The inquest into the death of Mansfield former soldier Ashley Clarkson found that evidence into his death was ‘not sufficiently clear’ that he had intended to end his own life.
Nottinghamshire deputy coroner Heidi Connor delivered a narrative verdict at the hearing on Thursday into the untimely death of the 23-year-old in March 2012.
The troubled ex-Royal Logistic Corps private, had been found hanging at his home on Clifford Street by his girlfriend Chloe.
The day-long inquest, in which numerous witnesses were called including family and military and medical spokesmen, heard that Mr Clarkson had suffered from anxiety and depression, caused by numerous factors that included the death of close family and friends, and the horrors of what he witnessed while on tour of Iraq during his time in the army.
However, the army deemed a low risk in terms of suicidal thoughts by the time he was discharged from the army in 2011.
Medical staff within the army said that there was no evidence that he had been suffering from post-traumatic stress disorder (PTSD), and that he had been looking forward to leaving the services.
The inquest heard that it is only in the last six months that veterans suffering mental health problems at the time of discharge have been given continuing medical support.
In Ashley’s case, his medical notes were never passed to a civilian GP after his discharge, although one military doctor who assessed him before he was discharged said he would not have recommended that Ashley needed to visit a doctor.
The inquest heard that Ashley, who grew up in the Ladybrook area, had wanted to join the army from a young age, and signed up as soon as he left school in 2005.
But his situation began to deteriorate when he showed signs of homesickness and depression when he was posted to Germany.
In a statement read out by the coroner, from Ashley’s mother, Mary Fells, she said he was also ‘daunted’ of going on a tour of Iraq in 2007.
She would speak regularly with him on the phone, and on one occasion he was crying after he had witnessed a baby die after stepping on a land mine, blaming himself.
On his return from Iraq in 2008, Mary described him as ‘vacant’ and said he refused to talk about the land mine incident.
During conversations with his father, Wayne, Ashley told him that no-one would listen to his problems because soldiers were always told to ‘man-up’.
Ashley’s drinking became heavy, and he was dealt further blows following the death of a friend from cancer and another who was killed on active service.
Getting into debt, and continuing to drink to excess, he became a cause for concern for his superiors at his barracks in Preston, Lancashire, having gone AWOL several times.
His mother said he feared being sent back to the Middle East and was eventually arrested for drink driving, getting a two-year ban. He told Mary he could get out of another tour if he was convicted.
His regiment was sent to Afghanistan in October 2009 without him.
After deciding that he wanted to leave the forces, Mary said he was then ‘messed around’ by the army on his leaving date.
Sgt Benjamin Hall, a registered mental health nurse, assessed Ashley in March 2011 after he was referred for being a possible suicide risk.
Sgt Hall found him to be at ‘moderate risk’ of suicide, that Ashley was anxious about being in the army, and that he admitted previous suicide attempts which he was embarrassed about.
It was recommended he be discharged from the army as soon as possible, because it was his stay that had become the main issue for the young private.
Sgt Hall said he was not at high risk because Ashley had plans for the future, was not dependant on alcohol despite his heavy drinking, and showed no signs of mental illness.
He was given his discharge date in March 2011, but was told he needed to serve 28-days at the military prison in Colchester for his indiscipline.
There, another doctor assessed him and found him to be at a low risk of suicide, saying that his mood was directly linked to him leaving the army.
The same doctor saw him again before the end of his 28-day stint, who then added there had been no issues or concerns and that he was not suffering from any mental health concerns.
After leaving the army, Ashley eventually gained employment at Jet Joinery in Kirkby, but began drinking heavily again and missing work.
On the day of his death, and almost a year after his discharge, Ashley had visited his mother at work on the morning, where she said he looked vacant and distant, had been up all night and smelled of alcohol.
Later that day family members became worried after text messages were not being returned by Ashley.
His girlfriend, Chloe Thompson, with whom he lived with at Clifford Street, returned to their house where she found him hanging from the top of the stairs. No letter or suicide not note had been left.
Passing the narrative verdict, Ms Connor absolved responsibility from the army by saying: “For a tragedy like this to be preventable, it has to be predictable. Ashley was not thought to be suffering from a mental illness before he was discharged.”
She said suicide was suggestive but not conclusive, adding: “He was at the time very intoxicated but it is not sufficiently clear from the evidence that he intended to end his life on that day.”
Turning to Ashley’s parents she said: “There are no words to express what you have experienced. I hope that at least some of your questions have been answered today.
“Sadly, this is not the first or the last type of case I have dealt with. There is a common theme in these cases, those who take their own lives often hide it from those closest to them.
“There was nothing else you as Ashley’s family could have done. You did not let Ashley down.”