Do not seek outside medical help; they may admit you to a hospital: That’s what Hell Week sailors were told. Hours later, one died.
The U.S. Navy SEAL training program came under public fire in wake of the death of 24-year-old Kyle Mullen at a Coronado hospital last year. By design, it’s a grueling program for the elite force, but an internal investigation by the Navy found that it “put its candidates at significant risk.”
The nearly 200-page report describes poor medical oversight, increasingly rigorous protocols that plummeted graduation rates, and insufficient risk management and safety precautions at the Basic Underwater Demolition/SEAL (Sea Air Land) (BUD/S) training course.
Mullen died of bacterial pneumonia on Feb. 4, 2022 after pushing through Hell Week, notorious as the most difficult part of BUD/S.
He’d suffered respiratory issues throughout the week and was monitored by contracted paramedics. Observers saw him spitting blood.
After completing his training, Mullen received his final medical check at the Naval Special Warfare Medical Clinic, but personnel were not advised of his prior respiratory concerns and were ill trained in screening for pneumonia, the report says.
He was declared healthy and sent with his class to a debrief, where candidates were given pizza, Gatorade, and printed instructions.
“Do not see other medical providers,” the handout read. “We will see you at any time. (If it is a true emergency call 911).” The paper continued in all capital letters: “If you go and see other medical personnel who do not understand Hell Week, they may admit you to the hospital or give you medicines that are not compatible with training.”
Witnesses saw Mullen spit blood into an empty Gatorade bottle and put his head on his desk.
After the brief, he called his mom: “I did it.”
His mother told investigators that he was having difficulty formulating words and that she could tell his breathing was labored. Mullen was visibly swollen and told someone present that he was 40 to 50 pounds heavier than usual due to swelling.
Mullen was transported to the barracks by wheelchair, where he and his class were monitored by junior watch standers with no medical training or guidance on their task.
The report describes his eight final hours, mostly under watch in the barracks, during which he was spitting up blood, struggling to breathe, spending 30 to 45 minutes in the bathroom vomiting and defecating, and “sounded like he was drowning.”
Mullen repeatedly declined to go to a hospital, saying he didn’t want to be disqualified, the report says.
Watch standers attempted to seek help from the NSW medical clinic’s doctors, but nobody was there. They reached a member of the medical team by phone, who said the clinic could see Mullen the next morning, and to call 911 if necessary, but cautioned again that the hospital, unfamiliar with BUD/S training, would admit him. Eventually, watch standers called an ambulance.
Eight hours after finishing Hell Week, Mullen was pronounced dead of bacterial pneumonia at a Coronado hospital. Two of his classmates were hospitalized for pneumonia as well.
The sailor’s death sparked public scrutiny of the Navy’s SEALs training program, although internally, leaders had been warned of increasingly difficult training procedures impacting sailors as early as 2021, the report says.
The Navy ordered an investigation into BUD/S last September. It found four key areas – described as a “perfect storm” of unsafe training conditions: instructors and curriculum, safety oversight, medical oversight, and performance-enhancing drugs.
“Candidates must be pushed close to operational limits to ensure they are adequately prepared for combat,” the report states. “However, effective risk management and training support systems can and should significantly mitigate injuries and illnesses associated with high risk training.”
Instructors ‘stopped teaching’ and focused on ‘weeding out the candidates’
Mullen endured Hell Week as a part of Class 352, after an already-grueling three weeks of “pre-Hell Week” BUD/S. During the week, his respiratory symptoms developed and escalated.
“Instructors during this time were executing the curriculum at a constant high intensity, deviating from past practice with little to no recovery time afforded,” the report states. Many instructors said in interviews with investigators that they felt that the quality of candidates had declined in recent years, and that their role was to maintain a high standard of quality throughout the program.
At the time of Mullen’s death, attrition – when a SEAL candidate drops out – had been on the rise for a number of years. The historic attrition rate for the first three weeks of BUD/S is 30 percent, but in 2021 and 2022 it was 48 and 49 percent, respectively.
Capt. Bradley Geary, commanding officer of Naval Special Warfare’s Basic Training Command (BTC) at the time of Mullen’s death, believed the primary reason for the increase was that “the current generation had less mental toughness,” according to the investigation.
Civilian contractors cautioned Geary that increasing rigor known as “intensity creep” was causing the decline in graduation rates, but he did not adjust the program.
Rear Adm. Hugh W. Howard III, commander of the Naval Special Warfare Center at the time, agreed, telling BTC leadership and instructors that a graduation rate of “zero is an okay number – hold the standard,” according to the report.
Geary was issued a letter of reprimand after Mullen’s death, but was not directly blamed or fired. An unnamed senior medical officer also received such a letter. Later, Dr. Erik Ramey, the former chief medical officer for the BTC, was reassigned.
Capt. Brian Drechsler, commanding officer of the Naval Special Warfare Center, which oversees BUD/S, was relieved of his command in May due to Mullen’s death, according to the Navy. He was replaced by Capt. Mark Burke.
In an audit of Class 354 (the second class succeeding Mullen’s), a deputy operations officer found that “the instructor cadre stopped teaching the candidates and just spent the time with physical remediation, seemingly with an intent to weed out some candidates.”
Balancing elite training with medical supervision
Although it was clear to observers that Mullen was suffering after his training, he was not an outlier.
“By the conclusion of BUD/S Hell Week,” the report reads, “all candidates demonstrate a significant degree of exhaustion and difficulty with physical mobility to the point that their physical appearance could be immediately concerning to anyone that does not have experience with BUD/S candidates and Hell Week evolutions.”
There is a balance between training the nation’s elite combatants with appropriate rigor and keeping them safe as candidates are selected. This is why, according to the investigation, candidates “were encouraged not to seek civilian medical care as it might result in treatment incompatible with training.”
Class 352’s medical team was divided into three divisions, with its primary care provided by a team of three naval officers: two physicians and one physician’s assistant. Mullen and his class, after completing Hell Week, were monitored by junior enlisted watch standers with no medical or emergency care training.
“Mullen’s death was not a singular, unforeseeable event,” the report says. “At least 11 visits to medical occurred by candidates for pneumonia during Classes 347-357, with 112 other visits for SIPE (swimming-induced pulmonary edema) or pneumonia, there have been at least three prior mishaps involving pneumonia.”
The report also found that many SEAL candidates used performance-enhancing drugs to endure their training. Mullen and the two other members of Class 352 who were treated for pneumonia tested negative for these drugs, though examiners were unable to test Mullen for human growth hormone due to an insufficient urine sample.
The report condemns the Navy for lack of testing for the drugs, saying until a system is implemented, their use will remain common. It’s an ongoing problem that risks recruits’ health, particularly because such drugs impact the cardiovascular and immune systems, potentially exacerbating health concerns that arise during training.
One year later, how SEAL training has changed
Based on the Navy’s findings, it has made a number of changes to its Navy SEAL selection course, focused largely on more medical oversight and monitoring.
Part of the reason Mullen’s critical condition wasn’t caught sooner, the report says, is because his medical care was so disjointed: contracted paramedics witnessed him struggling to breathe during Hell Week training, but did not relay that information to the medical team that evaluated him upon completion, and the junior enlisted watch standers who monitored him afterward not only had no medical training, but also were encouraged not to seek medical help for sailors.
The Navy has also reassigned eight sailors and officers for failure to perform their duties at BTS, including Drechlser and Ramey.
The course was “poorly organized, poorly integrated, and poorly led,” the report said. It “put candidates at significant risk.”
Under new leadership, course graduation rates have returned to their historic average.
“I wish to extend my sincere gratitude to the Naval Education and Training Command investigation team for their insightful recommendations,” said Rear Adm. Keith Davids, the current commander for the Naval Special Warfare Command, in a statement. “We will honor Seaman Mullen’s memory by ensuring that the legacy of our fallen teammate guides us towards the best training program possible for our future Navy SEALs.”
Megan Kitt is married to an active duty service member.
