Opportunities were missed to reassess the risk a special forces soldier posed to himself before he took his life, a coroner has found, but he was not neglected by his superiors or military mental health staff.
Corporal Alexander Tostevin was serving with the Poole-based Special Boat Service when he was found dead at his home on 18 March, 2018.
The 28-year-old had been left on his own with just a list of phone numbers for support, the inquest heard.
Cpl Tostevin’s family believe he had developed PTSD after narrowly avoiding death while serving with the Royal Marines in Afghanistan in 2010 - for which he had been recognised for bravery.
The inquest heard that he “changed” after that tour and was drinking heavily, using cocaine and spending money excessively.
The 28-year-old, who grew up in Guernsey and joined the Royal Marines aged 18, told a welfare officer he had been left a “dead man walking” after the 2010 Sangin tour and his “whole outlook on life changed”.
It culminated in a conviction in April 2017 for assault occasioning actual bodily harm after a bust-up in a nightclub, for which he was fined £10,000.
And the following September, Cpl Tostevin went absent without leave and used a military credit card to buy cocaine and hire a prostitute during a weekend in London, after which he planned to take an overdose.
He was then moved to non-operational duties and was facing disciplinary action at the time of his death.
Cpl Tostevin was also assigned a welfare officer, a community psychiatric nurse and had appointments with a Royal Navy psychiatrist, who diagnosed him with an adjustment disorder.
The nurse said Cpl Tostevin had low mood, anxiety and problems sleeping and was receiving low intensity psychotherapy.
Days before his death he had sat in a darkened room with a noose around his neck and had also stockpiled tablets.
A plan drawn up by Royal Navy psychiatrist Captain John Sharpley had a civilian friend of Cpl Tostevin stay with him at all times - but he left three days before his death.
Instead, Cpl Tostevin was checked twice daily by text message and had the phone numbers of colleagues and the Samaritans if he needed help.
Capt Sharpley admitted he “got it wrong” in assessing Cpl Tostevin’s suicide risk.
“On the Wednesday I made a judgment that he was fit to go home with various interventions in place. I got that wrong,” he said.
Coroner Brendan Allen found that the plan to have the civilian friend remain with Cpl Tostevin was not inappropriate, but concluded that it had not been explained to the individual that he must remain with him at all times.
“It was not inappropriate in my view to make use of friends who (Cpl Tostevin) trusted in a formulation of a safety plan,” Mr Allen said.
He added he was sure the friend would never have left for London if it had been impressed upon him “his presence was an important factor in managing (Cpl Tostevin’s) risk to himself”.
Mr Allen found that the mental health professionals working with Cpl Tostevin had made decisions based on their clinical judgment, but found opportunities had been missed to reassess the risk he posed to himself.
In particular, an email sent by a welfare officer on Friday 16 March containing vital information about a sharp deterioration in his mental health was not picked up by those managing his treatment until the following Monday, a day after his death.
But he found that missed opportunities by mental health professionals to help Alex did not amount to “gross failure” in care and would only have had a “minimal” or “trivial” impact on Cpl Tostevin’s actions.
Recording a conclusion of suicide, Mr Allen said: “I formally record (Cpl Tostevin) died by suicide in circumstances where there was a missed opportunity to reassess his risk of suicide in the light of information disclosed three days before his death.”
Additional reporting by PA
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