Coroner says there were 'missed opportunities' to avoid death of Royal Navy sailor Ian Fleming who collapsed during fearsome training exercise at HMS Collingwood

Decorated Acting Petty Officer Ian Fleming died from a cardiac episode at HMS Collingwood in Fareham on the first day of a four-week leadership programme which he believed he had to take or risk a pay cut.

The coroner at the four-day inquest into his death said a decision to exempt APO Fleming from physical training had been overlooked. Staff failed to check his medical questionnaire despite his complaints of chest pains and high blood pressure.

The 53-year-old, who was a smoker and had heart disease, collapsed 'in the early stages' of a jogging exercise.

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The serviceman had been so anxious about the ‘mentally and physically challenging' course that he had been suffering panic attacks, the inquest heard.

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. 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.

Mrs Rhodes-Kemp told the hearing, at Portsmouth Coroner's Court: ‘We heard from evidence that he had run out of time for deferment. 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 undergo 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, and his comments regarding chest pain and high blood pressure were not picked up.

‘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, APO Fleming’s mother, Audrey Wales, paid tribute to her ‘super son’, who was born in Ballymena, Northern Ireland, and was known in 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.’