A special forces soldier should not have been left alone in the days before he killed himself, an expert psychiatrist told an inquest.
Professor Chris Fox said the “risk was too high” in leaving Corporal Alexander Tostevin on his own in his flat with twice daily phone call checks and a list of phone numbers for support.
The 28-year-old, who served with the elite Special Boat Service, was found dead in March 2018 after he failed to respond to telephone contact having taken his own life.
The inquest heard in the week of Cpl Tostevin’s death he was assessed by a community psychiatric nurse and Royal Navy psychiatrist Captain John Sharpley.
Prof Fox said the nurse had considered a hospital admission due to threats of self-harm but instead a safety plan was put in place for welfare checks.
“Given the information that was available to those looking after him at the time, I think the risks were too great for that,” Prof Fox told the inquest.
“The individuals checking up on him were not trained in mental health. They were just checking in to see if he was okay and still alive.
“The documented evidence says he was minimising in January and also admitted to Capt Sharpley and the community psychiatric nurse that he had not been forthcoming about everything to professional experts.
“Should I really allow people who are not trained, not medical – that was a risk too far to just do a couple of checks and have a friendly chat.
“In the NHS we would have probably put the crisis team in at that point. That might have just been about acceptable.”
Prof Fox told the inquest in Bournemouth that had he been treating Cpl Tostevin he would have trusted the nurse’s judgment on the need for hospital assessment.
“The failure then was not to proceed with the nurse’s plan the day before,” he said.
“I know admitting people doesn’t prevent suicide but at least you can get a better assessment and improve the management of him.
“I don’t see how this man could have been kept safe. Asking a friend to stay with him untrained in mental health or getting the Royal Military Police to sit with him – they are not trained either.
“Only over a whole period of 24 hours can you start to see – people can’t hold it together – and you can start to see what’s really going on.
“He was happy to go in. I would have pushed for admission. I just don’t understand why that was taken off the table then and bearing in mind the previous day’s assessment from the nurse.”
Cpl Tostevin, from Guernsey, had been placed on restrictive duties and was facing disciplinary action after an incident the previous September when he had gone absent without leave and used a military credit card to buy cocaine and hire a prostitute.
Following that incident, he was being seen regularly by a welfare officer, the community psychiatric nurse and Capt Sharpley, who diagnosed Cpl Tostevin with adjustment disorder.
Cpl Tostevin’s family had previously told the inquest there had been a decline in his mental health after returning from a tour to Afghanistan in 2010 with the Royal Marines and believe he was suffering from PTSD.
He had started drinking heavily, was using cocaine and spending excessive amounts of money – getting into massive debt.
Prof Fox said he disagreed with Capt Sharpley’s diagnosis of adjustment disorder.
“At best it should have been tentative, and I don’t think alcohol and potential PTSD should have been so readily dismissed because of some of the symptoms he suggested, particularly to the community psychiatric nurse,” he said.
Prof Fox said Cpl Tostevin’s use of alcohol was “played down and ignored” by those treating him and that spending £500 in a weekend was a “red flag”.
“Perhaps it should have been kept there and kept an eye on and questioned,” he said.
“The PTSD, again we have symptoms of that – the intrusive thoughts, the change in his behaviour, the dreams.”
He said in February 2018 there was a “significant deterioration” in Cpl Tostevin’s mental health where he was telling people he was thinking of taking his life.
“It looked severe and it possibly indicated that the diagnosis of adjustment reaction was wrong and needed to explore things that had not been explored by that date,” he said.
“It might have been an opportunity to look at some of the trauma symptoms over the next week or two.”
The hearing continues.