There were ‘missed opportunities’ linked to the death of a soldier who took his own life at an army base but it didn’t constitute negligence from the British Army, an inquest heard.
Highlander Nicki Hart, 33, who served with the 4th Battalion of the Royal Regiment of Scotland, died on February 5, 2022, at the Munster Barracks at Catterick Garrison.
Over the last ten days, an inquest into his death has been conducted at Northallerton Coroners’ Court, with it concluding on Friday (November 15).
Mr Leach also highlighted that there had been ‘learnings’ and ‘missed opportunities’ at stages of Highlander Hart’s treatment, but admitted that this didn’t amount to negligence or weren’t ‘significant factors’ in the soldier’s death.
This included the mental health provision given to Highlander Hart at Catterick Garrison, checks carried out on the dad-of-three, and messages passed between the chain of command.
The inquest previously heard that Nicki joined the territorial army in 2008, before joining the main Army in 2010 and becoming part of the 4th Battalion of the Royal Regiment of Scotland in 2013.
It was also found at the inquest that the father-of-three, who was originally from South Wales, had a 'complex' and 'extensive' history of mental health.
This mental health struggle for Highlander Hart began in 2012 after he developed post-traumatic stress disorder (PTSD) after a 2012 tour of Afghanistan, which intensified following a second tour of Afghanistan in 2020.
Other tragedies and stresses in Nicki's life included the death of a close friend Ryan Mackenzie at the barracks six months before, as well as family problems and his wife experiencing a miscarriage, which were all factors in a mental health deterioration.
During the previous days of the inquest, it was heard that the Army had put several 'learning points' in place following Highlander Hart's death, which included more checks when it comes to mental health.
This was a direct result of four other soldiers taking their own lives within 18 months in the 4th Battalion of the Royal Regiment of Scotland, with all of the deaths taking place at Catterick Garrison.
Previously in the inquest, the court heard from Major Simon Russell, who was Highlander Hart's commanding officer, who said that the whole battalion had tried to be "proactive" when it came to tackling the mental health issues - but he admitted that suicide within the barracks could be 'contagious' and that lessons could be learned.
Speaking at the inquest, he said: "The issue of suicide in the battalion was an issue. If multiple people took their own lives in a short timeframe, it was certainly normalised, and it probably made others less shielded.
"The proximity that soldiers have to suicide and self-harm, risk factors were in place and work was done around this - but lessons can be learned."
Despite Maj. Russell's beliefs about suicide being 'contagious' at the barracks, he noted that it wasn't exclusive to the 4th Battalion of the Royal Regiment of Scotland or Catterick Garrison, and said he thought it was part of a 'wider societal issue' when it comes to men's mental health.
This proactive approach to helping Nicki was also taken by the Highlander's colleagues, who were credited with 'going above and beyond to try and save Nicki's life' by Coroner Jonathan Leach.
This included spending evenings with him in the barracks, inviting him out of the barracks on a weekend on day trips, and performing consistent checks on him.
One of those who kept an eye on Nicki was former soldier David Twiname, who lived above Nicki at Catterick, who previously told the inquest that he would sit with Nicki in his room and keep him company and text him when he wasn't there to make sure he was okay.
The inquest also heard that several meetings about Highlander Hart's mental health were staged six months before his death at Catterick Garrison, with the mental health provision at the army base believing the soldier posed "little threat" to himself.
But these worries about Nicki's mental health were stepped up in January 2022, when it was agreed to monitor him twice a day and put him on light duties in the Army stores at Catterick Garrison, due to concerns about his drinking, his welfare, and his meetings with mental health services.
He was referred to mental health specialists and attended an appointment two days before his death.
But, according to military GP Simon Bloodworth, who saw Nicki during a mental health appointment in 2021, there wasn't any 'immediate danger' to the soldier during that consultation.
Mr Bloodworth told the inquest previously: "No emergency appointment or intervention was needed for Nicki. He was speaking to me normally and with eye contact, and there were no immediate signs that he was experiencing deep depression or a mental health battle."
But the coroner noted that factors, including several of Highlander Hart's superiors not knowing about his complex mental health history and the fact he wasn't put on a Care Action Plan (CAP) after he expressed his mental health struggles weren't "significant" factors in his death.
A toxicology report found the amount of alcohol in Highlander Hart's system would have put the soldier more than twice the legal drink-drive limit when he died.
A Service Inquiry Report has found that there were “missed opportunities” in the care he received before he died.
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