A young soldier who fatally shot himself in the Deepcut barracks for hours after being informed that he was fired from the army was abandoned by lack of military support, decided a coroner.
The 26-year-old private investigator Sean Benton died on June 9, 1995 with five gunshot wounds at the military base in Surrey, followed by episodes of verbal and physical violence by a high-level employee and at least one junior colleagues.
Coroner Peter Rook QC said a campaign conducted by Pte Benton's family to conduct a second investigation – 23 years after the first – was "confirmed" after the underlying failures had been revealed.
The soldier's family spoke Wednesday at the Woking Coroner's Court, saying they would ask the police to start a criminal investigation into death.
A native of Hastings, Pte Benton was the first of four soldiers to die in Deepcut between 1995 and 2002.
Even the private individuals Cheryl James, James Collinson and Geoff Gray died of gunshot wounds.
Pte Benton's investigations, which began in January and listened to by more than 170 witnesses, have shown that it was "too sparkling" and a too withdrawn prankster.
He had fallen into drunken fights and was prone to violence and command, witnesses said.
But there were also signs of bullying, especially by Sergeant Andrew Gavaghan, the medical examiner, who was pleased with the fact that the officer had beaten and kicked some interns and abused his power.
Mr. Rook added: "What made the Sergeant Gavaghan particularly memorable was his use of a management tool – to interpret his twin brother.
"Sometimes he lost control of himself."
Mr. Rook realized that Pte Benton had been selected at a time when he was developing an emerging personality disorder that made it difficult for the soldier to face personal and professional challenges.
He said: "These events are likely to have weakened Sean's responsiveness and reduced his stress tolerance.
"They could have had a very negative impact on Sean because of his emerging personality disorder."
He said it was "possible" but it is not likely that these events contributed to Pte Benton's decision to kill himself.
In his concluding remarks, the coroner said: "Given the clear evidence of a deterioration of Sean's physical and mental health in the weeks prior to June 9, 1995, there was a failure of the army in providing Sean with adequate monitoring and support.
"If he had been offered such support and he had accepted it, it is possible that Sean had not committed the fatal act.
"However, the evidence does not prove this could happen."
Even for the 1995 standards, the study of Sean's death was extremely inadequate Coroner Peter Rook QC
The coroner described a series of failures with the original investigation into the death of Pte Benton.
He said that he was hampered by the lack of evidence, by bad photos of the scene and by the lack of scrutiny of witness accounts, among others.
He said: "Even after the 1995 standards, the study of Sean's death was extremely inadequate."
The court found Pte Benton embarrassed by the fact that he had been released from the army in the hours before his death and worried about his future prospects.
The coroner said it was a failure by Deepcut's staff to spread word that the desperate Pte Benton was not to be allowed close to arms.
It meant that he could get a younger corporal to lighten his guard and give him access to a rifle. He took and fired two shots in his chest.
The coroner made a decision about suicide.
In the classroom, Tracy Lewis's sister said: "Sean said he wanted to travel the world and support peacekeeping abroad, but he had bullying, violence and a terrible lack of care.
"When his sanity broke down, the people in his chain of command who were supposed to take care of him did not do or made things worse.
"The army will say today that things are different, but I do not think it's changed enough".
She was supported outside of Pte Benton's twin brother, Tony Benton.
His parents, Linda and Harry, died before permission was given for the second investigation.
In a statement, Brigadier General Christopher Coles, Head of the Personal Army Service Group, said: "In every area relevant to the death of Sean, the army has undergone significant changes in training. and in the tutoring of the apprentices both in Deepcut and in all the other training facilities,
"The four deaths of Deepcut and our desire to learn the lessons were at the heart of the army's improvements.
"I assure you that we will consider all the insights that the coroner has done today."