'Instructed Not To Call 911': Report Reveals Confusion, Failure and Fear in SEAL Candidate Death

A Navy investigation into the death of Seaman Kyle Mullen determined the young sailor died of pneumonia that was aggravated by an enlarged heart. However, the investigation also provided further evidence that SEAL recruits are not given adequate care and the course has fostered a culture where seeking help in emergency situations is discouraged.

Mullen, who died in California just after completing the torturous "Hell Week" portion of the Navy's Basic Underwater Demolition/SEAL training, or BUD/S, was found to have perished in the line of duty, according to the report provided to Military.com on Wednesday.

Another broader investigation was also ordered into the training program after reports emerged that the program is rife with drug use, cheating and abuse. Cmdr. Ben Tisdale, a spokesman for the Naval Special Warfare Command, confirmed that "administrative actions" have already been taken against the commanders of the special warfare center and training program as well as the senior medical staff under their command.

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The initial investigation, which includes documents like the military's autopsy report of Mullen, dozens of interviews with officials and sailors, and medical records from paramedics, paints a clear picture of a sailor who was struggling for days with symptoms but was not afforded the care he needed.

The investigation also made clear that recruits -- including Mullen -- are driven to hide symptoms and pain either out of a desire to complete the training, a fear of being made to start over or fear of being dropped from the program entirely.

The drive to push on at any cost is true of many SEAL recruits, and one medical professional on the training course told investigators that he "'takes it with a grain of salt' when students say they want to continue."

Another sailor explained that "'the kids don't want to quit,' so even if a student had a significant medical complaint they would be unlikely to disclose it."

Combined with that drive to push on, the report also highlighted a dangerous message that recruits were told by leadership -- calling outside doctors can only lead to trouble.

A post-Hell Week flier given to the recruits explicitly said "DO NOT go and see other/outside medical providers" before explaining, in all capital letters, that "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."

As a result, one sailor told investigators that "he and the other students were instructed not to call 911 and not to go to the emergency room."

One doctor interviewed by investigators explained that instead, the command promises to see recruits anytime, though that is typically done over the phone.

In a statement released Wednesday, Rear Adm. Keith Davids, the commander of Naval Special Warfare Command, said the normally secretive wing of the Navy "remains committed to transparency, and we welcome the opportunity to review our assessment and selection programs, and help us look for additional ways to improve and prevent this kind of tragedy from happening again."

Several Navy officials interviewed for the investigation outlined that during the training course, medical conditions like Mullen's are routine.

According to the investigation, in the early days of Hell Week, the 24-year-old Mullen was doing fine. However, by Thursday -- day four of seven -- things had taken a turn. One sailor told investigators that Mullen had become so swollen that he had gained "a significant amount of weight," and that by Feb. 3, he "was in 'full messed up mode.'" Mullen told some sailors that his knees hurt.

Another sailor described Mullen's breathing as "sounding like 'gurgling water'" while sleeping and that he and others were "pretty concerned."

One sailor noted that Mullen was "in the worst medical shape out of anyone in the class" in the last days of Hell Week, and many reported seeing him with bottles full of dark-colored liquid that he was coughing up. A few sailors remarked they thought it was actually darkened spit from chewing tobacco.

By the fifth day, Friday, one sailor recalled that Mullen could "barely walk." The investigation said that Mullen received supplemental oxygen that day. A medical form in the report also showed that Mullen was evaluated, and course officials heard crackling in his lungs and his right leg was swollen.

He was found fit to train but told to follow up with post-Hell Week medical checks. Several sailors noted that Mullen's attitude improved after Hell Week finished, though he needed to be wheeled out of the classroom in a wheelchair and one sailor described him looking like the "Michelin man" from all his swelling. A doctor attached to the medical department at the command told investigators that both the swelling and wheelchair were common.

He would die that night.

Mullen's report is filled with instances of the recruit doggedly pushing forward as medical issues mounted. One of Mullen's friends in the program told investigators that Mullen explicitly said he was "worried about getting rolled" -- slang for being made to restart the training.

One sailor who was part of Mullen's boat crew recalled that on the fourth day of training, Mullen suddenly woke up from a nap with blood coming out of his mouth. The sailor tried to get Mullen to get medical attention, but he refused. "I don't want to be a b***h," Mullen told the sailor.

"I don't want to be seen as the guy who keeps going to medical," he added.

After the sailor prevailed on Mullen, the two looked out of the tent where they were recovering to try and get help but an instructor spotten the pair and "told them to go back to the tent."

Another sailor, assigned to keep an eye on recruits after Hell Week ended, remembered seeing a seemingly delirious Mullen "talking to himself in the bathroom and saying, 'I can't believe I'm such a p***y.'"

In Mullen's case, the instructions for recruits not to seek outside medical help proved disastrous. After Hell Week, the same sailor who spotted Mullen in the bathroom called the duty physician, concerned about Mullen's trouble breathing. The person on the other end said Mullen could go but reiterated the warning about outside medical care.

Another trainee said Mullen "was 'so adamant' about not going to the hospital" that despite asking multiple times, he waited until medical checks the next morning. Meanwhile, his fellow sailors were left not knowing what to do about their rapidly deteriorating friend.

"They should have made an executive decision to take [Mullen] to the hospital," one sailor said in his interview.

Ultimately, it's not entirely clear what led to Mullen's death. The autopsy report pins the death on a pneumonia infection but notes that the sailor's enlarged heart was a contributing factor.

A memo from a Navy cardiologist specialist in the report notes other contributing factors included "the use of prohibited performance enhancing drugs (PEDs), possible swimming induced pulmonary edema (SIPE), and the rigorous physical demands of BUD/S Assessment and Selection."

After his death, Mullen was found "in possession of and suspected of misusing several PEDs," including human growth hormone and testosterone. One entry in the report notes that all the substances found "are commonly abused to increase muscle mass."

The role that the drugs played in his death is a matter of debate for the Navy experts in the report. One doctor wrote that "Mullen's heart size being 64.7% over the upper limit of the reference range suggests that his exposure to anabolic agents may have been large" and another noted that such drugs have been noted to cause Mullen's symptoms. Yet a third expert pushed back on the idea of a "possible correlation" between the drugs and pneumonia as "speculative" and lacking evidence.

In response to the death the Navy has announced that it is adding a cardiac screening program as well as increased prevention measures for pneumonia and it is extending the observation period to 24 hours for recruits who make it past Hell Week. They will also begin to screen for performance-enhancing drugs through urine tests.

"Kyle's death will not be in vain," Davids promised in his statement. "We have a moral obligation to learn everything we can from Kyle's tragic death so that we can ensure the safety of all future candidates."

-- Konstantin Toropin can be reached at konstantin.toropin@military.com. Follow him on Twitter @ktoropin.

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