A Navy investigation found that the already tough selection course for Navy SEALs had become dangerous with lax oversight and medical care as course instructors pushed SEAL candidates to their physical limits, leaving some injured and hospitalized, and leading some to use performance enhancing drugs they believed would help them pass the course.
The Navy has committed to putting in place the investigation's recommendations that followed earlier changes prompted by the investigation of the February, 2022 death of SEAL candidate Kyle Mullen.
The 24-year-old former Yale football team captain died just hours after having successfully completed the grueling "Hell Week" that is part of the Basic Underwater Demolition/SEAL course, known as BUD/S, that selects sailors to become elite SEALs.
His death triggered investigations into how he had died and a broad command investigation of the entire BUD/S program.
The report into Mullen's death led to changes that included better oversight of course instructors, more thorough medical screenings for cardiac conditions, updated medical policies, and more authorization to screen for performance enhancing drugs.
The nearly 200-page command investigation released Thursday identified "failures across multiple systems that led to a number of candidates being at a high risk of serious injury," Rear Adm. Peter Garvin, the commander of Naval Education and Training Command, wrote in a summary accompanying the report.
Garvin said the safety risk to SEAL candidates amounted to "a near perfect storm" that resulted from "inadequate oversight, insufficient risk assessment, poor medical command and control, and undetected performance enhancing drug use," and "wholly inadequate" medical monitoring and care following Hell Week.
He also described "a degree of complacency and insufficient attentiveness to a wide range of important inputs meant to keep the students safe."
Already a grueling course, the investigation found that in recent years the SEAL selection process had become dangerous with poor leadership and little medical oversight.
Inexperienced instructors focused on "weeding out" candidates and "hunting the back of the pack" instead of fostering teamwork that led to a significant increase in attrition rates from the course.
One commander urged instructors to keep pushing the SEAL candidates whom he described as having "less mental toughness" than previous generations.
The change in tone increased the risks for potential injury to SEAL candidates as the medical care available to them was insufficient and inadequate according to the report.
Garvin described the course's medical care as "poorly organized, poorly integrated, and poorly led" a situation that "put candidates at significant risk."
The investigation also found what Garvin described as "strong indicators" of the use of performance-enhancing drugs (PEDS) in BUD/S by some SEAL candidates who believed they could help improve their chances of making it through the course.
"Illicit PEDS use represents a significant hazard to candidate health, and is also contrary to the SEAL ethos and the Navy's core values," wrote Garvin who supports the investigation's recommendations to put in place a "robust" and increased education program to eliminate its use.
The report also provided additional details about the circumstances surrounding Mullen's death, noting that in his final medical check after completing the course his lungs were weak and his legs were so swollen that he was sent back to his barracks in a wheelchair.
Once back at the barracks, there were delays in getting Mullen the medical care he needed and by the time emergency medics arrived he was already "without a pulse," the report said. He died shortly after having been taken to a hospital.
"We want to make sure people are getting adequate care and not being left to die on the ground," T.J. Mullen, Kyle Mullen's brother, told ABC News in an exclusive interview. "We just need medical to look at these guys, it's utterly pathetic that they weren't being taken care of."
Based on the report's conclusions, Garvin determined that "accountability actions are also necessary." A Navy spokesman told ABC News that some Navy personnel could face "potential accountability actions."
"From our perspective, many people were involved and many people tried to cover up committed wrongdoings and accountability has not come," T.J. Mullen told ABC News.
"We've been waiting for a year and a half almost at this point since my brother passed, and no one has gotten in trouble," he added.
Following the Navy investigation of Mullen's deat, three Navy officers who oversaw the program received administrative "non-punitive" letters. Earlier this month, two of the officers who headed the program were pulled from their jobs two months ahead of schedule.
"In the case of the training death of Seaman Mullen, the investigation revealed a lack of leadership and medical oversight and support," said Eric Oehlerich, an ABC News contributor and a former SEAL commander. "It's tragic, but where required, accountability is occurring."
"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," said Rear Adm. Keith Davids, commander, Naval Special Warfare Command, in a statement.