A British soldier killed by an elephant charge on an anti-poaching operation was “deprived of one of the main protective measures” after a ban on the use of warning shots, a coroner has concluded.

Guardsman Mathew Talbot of the 1st Battalion the Coldstream Guards was fatally injured in the incident in Liwonde National Park in Malawi on May 5, 2019.

A week-long inquest into the Walsall-born soldier’s death at Oxford Coroner’s Court, concluding on Monday, heard evidence of how warning shots against dangerous game had been banned, under the Army’s rules of engagement.

After hearing evidence, the senior coroner, Darren Salter, said the reasons for this prohibition were “still not entirely clear”.

Guardsman Mathew Talbot
Guardsman Mathew Talbot, who was killed while on an anti-poaching patrol (MoD/PA)

He was told the use of force rules had since been changed, allowing warning shots on anti-poaching operations.

The 22-year-old, of Great Barr, West Midlands, suffered fatal chest and soft tissue injuries while on day three of an eight-day patrol.

Gdsm Talbot, who “loved the Army”, was part of a five-man mixed Malawian and British group on his first operational tour when he was attacked.

His parents, Steve and Michelle Talbot, said their son was “badly let down by” Army planners, adding that “had the right things been put in place” he may have survived.

A Ministry of Defence (MOD) service inquiry, published in October last year and shared with the inquest, concluded there had been several failings and made 30 recommendations.

The coroner said the availability of a person medically qualified to insert a chest drain to treat Gdsm Talbot and the presence of a med-evac helicopter “may have led to Mathew’s survival”.

He said evidence had been heard about an Army risk assessment, stating that casualties should reach hospital within four hours of an incident, known as the medical timeline.

That included an “overly optimistic assessment of the capability of the available Land Rover”, to be used to move any casualties.

A memorial erected to Guardsman Talbot
A memorial erected to Guardsman Talbot in Liwonde National Park (Dominic Lipinski/PA)

The coroner said the “underestimate of the impact of an attack by dangerous game and the length of time to move the patient by road, meant the (medical) timeline was not achievable”.

Turning to three “contributory causes” to the death, also borne out in the service inquiry, he said: “Firstly, it was known from two previous deployment patrols… elephant grass should be avoided.

“This should have been made clearer, particularly when the helicopter was unavailable.

“Secondly, the wrong immediate actions for an elephant attack; namely climbing a tree, taken in the heat of the moment.”

He added: “I think, as has been recognised, there should have been refresher training and reinforcement of what the correct actions were to be taken when faced by an elephant attack.”

Turning to the third factor, the use of warning shots, he said: “To be honest, I am still not entirely clear why they were not permitted.

“I’ve heard reasons they weren’t permitted – but those reasons don’t seem terribly convincing.

“But the result of that is Mathew and his fellow soldiers were deprived of one of the main protective measures.

The Duke of Sussex
The Duke of Sussex lays a wreath in tribute to Guardsman Talbot in 2019 (Dominic Lipinski/PA)

“Warning shots were known to be effective (on a previous operation), but I would have thought actually that’s something which is fairly obvious.”

He added, “warning shots appear to have been effective afterwards”, as the elephants were scared off by the African park rangers using their guns.

Mr Salter said: “I note actually in terms of contributory causes, those three things; patrolling in elephant grass, the wrong immediate actions, and the prohibition of warning shots are essentially the three contributory causes identified by the service inquiry.”

Gdsm Talbot and his patrol were navigating through two-metre-high elephant grass when they spotted three elephants 30 metres ahead.

As they tried to backtrack, the soldier was injured when another elephant, unseen, charged the patrol from the side.

The British Army sergeant commanding the group managed to climb a tree but as Gdsm Talbot tried to do the same he “was caught by the charging elephant”, the coroner found.

“He was knocked and thrown into the air and then injured by the elephant’s tusks while on the ground,” added Mr Salter.

The coroner found there was initial “highly commendable” lifesaving treatment in the field, before the injured soldier was stretchered to a Land Rover, which set off for the park’s gates.

However, progress was slow over the rough terrain and Gdsm Talbot suffered a cardiac arrest and died more than four hours after the incident – the hospital still two hours’ drive away.

“If Gdsm Talbot had reached hospital within four hours of sustaining injuries, it is likely he would have survived,” Mr Salter said.

After delivering a narrative conclusion, Mr Salter said: “It is right to recognise the task that Mathew was engaged upon.

“A task he himself considered very important.

“Indeed I was struck, and recall the statement where he said it was a combination of being a soldier and David Attenborough, and that did strike a chord.”

In September 2019 the Duke of Sussex honoured the sacrifice of Gdsm Talbot by laying a wreath at a memorial during a visit to the national park.