A member of the UK special forces who took his life was not neglected by his superiors or military mental health staff, a coroner has found, but there were "missed opportunities" to reassess the risk he posed to himself.
Corporal Alexander Tostevin, 28, was serving with the Poole-based Special Boat Service when he was found dead at his home in March 2018.
Coroner Brendan Allan concluded at an inquest in Bournemouth that mental health professionals had used their clinical judgment when treating Cpl Tostevin based on the evidence available to them, and that neglect was not a cause of his death.
But Mr Allan found that there had been missed opportunities to reassess Cpl Tostevin’s risk of suicide, after an email sent by a welfare officer over the weekend containing vital information about a sharp deterioration in his mental health was not picked up by those managing his treatment.
Recording a conclusion of suicide, Mr Allan 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."
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.
They said he had "changed" following that tour and friends told the inquest he was drinking heavily, was using cocaine and was spending money excessively, including on prostitutes, and racking up large debts.
Mr Allan said he would be writing a report to prevent future deaths, looking at the risk of underreporting by service personnel of mental health symptoms due to the fact military mental health practitioners are required to report their concerns to superiors if the condition could "undermine operational effectiveness".
"It is not for me to identify the action taken to address that concern, but it is my duty to highlight that there is a concern that has been aired during the course of this inquest," he said.
Cpl Tostevin had been 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.
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.
"On the Wednesday I made a judgment that he was fit to go home with various interventions in place. I got that wrong," Capt Sharpley said.