The Army has been heavily criticised by a coroner over the death of a young recruit who died from heatstroke after being subjected to a beasting.
Alan Large said the Army failed to notice the "fundamental defects in the disciplinary and punishment system" and officers should have spent more time talking to their soldiers instead of sitting in their offices reading emails.
Mr Large, the assistant coroner for Wiltshire and Swindon, condemned the Army top brass following an inquest into the death of Private Gavin Williams, of the Second Battalion the Royal Welsh Regiment.
Pte Williams's mother, Debra, also criticised the service for its "inhuman and degrading" treatment of her son.
The Army apologised to Mrs Williams for the failing that led to her son's death and acknowledged there had been a "culture of unofficial punishments" within the regiment.
The 22-year-old had been a soldier for just a year when he was subjected to the beasting on July 3 2006 – one of the hottest days of the year.
The young recruit had been subjected to the informal session of intense physical exercise by three non-commissioned officers to punish him for disobedience and a series of drunken incidents at Lucknow Barracks in Tidworth, Wiltshire.
Pte Williams, from Hengoed in South Wales, was later admitted to hospital where his body temperature was 41.7C (107F) – way above the norm of 37C (98.6F). Tests later showed he had ecstasy in his body when he died.
Sergeant Russell Price, the Provost Sergeant in charge of discipline, and two colleagues – physical training instructor Sergeant Paul Blake and Provost Corporal John Edwards – were cleared of manslaughter in 2008 by a court.
Mr Large recorded a narrative conclusion after hearing from more than 100 witnesses over six weeks at Wiltshire and Swindon Coroner's Court in Salisbury.
He said that despite the banning of unofficial punishments and the introduction of new rules in 2005 "nothing much had changed".
"The system of unofficial punishments operated openly and no effort was ever made to conceal punishments being administered," he said.
"The frequency of the award of unofficial punishments is more difficult to assess but I consider that they were being awarded around once a week.
"The commissioned officers at all levels should have also have been aware. Some, including the commanding officer, accepted this with considerable regret and remorse.
"Greater diligence and inquiry rather than an acceptance, more detailed discussions with their subordinates in the chain of command and more time spent out of the office with their men would have meant that at least some would have made them aware that the disciplinary system in the battalion was not functioning properly.
"Many officers who worked in the headquarters building accepted that the arrival of email had led to them spending too much time at their desks and too little time watching and listening to what was happening at the barracks.
"I consider it unlikely that a junior soldier would have plucked up courage to complain of a beasting session to the commanding officer."
Mr Large added: "More junior officers should have spent more time talking with soldiers of all ranks to get a better understanding of what was happening in the junior ranks under their command."
He also said there had been a "missed opportunity" to diagnose Pte Williams with a heat injury and he would have survived had he received effective treatment earlier.
Pte Williams had been out drinking heavily with colleagues on the Friday and Saturday nights before his death and had taken ecstasy.
During one drunken incident he sprayed the guests of the battalion adjutant, Captain Mark Davis, with a fire extinguisher.
He later turned up unfit for guard duty wearing flip-flops, a pair of combat trousers and a vest – smelling of alcohol.
Mr Large criticised Capt Davis, who is now a lieutenant colonel, for ordering Pte Williams to be brought to him "hot and sweaty" – meaning he would be drilled.
Witnesses described seeing Pte Williams sweating and looking weak and exhausted, with some soldiers saying beastings were a "regular occurrence" and "part of Army life".
Later after a gym session with Mr Blake, Pte Williams complained of stomach ache, was suffering from diarrhoea and was visibly shaking before he was taken to the medical centre – although he had to carry an 11lb (5kg) power bag to stop him running away.
Speaking after the inquest, Mrs Williams said: "What happened to Gavin was wrong, plain and simple. He was killed by the way in which his fellow soldiers chose to punish him unlawfully – to beast him – for nothing more than a silly prank.
"I know that the nature of that beasting was so inhuman and degrading that it cannot be tolerated in any civilised world.
"The coroner's conclusions and findings demand urgent and careful attention of the highest ranks within the Army and I look to them to act on those findings without delay, to accept full responsibility for Gavin's death, so that all of us can be reassured that they are willing and able to learn the lessons of simple humanity."
Brigadier John Donnelly, the Army's head of personnel services, apologised, saying: "We acknowledge that there was a culture of unofficial punishments within 2 Royal Welsh at the time of Gavin's death.
"This is unacceptable and was unacceptable. We have already conducted our own inquiry into the incident and made a number of improvements to try to ensure that it does not happen again which the coroner has recognised."