Royal Marine inquest: Mental health failings contributed to recruit's death, says coroner

A failure to call a mental health conference for a marine recruit who took his own life may have contributed to his death, an inquest in Exeter heard on Wednesday 3 July.

Connor Clark, 18, from Norfolk had used a duvet to scale a razor wire fence at the commando training centre (CTC) in Lympstone, Devon, before being struck by a train on the morning of June 12 2021.

The teenager had made comments prior to his death about being called a “failure” and the “worst recruit”, and was worried about losing weekend leave for misplacing the blank firing adapter for his weapon.

A faulty CCTV camera was also highlighted by the coroner Philip Spinney, as he gave his conclusions today.

He said that, when Connor Clark presented himself to sick bay with a wound that he had made worse himself, a referral should have been made as an incident of self-harm.

Mr Spinney said this was a significant failure that probably contributed to his death.

On the night that Connor Clark left the camp, the night guards were two members short - with three on duty instead of five.

The camera, which covered the area of the fence where Connor had placed his bedding to climb, was said to sometimes malfunction.

The inquest heard that it was stationary between 2.20am and 3.50am, and focused on an area of grass.

The duvet was only confirmed when the CCTV was reviewed later that morning.

The coroner said he was aware that the CCTV system at the base is under review, and that it is set up to guard against intruders and not to stop people from leaving.

He said he did not consider it a significant factor towards the cause of Connor's death, but was critical of what happened when people realised he was missing.

He described the response as "inadequate" with "no effective coordinated approach", a lack of indication of where he may be.

However, he said that where Connor died was three kilometres away and a search may not have resulted in him being found.

Mr Spinney felt there was no need to place any further orders to prevent future deaths as he said he was aware that a number of policy changes had been made by the Ministry of Defence and that he knew that, Connor's death was still very much on their minds.

He 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.

In his findings, Mr Spinney said Mr Clark had become “overwhelmed with the situation” and had left the camp and ended his life.

“I attach no criticism to the training staff in relation to the loss of the blank firing attachment,” he said.

“I conclude that Connor losing his blank firing attachment probably contributed more than minimally to the cause of his death.”

Mr Spinney said Mr Clark had died from multiple severe injuries as he recorded a conclusion of suicide.

Hilary Meredith Solicitors represented Connor's mum Tracy at the inquest.

Following the Coroner’s conclusions today, Simon Quinn, Partner and Head of Military at Hilary Meredith Solicitors said: “This is a very sad case and unfortunately yet another example of a young life lost too soon.

“After delays by the Ministry of Defence (MoD) and following a long wait for an Inquest date, we welcome the Coroner’s conclusions and hope that Mrs Clark is finally provided with the answers she needed and deserved.

“As the MoD’s actions, inactions and failings have once again been brought to light, it is beyond clear that a change within the MoD is long overdue.

"Lessons need to be learnt and immediate changes made to prevent future loss of life. This is a tragic case which included a Doctor who, in his mind was trying to help Connor, but who failed to follow policy in referring Connor on at the moment he needed it most.

“At Hilary Meredith Solicitors we have witnessed first-hand the devastating impact of suicide, not only affecting the victim but also their family and friends.

"Hilary Meredith Solicitors Limited was privileged to represent Mrs Clark throughout this ordeal and would also like to thank our Counsel, Mr Christian Taylor of Exchange Chambers for his representations at the Inquest.”

"Hilary Meredith Solicitors would also like to thank Mrs Clark for the strength and courage she has displayed throughout this matter and at the Inquest in particular when providing her evidence on the first day."

A Royal Navy spokesperson said: “The death of Recruit Connor Clarke is a tragedy, and our thoughts remain with his family at this very difficult time.

"Our service personnel are our most valued asset, and we take the condition of their health and wellbeing extremely seriously. “