special Operations Forces * Naval Special Warfare Basic Training Command (BTC) + Conducts special operations training and education (BUD/S) + Navy Bureau of Medicine (BUMED) + Develops policy and guidance, and manages manpower, personnel and resources throughout Navy medicineScope and Overview uncussrea@ Command Investigation Scope Exactly as briefed on 11 Oct 22 * The facts and circumstances surrounding Naval Special Warfare Basic Training Command (BTC) oversight of BUD/S Class 352 as it relates to SN Kyle Mullen’s death to include relevant circumstances associated with the incident + Description of and safety measures in place for BUD/S including Hell Week + Oversight of instructors assigned to BUD/S Class 352 during first phase, including Hell Week + Training, qualifications and experience of instructors of Hell week and ratio of instructors to candidates + Oversight, training, qualifications and experience of medical personnel assisting in Hell Week *+ Description of continuity of medical care for a candidate during Hell Week and the following 48 hrs * Policy for performance enhancing drugs relative to candidates in BUD/S, prevalence of use within class 352, and enforcement of such a policy * Changes made to doctrine, policy, training or manning at Naval Special Warfare Center and/or Basic Training Command with respect to these items since 4 Feb 22 uvcussen@ Overview of Findings dual and community tragedy... failures across multiple systems that led to a number of candidates being at a high risk of serious injury” “A near perfect-storm of converging factors... that accumulated unidentified and unmitigated risk” ‘Navy and Naval Special Warfare Command must: “Improve medical processes, procedures and policies” “Strengthen its high risk training safety program” “Develop an enduring system to educate candidates against the use of Performance Enhancing Drugs, and a testing and enforcement mechanism to detect illicit use” Conclusion “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” “The systemic deficiencies the investigation noted put all of Class 352 at unacceptable and underappreciated levels of risk. Overcoming these challenges requires relentless and continuous self-assessment and self-correction.”@ Overview of Findings (Instructors and Medical) Instructors “Increased intensity of execution exacerbated the risk to candidates, through increased fatigue, increased environmental exposure, and reduced... recovery time” Medical “Inadequate medical structure to provide necessary medit | command and control to a high risk training program” “Medical was poorly organized, poorly integrated, and poorly led, and put candidates at significant risk” “The flaws in the medical program likely had the most direct impact on the health and well-being of the members of Class 352, and specifically, to SN Mullen” “The flawed structure and inadequate leadership created a disconnected and inconsistent flow of information to proper authorities positioned to make informed risk determinations” “BUD/S candidates [were] reluctant to seek medical care, worried that doing so would put their continuation in training at risk, and are driven by a desire to remain in training, often at all costs” “Wholistic approach is required, not only by building a culture of trust with the candidates and instructors, as well as trust with medical, but in revising the curriculum and evaluation how NSWC trains its instructors, medical personnel, and contractors regarding student attitudes and self-report decision making”@ Overview of Findings (Safety and PEDs) Safety “While the safety program met minimum administrative requirements, it was not suitably robust for the degree of risk inherent to the BUD/s training program” “The safety program as implemented at the time of Class 352 was not managed and executed consistently and did not properly assess accumulating risk, hazards, and available mitigations” “The investigation revealed a degree of complacency and insufficient attentiveness to a wide range of important inputs meant to keep the students safe” Performance Enhancing Drugs (PEDs| “{PED use] creates a significant and unquantifiable risk to the safety of both the PEDs user and fellow ‘candidates pushing themselves to compete with an unnaturally enhanced peer” “While SN Mullen’s death was not caused by PEDs use, PEDs use must be eliminated from NSWC and other high risk training” “Strong indicators of PEDs use by some BUD/S candidates” “While SEALs are the leading indicator of this problem, they are not alone”@ Findings: Critical Moment during Class 352 Starting at 0816 on 4 Feb (SN Mullen taken to ambulance a second time) + Attentive instructor (monitoring 20 Sailors in crucible training event) identifies struggling, possibly injured candidate + Despite prior mishaps involving bacterial pneumonia, reintroduction of Bicilin had not been identified + Conditions resembled SIPE - No treatment/guides/aides to identify a more serious problem *+ Candidate had suffered progressively worsening conditions, but had not brought them to instructors or medical professionals + When previously evaluated for these symptoms, the candidate's desite to continue was accommodated by the paramedic and instructor cadre in returning him to training + The medic did not consult with a duty medical provider about his assessment, the treatment given, or whether further medical care was needed + Information about this evaluation, symptoms seen, treatment given and the recent history of such symptoms was recorded in a log book, but was not communicated to medical providers at the Clinic (there was no requirement to do 0 and no integrated drills had been conducted to identity this gap) + Candidate was at increased risk. Unknown cardiomegaly, regardless of cause, was an unappreciated source of accumulating risk + After securing training, all candidates were entrusted for monitoring to very junior enlisted watchstanders, with no ‘medical or emergency care training, and were encouraged not to seek civilian medical care, as it might result in treatment incompatible with training + A duty medical provider repeatedly advised the watchstanders not to call for medical aid outside NSWCEN Medical and the candidate declined to cal for medical care as he did not want to be medically rlled back uvcuassnenAdditional Facts about SN Mullen@ Hell Week (30 Jan — 4 Feb): Additional learnings + 30/31 Jan: + Wed, 2 Feb: + Thu, 3 Feb: + Fri, 4 Feb: Five candidates listed as “high-risk” for SIPE symptoms (did not include SN Mullen) ‘SN Mullen observed coughing up fluid/phlegm (no record/statement of him bei given Oxygen) Performance assessed as average-to-below average; and began to deteriorate Observed by candidate in “full messed up mode"; inflamed legs; coughing dark fluid 13-15: 0200: 0930: 1000: 1100: 1300: 1435: Cont: 1549: 1603: Escorted by classmate out of sleep tent for medical, directed back to tent Medical shift change, told by off-going to "keep an eye on” SN Mullen (deteriorating) Conclusion of Hell Week; SN Mullen’s final condition/treatment was not “turned over” Medical Check: Chief complaint pain & right knee swelling Debrief conducted: If you see providers that don’t understand Hell Week, they may admit you Medical Check: Observed while sleeping Phone call to NSWCEN Medical Duty Provider: Hospital will admit him — another medical check in the morning - Mullen adamant: Not going Staff Instructor on Duty deferred to Duty Medical Provider on medical conditions Phone call to NSWCEN Medical Duty Provider for different candidate Medical Duty Provider actively discouraged other candidate from going to hospital Phone call to Medical Duty Provider, told medical closed until 0730 and to call 911 On-scene personnel (prior to EMT arrival) not trained for CPR©) Medical Examiner Report Armed force medical examiner initial conclusions were reaffirmed on 19 Aug 22, with cause of death + Cause of death: Acute Pneumonia due to Streptococcus Pyogenes (in lungs, airway, and nasopharynx) + Cardiomegaly a contributing factor (normal heart: 438 grams; SN Mullen’s heart: 700 grams); thickening of left ventricular wall (largest of four chambers ~ pumps blood away from heart into the body) Autopsy toxicology screen was negative for alcohol or screened drugs Not tested for exogenous testosterone because testing required a 10mL sample of urine, which medical examiner did not have Not tested for human growth hormone because his blood was hemolyzed and no serum was able to be collected for testing ncasseo@ Performance Enhancing Drugs + Jan 22: Phoenix Division Sailor described widespread PED use at BTC * Decision made not to pause Hell Week + SN Mullen * Expressed a desire to use PEDs; encouraged by his mother not to use + After death: *+ In his car: Bottle of pills marked as sildenafil and vials labelled testosterone and human growth hormone, along with syringes + Onhis phone: + 14 Dec 21: Text conversation that discusses purchase of “More T", sent contact card for person to purchase from + 16 Dec 21: Sends a text asking for an “h needle” ‘+ 3-8 Jan 22: Text conversation that discussed the purchase of “H’, “T", “test”, and “Eutropen” and where to meet topickit up + 6 Jan 22: Text conversation that discusses a bad vial of PEDs and that his buttocks were swollen at injection site + Glan 22: Received video of someone holding up a needle with testosterone to a light, + Internet searches for the following: anastrozole with taking testosterone; Viagra and edema; Viagra and SIPE; albuterol ncassenKey Opinions© Opinions - BUD/S Execution * After BTC Change of Command (Fall 2020): drops on request began to noticeably increase * During weeks 1-3 of 1* phase: Rose to 48/49% (20/21) from historical average of 30% * Returned to normal levels by Classes 354/355 * Classes 348/349: Civilians expressed concerns to BTC CO * Civilians identified that an increase in intensity of training might be a contributing factor * BTC CO believed primary attrition issue was less mental toughness in current generation * Class 353: Peak attrition: 78% by beginning of Hell Week * Class 354 audited directed by NSWCEN * Instructors had lost the intent/why of evolutions; too much physical remediation * Less recovery time prior to Hell Week uncassien@ Opinions - Instructorship + BUD/S execution is dependent on instructor discretion *+ No formal pre-screen/selection process for BUD/S (BTC) instructor billets * After instructor Qualification, evaluations done by “like” personnel with potentially similar blind spots + High workload, worsened during Hell Week * Civilians hired to sustain longer-term view of training + Civilian role decreased by BTC CO; deferring to active duty personnel uncasssen@ Opinions - Safety * Safety program inconsistently executed * Underreporting of mishaps * Personnel did not have the training, tools or data to properly identify and mitigate risk * Operational Risk Management in the field doesn’t fully translate to the initial training environment (BUD/S) caste@ Opinions — Medical Care + NSWCEN and BTC are responsible to ensure candidates have continuous, adequate medical care NSWCEN Senior Medical Officer was responsible for ensuring subordinate medical departments had the tools necessary to successfully perform their mission BTC Medical Department head was inexperienced and ill-suited for leadership: most duties carried out by two overtasked First Class Petty Officers Failed to mitigate known risk of a candidate's desire to continue training© Opinions — Medical Care + Medical command and control was unclear in both written policy and practice, leading to unclear standards and gaps in candidate care, with the following impacts Military Corpsmen: Incomplete training and over-consideration of candidate preferences Civilian contractor paramedics: Less prepared than military counterparts (informal orientation to BTC) Disorganized and disconnected communication of medical information, beginning in Phase | (before Hell- week) Inadequate, untrained support for the care of candidates after securing Hell Week Lack of integrated training and processes Failure to develop a common medical operating picture of candidate conditions + SN Mullen was never identified as high risk by NSWCEN Medical personnel (others were)@ Opinions — Care after Hell Week + “Wholly inadequate” medical monitoring and care + No medical personnel on hand + Minimal medical monitoring - “eyes only” check + Watchstanders went beyond their guidance to assist SN Mullen + Duty provider insisted care wasn’t needed + Observation personnel had no CPR training or positional authority@ Opinions — Post Class 352 monitoring + Investigation Team visited Class 357 and found some corrective actions incompletely implemented + Subsequently resolved; clear command and control established for medical + Command Investigation and its recommendations will be turned over to Navy's Learning to Action Board (L2AB) for formal tracking and follow-up UuncussrenCorrective Actions@ Corrective Actions Briefed Previously (updates) * Expanded Cardiac Screening + 3 candidates ultimately unfit for SEAL duty + Pneumonia Prevention Process Improvement: * Diagnosed cases decreased from 2.2% to 1.5% * Modification of 24 hour Post-Hell Week Observation + ROC; Provider & Corpsman onsite; leading watchstander a high-tis + Psychologist and chaplain interviews are mandatory Modification of Medical Turnovers Establishment of a Training Selection Assessment Team (TSAT) *+ Formal instructor screening written into orders, Expansion of testing for Performance Enhancing Drugs (PEDs) + Random collections and unit sweeps for PEDS in urine now authorized 3k instructor * Prevalence testing for blood authorized Trident Order 14 wncussren© Corrective Actions (New) + New research to determine impact of fatigue and stress on judgment and decision-making + High Risk Training Safety (HRTS) Instruction *+ HRTS personnel must perform their duties as a primary responsibility + Contracting Oversight Updates *+ Program manager to improve contractor performance and integration + Each contract now has safety as part of the work statements + No longer use Contract paramedics uncassieo@ Corrective Actions (Education) + Instructors + 23 hours of training added to instructor qualification course + Students + Enhanced training & discussions prior to starting BUD/S *+ Discuss expected injuries and symptoms * Differentiate between Drop on Request & Medical Issue/Concern * Roles & responsibilities of staff, team, and candidates case@ Medical Changes (Locally) + New instruction in place to govern medical structure and authorities * Consolidates medical under NSWCEN * Standard Operating Procedures: turnover and reporting; ensures candidate medical common operating picture + Safety drills quarterly + Hot washes after every candidate referral to NSWCEN * Revised roles and responsibilities of Duty Medical Officer ‘+ Must be present at NSWCEN for duration of Hell Week; at medical department for 24-hrs after Hell Week * Any candidate seen by a Hospital Corpsman (HM) during field coverage is treated as a “medical encounter” and relayed to + NSWCEN: Evaluation for return to training * Central distribution list for immediate evaluation of severe cases + In field, documented on iPad, then uploaded into database + Revised SIPE protocol: + Oxygen in the field is treated as a medical encounter; verbally communicated to the medical duty provider; brought to NSWCEN for evaluation * Daily body weights are added to daily medical checks + HM remains in the tent with candidates during scheduled sleep per + Two HMs now present on-site during Hell Week ncussen@ Medical Changes (Navy) + Additional training now required for all “milestone” medical leadership positions + Ensures awareness-of how to lead and manage medical systems of systems + Fleet-level Quality Assist visits will commence later in CY23@ Review of Findings Opening “An individual and community tragedy... failures across multiple systems that led to a number of candidates, being at a high risk of serious injury” + “Anear perfect-storm of converging factors... that accumulated unidentified and unmitigated risk” + Navy and Navy Special Warfare Command must: + “Improve medical processes, procedures and policies” + “Strengthen its high risk training safety program” + “Develop an enduring system to educate candidates against the use of Performance Enhancing Drugs, and a testing and enforcement mechanism to detect illicit use” Conclusion + “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.” + “The systemic deficiencies the investigation noted put all of Class 352 at unacceptable and underappreciated levels of risk. Overcoming these challenges requires relentless and continuous self-assessment and self- correction."