The loss of a piece of equipment by a Royal Marine recruit led him to take his own life on a railway line, a coroner has concluded, as he criticised failures in his mental health care.

Connor Clark, 18, 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.

Philip Spinney, senior coroner for Devon, Plymouth & Torbay, 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.

The teenager, from Norfolk, was three weeks into a four-week recruit orientation phase (ROP) course that all marines undertake before they begin their initial training.

He had “struggled” with organising his personal kit and had failed inspections.

Fellow recruits said he had suffered more “thrashings” – a physical punishment for making mistakes – than anyone else.

The five-day inquest in Exeter heard fellow recruits describe a “hostile atmosphere” between them, and instructors would shout and swear and hand out group thrashings for collective mistakes.

They described the instructors being “in their face” shouting and swearing – calling them a “f****** twat, prick or punk” and “c***”.

Recruit Stuart Whitelaw said: “It was never personal. I would say the trainers really put pressure on Connor’s weaknesses and would shout at him more. He had more thrashings than anyone.”

Able Seaman Chris Lee, who was on the same course, rejected claims the teenager had been a target of bullying by instructors.

“I wouldn’t say he was singled out or targeted any more than the rest of the troop was,” he said.

The officer in charge the ROP, Major Mark Thrift, denied he had called Mr Clark the “worst recruit”, but accepted he told him he was failing the course.

Sergeant Clinton Williams, an instructor, said: “I couldn’t sit here and say I haven’t told people that maybe Royal Marines training wasn’t for them.”

Two days before Mr Clark died, he had gone to the sick bay seeking treatment for a wound to his elbow.

He told medical staff he had initially cut his elbow falling against a radiator, but then admitted he had self-harmed by using a knife to re-open the wound.

“It is clear that I did not adhere to the guidance and thus made a poor and a wrong decision in not seeking a case conference,” Surgeon Commander Jon Bedford, an experienced locum, said.

He added: “I considered many times why I diverged from the guidance on self-harm. I felt Recruit Clark’s self-harm was done to increase the gravity of the injury to his arm, so that he had sufficient reason to visit the medical centre.”

An internal review concluded Mr Clark should have received a mental health assessment.

In his findings, Mr Spinney said the failure to hold a case conference on inform Mr Clark’s chain of command about the self-harming “probably or more than minimally contributed” to his death.

“Connor was finding some aspects of the course difficult. Connor’s own perception of his performance on the course probably or more than minimally contributed to his death,” he said.

“Connor losing his blank firing attachment probably contributed more than minimally to his death.

“The response by the Commando Training Centre to the information that Connor had gone missing from the camp was inadequate. It cannot be said this made any contribution to Connor’s death.”

Mr Clark escaped the camp unnoticed by putting a duvet over the wire fence.

A “very temperamental” CCTV camera guarding the spot where Mr Clark left had malfunctioned and was pointing at the grass for 90 minutes.

Roommates had last seen Mr Clark at around midnight when they went to bed and discovered he was missing at 5am.

Lessons need to be learnt and immediate changes made to prevent future loss of life

A search of the camp was launched but not beyond the perimeter wire, and the police were informed.

Mr Clark’s body was soon found on the railway line adjacent to the camp.

Lawyer Simon Quinn, from Hilary Meredith Solicitors, represented Mr Clark’s mother Tracy during the inquest.

“This is a very sad case and unfortunately yet another example of a young life lost too soon,” he said.

“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.”