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Shortly before he was killed by a polar bear on an Arctic expedition, 17-year-old Horatio Chapple came upon a set of huge footprints.
"One was very distinct and I remember several of us taking photos," said Lauren Beech, another of the young people on the schools trip to the Norwegian archipelago of Svalbard. "It may make me sound naive but I remember thinking, 'Wow, it's a polar bear footprint.' But I do not remember it making me any more worried."
A few days later tragedy struck when a starving polar bear evaded makeshift defences at the party's camp and ripped open the tent where Horatio was sleeping. Made aggressive and unpredictable by hunger, bad teeth and age, the bear attacked the schoolboy, leaving him with fatal head and upper body injuries. Two of the young people he was sharing the tent with were wounded and two leaders who fought off the bear before it was shot dead were also hurt.
A series of inquiries have highlighted serious concerns with how the expedition, organised by the charity the British Schools Exploring Society (BSES), was run.
It has emerged that a tripwire system designed to alert the campers to the approach of a bear was "defective" and the party had tried to get it working with paperclips. The rifle the party was equipped with was old and difficult to use – and only very limited firearms training had been given.
Horatio's father, David Chapple said the boy had been left with just his "bare hands" to try to fight off the bear.
During an extraordinary week-long inquest in Salisbury, Wiltshire, vivid accounts of what took place on the morning of 5 August 2011 were given.
Scott Bennell-Smith, another of the young adventurers sharing the tent as Horatio, described how he was woken by the "shaking of the tent". He thought someone was trying to wake him. But then the tent was ripped to shreds by the bear. He sustained head an back injuries when the bear struck out at him.
Patrick Flinders, who was also in the tent, said he curled up into a little ball but sustained a skull fracture when the animal swiped at his head. "I saw the bear drag someone by the head … I hid my head back under the cover," he said.
Another adventurer, Matthew Burke, who was in a different tent said he sat bolt upright when somebody screamed: "Bear, bear!" He looked out and saw Horatio, dressed only in boxer shorts, being savaged. Burke told the inquest: "The bear reared up and then slammed itself down on to Horatio, it used its paws and slammed down."
One of the adults, science leader Michael Reid, was also woken by the shouts. He grabbed the group's rifle and left his tent. He told the inquest: "The bear was close and it was on top of one of the YEs [young explorers] in their sleeping bags. I cocked the rifle … I took a carefully aimed shot at the bear in the chest area but the rifle didn't fire." Reid attempted to fire four or five times. But the bullets fell on to the ground.
The animal turned its attention on Reid. "I remember the bear biting my head and I thought the weakest part is the eyes so I tried to take out the eyes with my fingers, but was unsuccessful."
Another of the men, mountain leader Andrew Ruck, tried to distract the animal. He said: "I just charged towards the bear, shouted and picked up rocks and threw them at its face. The bear attacked me and knocked me straight to the floor, it's paws were on my shoulder, I remember seeing its face. It swiped my face with its claw and my head would have ended up in its mouth at some point." Reid found one of the rounds that had fallen on to the ground, loaded it into the gun and fired at the animal, killing it.
Norwegian officials ruled that Horatio's death resulted from "a number of unfortunate circumstances" but stressed the BSES did not act negligently under criminal law. His parents lodged an appeal but prosecutors in Norway agreed that no criminal charges should be brought.
BSES, which was founded by a member of Robert Scott's fateful expedition to the Antarctic in the 1930s to give young people a taste of adventure, commissioned high court judge Sir David Steel to examine what happened. He said that the intrusion of a "starving" polar bear into the camp was "a remote possibility but not unforeseeable".
Steel's report (pdf), which was published to coincide with the inquest, said the tripwire system – of a kind principally used by gamekeepers to protect bird pens from foxes – was "defective in terms of missing pieces of equipment".
It also highlighted problems with the way the party's Mauser 98K rifle, which dated back to the second world war, was stored and handled. Steel concluded it must have been stored with the safety catch in a position that disabled the firing mechanism. Training in the use of the rifle was "very limited" amounting to "some general handling and the firing of four shots."
The report pointed out that no guard – or "bear watch" – was organised though bears had been seen in the area and pack ice drifting close to shore increased the likelihood of one being there.
Richard Payne, chief leader of the expedition, accepted there was a shortage of parts for the trip wires and the system was "compromised".
Payne said access to a second rifle would have helped safety. He added: "There weren't any additional rifles to be had in July and August … in an ideal world there would have been two weapons."
Lt Gen Peter Pearson, executive director of BSES – which is now re-branded as British Exploring – said the makeshift adaptations were unsatisfactory, but added: "This is not a fly-by-night organisation, we tasked a high court judge to carry out an independent inquiry … we are absolutely an open book."
Pearson said the tripwire did not fire because the bear hit a post rather than the wire, and added: "However, much equipment we had around that camp, if the bear had hit a post it would not have gone bang."
He said a bear watch would be set up for any future expeditions to Svalbard and more rifle training would be provided in the future.
During the inquest, Horatio's parents said they were wrongly assured that a raft of safety measures would help keep their son secure. Horatio's mother, Olivia Chapple, said she was "more anxious" than her husband and son and went through every detail in the expedition's risk assessment to reassure herself. She said: "The trip was an expensive trip, I believed that they would have proper equipment … I was naive."
Arguing that the charity had been negligent, the Chapple family's barrister, Lizanne Gumbel QC, was critical of the attempts to patch the tripwire together with paper clips. "When safety equipment is modified, it needs to be tried and tested by the manufacturer, not by children," she said.
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