The loss of a piece of equipment by a Royal Marine recruit led him to take his own life on a railway line, a coroner has concluded, as he criticised failures in his mental health care.
Philip Spinney, senior coroner for Devon, Plymouth & Torbay, said there was evidence Mr Clark had been looking for the piece of equipment as he was due to have an inspection on the day he died. Mr Spinney said Mr Clark had died from multiple severe injuries as he recorded a conclusion of suicide. Recruit Stuart Whitelaw said: “It was never personal. I would say the trainers really put pressure on Connor’s weaknesses and would shout at him more. He had more thrashings than anyone.”
He told medical staff he had initially cut his elbow falling against a radiator, but then admitted he had self-harmed by using a knife to re-open the wound.“It is clear that I did not adhere to the guidance and thus made a poor and a wrong decision in not seeking a case conference,” Surgeon Commander Jon Bedford, an experienced locum, said.
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