Deepcut verdict: Cheryl James' death was caused by 'self-inflicted shot', rules coroner
Private Cheryl James died as a result of an intentional "self-inflicted shot" while on guard duty at Deepcut barracks, a coroner has ruled.
The young recruit, 18, died from a gunshot wound to the head at the Surrey base in November 1995 - one of four recruits who died there over seven years.
Delivering his conclusion following a three-month inquest into her death, Coroner Brian Barker QC said: "The conclusion is self infliction."
He added: "This was an intentional discharge by Ms James."
The coroner said Pte James had a "preoccupation with death" and would sometimes talk to her friends about what guests she would want at her funeral.
He said she was "disillusioned" with the Army and had a troubled adolescence which included an overdose.
She had light-heartedly talked to friends about how "easy" it would be to shoot oneself at the Army barracks.
Mr Barker said: "There can be no reasonable doubt that Ms James carried out an intended action and knew that its consequence would be death.
"I'm satisfied so that I'm sure Ms James inflicted the fatal shot and intended to die."
Formally recording his verdict, Mr Barker said Pte James died as a result of suicide.
He said: "Without knowing the reasons for her actions, it is of course difficult to identify the cause.
"Ms James' morale may have been lowered by the general regime where she lived.
"In the last week of her life, she wrote of her wish to leave the Army and her plans to feign migraines to achieve this.
"There is, however, no basis to establish that Ms James' disillusionment with the Army or any dislike of the Deepcut regime was, on the balance of probabilities, such as to cause her to wish to die.
Mr Barker suggested the system at the barracks had created a "dangerous situation and provided the opportunity for her to take her life. That is lone armed guard duty".
He added: "Ms James should not have been on armed guard duty alone. Moreover, the failure sits within the wider context of the Army at the time neither recognising, nor taking any steps to reduce, the potential risk of trainees using their service weapons against themselves."
Mr Barker praised Pte James' parents, Des and Doreen, form Llanymynech near Oswestry, for fighting to discover the truth behind their daughter's death.
He said: "Mr and Mrs James, for you it has been a long and very harrowing road to try to obtain a proper forum for the investigation.
"We have explored as best we can what could be unearthed at this late stage within the legal constraints I am bound by.
"Clear answers as to why are just not there to be seen."
He praised Mr James' tenacity and said his battle for justice had been key in encouraging the Army to drive through reforms to improve the welfare and support it gives its young recruits.
Mr Barker said there has been "a complete re-evaluation of the approach to proper care given to young people who volunteer to train and eventually serve their country".
The young female recruit died from a gunshot wound to the head while on guard duty at the Surrey base in November 1995 - one of four recruits who died there over seven years.
Delivering his conclusion following a three-month inquest into her death, Coroner Brian Barker QC said he was satisfied there is "no" evidence she was unlawfully killed.
He said: "When I ask myself if there is sufficient evidence with which I can properly reach a conclusion of unlawful killing the only answer I have is 'no'."
A fresh inquest was ordered into her death after High Court judges quashed an open verdict recorded in December 1995.
The coroner said Deepcut Army barracks had failed in its duty of care to its young recruits, with far too few officers to train and look after the recruits, who were left bored and indisciplined.
Deepcut Army barracks in Surrey has been at the centre of controversy since the deaths of four young soldiers at the base between 1995 and 2002 amid accusations of bullying and harassment.
Here are some of the key events in Deepcut's history.
April 5 1993 - The Royal Barracks, Deepcut, an Army base since around 1900, becomes the home of the newly-formed Royal Logistic Corps, offering training for young soldiers.
June 9 1995 - Private Sean Benton, 20, from Hastings, East Sussex, is found dead at the Princess Royal Barracks, Deepcut.
July 6 1995 - The inquest into Pte Benton's death records a verdict of suicide.
November 27 1995 - 18-year-old Pte Cheryl James, of Llangollen, Clwyd, is found dead at Deepcut.
December 21 1995 - The inquest into Pte James's death records an open verdict.
September 17 2001 - Pte Geoff Gray, 17, from Hackney, east London, is found dead with two gunshot wounds to his head while on guard duty.
March 19 2002 - The inquest into Pte Gray's death records an open verdict.
March 23 2002 - Pte James Collinson, 17, from Perth, is found dead with a single gunshot wound while on guard duty at the barracks.
April 30 2002 - Surrey Police opens a joint investigation into the deaths of Pte Gray and Pte Collinson. The force later confirms they are also reviewing the deaths of Pte James and Pte Benton.
June 10 2002 - The families of the four soldiers launch a call for a public inquiry into their deaths.
October 3 2002 - The body of James Collinson is exhumed from a grave in Scotland. A forensic pathologist carries out a second post-mortem examination to try to establish how he died.
September 19 2003 - Surrey Police concludes there are no grounds for prosecutions over the deaths of the four young soldiers at Deepcut.
May 24 2004 - The Government rejects calls for a public inquiry into the soldiers' deaths but announces an "independent" inspection regime into armed forces training.
October 29 2004 - New allegations of gang rape, systematic bullying and sexual harassment at Deepcut are disclosed in a leaked police report - 173 separate allegations in total.
October 30 2004 - The Government announces a new review of allegations of abuse and bullying at Deepcut but stops short of the full public inquiry demanded by families and MPs. Nicholas Blake QC is later chosen to lead the review.
March 10 2006 - The inquest jury looking into the death of Pte Collinson returns an open verdict.
March 29 2006 - The Blake Review criticises Army training, citing "harassment, discrimination and oppressive behaviour", but concludes that the deaths were probably self-inflicted.
May 14 2009 - The Government again rejects calls for a public inquiry into why the four soldiers died after the publication of Army Board of Inquiry reports into the deaths of Pte Gray and Pte Collinson.
March 11 2011 - A review by Devon and Cornwall Police found Surrey Police failed to fully investigate a potential suspect known as the "unknown white male" in the death of Pte James.
March 25 2014 - The Attorney General grants Pte James' family consent to apply to the High Court for a new inquest into her death.
July 18 2014 - High Court judges order a fresh inquest into the death of Pte James.
September 10 2015 - A pre-inquest review hears the body of Pte James was exhumed and reburied the previous month and bullet fragments from the body were undergoing further testing.
December 14 2015 - The MoD fails to submit crucial documents by an agreed deadline. Pte James' father, Des, accuses the MoD of acting in an "extraordinarily arrogant" way.
January 11 2016 - Alison Foster QC, representing Pte James's family, tells a pre-inquest hearing they have material suggesting the soldier "may have been sexually coerced or raped the night before, or before the time of her death", and a direct allegation Pte James may have been ordered to sleep with a person by someone superior in rank to her.
February 1 - Coroner Brian Barker QC rules that the inquest will not consider whether Deepcut barracks had a "culture of sexual abuse", saying it was outside hearing's scope to examine whether there was "sexually inappropriate treatment of female recruits within the chain of command".
February 8 - The inquest hears that new scientific evidence suggests Pte James may not have killed herself. Ms Foster says there is "distinguished pathological evidence" showing the injury may not have been self-inflicted.
February 9 - Brigadier John Donnelly, director of personal services for the Army, apologises to Pte James' family for the situation at Deepcut, which he recognised as having failed new soldiers stationed there.
March 16 - Former Surrey Police inspector Michael Day apologises to Pte James' family about the limited police investigation into her death.
Launching an attack on welfare standards at Deepcut, Mr Barker said the general culture of the base fell below the standard expected, saying the "haphazard provision of welfare support was insufficient".
He also highlighted a culture of sexual promiscuity and heavy drinking at the Surrey base.
Mr Barker said the Army accepted that some instructors "saw young females as a sexual challenge".
He added: "The evidence of this inquest supports the presence of consensual but improper relations between instructors and trainees."
He was also scathing about the poor quality of the initial investigation into Pte James' death, saying there was an early assumption of suicide.
The scene was also compromised and not adequately investigated and ballistics tests were not carried out to see if the bullet was fired by her rifle.
There was no forensic post-mortem examination, no detailed record of the presence or absence of gunshot residue, and bullet fragments were not preserved.
Pte James' clothes were also burned, and interviews of those at the barracks were inadequate.
Mr Barker said: "This has left unanswered questions which understandably fuelled speculation as to how Ms James died."
And in the absence of direct scientific evidence, experts investigating later were left to form conclusions without the evidence they usually have available to them.
In response to today's verdict Air Vice-Marshal David Murray, chief executive of SSAFA, the Armed Forces charity, said: "Nine years ago, as a direct response to the Deepcut tragedies, SSAFA, the Armed Forces charity, set up Forcesline, a confidential helpline to ensure that our Forces had someone independent to turn to.
"In the last year Forcesline saw an 85% increase in calls from serving personnel, many relating to mental health issues. Some of those that we help are concerned that asking for support from their chain of command could be perceived as a sign of weakness.
"This is a real concern for us and in light of today's verdict, serving troops must be encouraged to come forward with their problems and it is incumbent on all of us to let them know that it is OK to ask for help."
During the three-month inquest, a complex portrait emerged of Private Cheryl James - that of a young woman who was deeply troubled but at the same time bubbly, happy and free-spirited.
The soldier, who was found shot dead on November 27 1995 at Deepcut Barracks, just yards from where she had been performing guard duty, repeatedly spoke about death with her fellow recruits, often joking that killing herself was the only way to get off the base.
But she was also a fun-loving party girl with a wide circle of friends, a teenager who discussed the possibility of marriage with a boyfriend, planned a Christmas shopping trip and was excited about a potential posting to Germany.
She was also sexually adventurous, listing 11 men she had slept with during her Army training and struggling with the angst of being torn between two boyfriends.
But the 18-year-old also attracted unwanted attention from superiors at Deepcut, a "toxic" environment where there was a "highly sexualised atmosphere".
And the inquest was told that a fortnight before her death a sergeant had locked her in a room at Leconfield in Hull and "tried to have his way with her".
There were also claims she was ordered by a superior officer, Sergeant Andrew Gavaghan, to have sex with another soldier the night before she died, claims which were denied.
Simeon Carr-Minns, one of her two boyfriends, said he thought Pte James had a "secret anguish" she could not share with him, and that in the days before her death she drank to "anaesthetise" herself from her problems.
Those issues appear to have originated in her childhood.
Pte James, adopted by her parents Des and Doreen James, was described by a former teacher as a "mixed-up kid" who was "crying out for help".
Heather Williams, who taught her for five years at Ysgol Dinas Bran in Llangollen, Wales, said she had a "chip on her shoulder" about not knowing her true background or where she belonged.
Ms Williams said that while she seemed extroverted, this was a front and she "put up barriers" and had "deep-seated" problems.
Pte James had been the victim of an alleged rape by two boys when she was 14 and took an overdose of paracetamol after the suicide of her 18-year-old cousin Rob in 1992.
Mr James, 66, fought back tears as he told the inquest his nephew's death was the "final straw" for his adopted daughter, who ran away from home twice before moving out at 17.
Pte James had been excited about the prospect of joining the Army, saying on her application to enlist that it would give her chances to travel and good career prospects.
Fellow recruits described her as "fun-loving", "bubbly" and vivacious, with one friend and lover, Steven Storey, saying she "loved life" and was "full of confidence".
But other friends painted a different picture - of Pte James hating life in the Army and talking of going Awol (absent without leave), being singled out for discipline and frequently bringing up the subject of death.
One friend, Marina Fawcett, was among a number of fellow recruits who told the inquest Pte James had joked about shooting herself.
She said: "She literally mentioned, 'We're going to shoot ourselves on guard duty one day aren't we?', and I said 'Yes'.
"She was saying it as general banter ... I don't know why she said it, it just sounded like a laugh like when someone says something stupid."
Another friend, Yvonne Sneddon, said Pte James told her out of the blue while on a coach journey back to Deepcut how "easy it would be to shoot yourself", saying in a statement she "wasn't mucking about" and "it sent a chill through me".
And an old school friend, Kathryn Hughes, said she would regularly bring up the topic of death, even making lists of who she would invite to her funeral.
But the inquest heard Pte James was not listed on a welfare register at Deepcut for soldiers who might have been having difficulties.
While at the barracks Pte James often got drunk with fellow recruits, enjoyed secret parties and on at least one occasion took drugs at a nightclub.
In the weeks before her death she went to Leconfield for HGV training, but close friend Jane Warboys said Pte James told her she had been targeted by a sergeant who locked her in his office and chased her around a desk.
The pair discussed the incident but did not know whom to report it to.
Mr Storey said that after she returned from Leconfield, "her sparkle had gone" and she was considering leaving the Army.
The weekend before she died Pte James was forced to face up to choosing between two boyfriends, Mr Carr-Minns - with whom she had discussed marriage - and Pte Paul Wilkinson.
On November 26 she and Mr Carr-Minns went to a party, at which Pte Wilkinson was also present.
Mr Carr-Minns said she had been drinking and her mood was up and down, saying: "She would be laughing and joking one minute and quite aggressive or sad or angry the next minute.
"She seemed to go from one state to the other. I had not seen her like this before."
He added: "I think towards the end, on that weekend, I realised probably at some point that she was drinking to anaesthetise herself from certain problems. I remember having that impression."
The inquest heard conflicting accounts of Pte James' mood on the morning she died.
Ms Warboys, who reported for guard duty with her, said they enjoyed a "girly chat" together, while others who saw her at the Royal Way Gate said she was "jolly" and "bubbly".
But friend Claire Barnett said she could see "in her eyes that something was not right", while a corporal she stopped for an identity check said she was "down in the dumps" and "miserable".
Pte Wilkinson, one of her boyfriends, was with her at the gate in the hour before she died. The then-16-year-old said she was "happy and laughing", but that they argued about which man she was going to choose.
Pte James never had the opportunity to do so - her body was found in a copse not far from the gate at around 8.30am on November 27.