The Navy failed to identify and treat special warfare personnel who showed symptoms of traumatic brain injury, according to a government watchdog report that detailed breakdowns in screening, evaluation, and follow up care.

The War Department Inspector General published the report Wednesday and criticized Naval Special Warfare Command for relying on an evaluation system weakened by poor oversight and inconsistent compliance with established policies.

“The Naval Special Warfare Command did not consistently implement DoW and Naval Special Warfare Group Four (NSWG-4) policies regarding the identification, clinical evaluation, and subsequent care of SWCCs presenting symptoms of TBI,” the report found.

The War Department defines traumatic brain injury as an injury that disrupts brain function because of external force. Signs can include confusion, slower mental processing, memory loss, and declines in consciousness.

Navy special warfare personnel must complete a mild TBI and Exposure Report form after returning from time away at sea. Sailors are expected to report symptoms they experienced that could be connected to a traumatic brain injury.

When a service member reports or displays symptoms associated with a concussion, medical personnel can conduct a Military Acute Concussion Evaluation, Version 2. The screening, known as MACE-2, is used in an attempt to diagnose a concussion and traumatic brain injury.

The inspector general found that many service members returning from an underway never completed the required report. Between Jan. 1 and April 1, 2026, only 24 Naval Special Warfare Command sailors filled out the form.

Those completed forms represented only 21 of the 193 underways reported by Special Boat Team 12 and Special Boat Team 20 during that period. The watchdog attributed the poor compliance to the absence of a program overseeing the process and enforcing the requirement.

Investigators found no evidence that commanders and senior leaders ensured service members completed the forms. The paperwork can also take several hours to finish, discouraging sailors from completing an important part of the injury reporting process.

The failures continued after symptoms were reported. Across six years, Naval Special Warfare Command did not record a single completed MACE-2 evaluation for Special Boat Team 12 or Special Boat Team 20.

Between 2020 and 2026, 144 service members completed 634 TBI Exposure Forms after displaying symptoms of traumatic brain injury. Despite those reports, none of the sailors received the MACE-2 concussion evaluation intended to diagnose TBI.

According to the inspector general, the problem stemmed from the Navy concussion management plan. That plan requires a corpsman to conduct a MACE-2 evaluation only when the service believes a sailor has suffered a concussion.

The watchdog warned that there is no foolproof method for identifying a concussion, leaving substantial room for human error. Medical personnel do not administer MACE-2 unless the Navy special warfare service member, or a senior official above that person, requests the evaluation.

The mild TBI and Exposure Report form also lists symptoms that are not exclusive to concussions. That makes it unclear which reported problems might indicate that a sailor has suffered a concussion requiring additional evaluation.

Investigators also discovered that some Navy special warfare personnel deliberately circumvented the TBI process. Service members sometimes provided answers to the MACE-2 evaluation that they had memorized beforehand, allowing them to downplay the severity of a possible symptom or injury.

The watchdog said this weakness resulted from the War Department lacking a standardized test for events involving impact from waves. The report therefore identified problems both in the required reporting process and in the evaluation available after symptoms emerged.

Naval Special Warfare Command also failed to ensure that service members displaying TBI symptoms attended follow up appointments for medical care. The Navy concussion management plan requires service members to return for a medical follow up appointment within two weeks of returning to duty.

None of the 634 TBI Exposure Forms completed between 2020 and 2026 documented a completed follow up appointment within the required period. That left the command with no documented timely follow up appointments among the cases examined.

One Navy special warfare service member told the inspector general that fear of losing a job on the boat influenced decisions to skip follow up appointments. The service member said reporting symptoms could derail deployment exercises.