The investigation found "failures across multiple systems" that put candidates at a high risk of serious injury.
WASHINGTON -- Inadequate medical screening and uninformed medical staff contributed to the death of a Navy SEAL candidate hours after he had completed a brutal part of the training course known as "Hell Week," a Navy investigation found.
The investigation prompted an overhaul of how the Navy monitors one of the military's most brutal and demanding processes.
It found that the medical support for the Basic Underwater Demolition/Sea Air and Land course was "poorly organized, poorly integrated, and poorly led," wrote Rear Adm. Peter Garvin, the commander of Naval Education and Training Command. The lack of proper medical care "put candidates at significant risk."
Garvin also said that additional accountability measures are necessary in the wake of the failures that contributed to Mullen's death. According to a Navy official, Garvin recommended considering accountability actions against approximately 10 people. A Navy regional legal service office is reviewing the investigation and will make recommendations about accountability, the official said, after which the command will decide what actions to take.
The training and selection course is designed to push SEAL candidates to the limit and beyond, creating an environment where only the most qualified and capable will finish, but Garvin said there must still be "effective risk management" to prevent injuries and illness during the high-risk training.
In February 2022, Navy SEAL candidate Kyle Mullen of New Jersey had just completed Hell Week and underwent a final medical check before he went to rest at his barracks. The investigation found Mullen had suffered respiratory issues during the arduous training, but information about the symptoms was not passed on to the Navy's medical clinic, leading them to conclude he was not at risk.
Eight hours later, Mullen was pronounced dead.
In the hours before his death, Mullen was coughing up an "orange-red fluid" and having trouble breathing, according to the investigation. Even as he repeatedly refused advanced medical care, he appeared to be choking on his words and gasping for air as if he was drowning. But the personnel assigned to check on Mullen and other SEAL candidates, known as watch standers, had no medical or emergency care training.
Candidates going through Hell Week are normally given a form of penicillin called Bicillin at the start of the course to reduce the risk of bacterial pneumonia. But the investigation found Mullen never received the preventative medicine, likely because there was a shortage at the time.
In the end, the investigation found "failures across multiple systems" that put candidates at a high risk of serious injury, Garvin wrote.
"Our effectiveness as the navy's maritime special operations force necessitates demanding, high-risk training," said Rear Adm. Keith Davids, the commander of Naval Special Warfare Command, at the conclusion of the investigation. "While rigorous and intensely demanding, our training must be conducted with an unwavering commitment to safety and methodical precision."
In October, following a separate investigation that focused specifically on Mullen's death, the Navy took administrative actions against the former commanding officer of Basic Training Command, Capt. Bradley Geary; the commander of Naval Special Warfare Center, Capt. Brian Drechsler; and senior medical staff under their command. An administrative action is typically in the form of a letter to the service member instructing them on correcting deficient performance.
Earlier this month, Drechsler was removed from his job two months early.
Following Mullen's death, the Navy revamped how it handles medical screening during the training and selection process. The Navy bolstered medical oversight during and after the Hell Week course, requiring medical screenings every 24 hours.
Candidates now recover from the course in a center located very close to the medical clinic, allowing more thorough observation at a critical time, and the leading watch stander is a qualified high-risk instructor. In addition, a medical officer must be at the Naval Special Warfare Center Medical Department during all of Hell Week to evaluate candidates going through the course.
The investigation also looked at how to handle the use of performance enhancing drugs (PEDs) during the course. In September, a naval special warfare senior officer who spoke to CNN on condition of anonymity said there is "beyond a reasonable doubt that a significant portion of the candidate population is utilizing a wide range of performance enhancing drugs."
A search of Mullen's car after his death found packages labeled "Big Genes Recombinant Human Growth Hormone" and "Testosterone Cypionate," a type of steroid. But Mullen was not tested after his death for the PEDs because of the need for a blood and urine sample.
Other members of Mullen's class told investigators they felt there was an implicit endorsement of the use of PEDs after an instructor told the candidates, "Don't use PEDs, it's cheating, and you don't need them. And whatever you do, don't get caught with them in your barracks room."
After Mullen's death, the Navy received from the Defense Department an expanded authority to test Naval Special Warfare Candidates for PEDs. All candidates going through the SEALs course and the Special Warfare Combatant-Craft Crewman course are subject to random drug testing.