20th June 2019
HH Peter Rook QC has today delivered detailed factual findings and a combined narrative and short form conclusion in the fresh inquest into the death of Pte Geoff Gray at Deepcut barracks on 17 September 2001. Nicholas Moss represented the Ministry of Defence and individual soldiers/civil servants, leading Richard Boyle (TGC), Georgina Wolfe and Cicely Hayward (5 Essex Court). The inquest sat for 28 days over 2½ months, and received evidence from 105 witnesses.
The short form conclusion was “suicide”. Following the decision in Maughan  EWCA Civ 809, the Coroner applied the civil standard of proof but was in any event satisfied to the criminal standard of proof that the death was by suicide.
As had been accepted in concessions made by MOD, the Coroner found that greater attention should have been paid to the self-harm risks of young trainees carrying out armed guard duty. The narrative findings in the Record of Inquest were that:
“At approximately 01.10 hours on 17 September 2001 in the grounds of the Officers’ Mess at the Princess Royal Barracks, Deepcut, Surrey, Private Geoff Gray shot himself with a SA80 rifle that was set to automatic, causing two wounds to the head. He died rapidly at the place where his body was found. No third party was involved in the shooting. At the time Geoff fired the shots he intended to take his own life, although that state of mind may have only been transient.
Geoff’s actions could not reasonably have been anticipated at the time. He did not suffer with any known psychological difficulties nor had he been the recipient of any ill treatment. Any concerns Geoff may have had did not relate to the camp regime. However the army had failed adequately to address the risk of self-harm that might arise in respect of young and inexperienced trainees performing guard duty with unsupervised access to firearms. Proposals that trainees should not provide the Barracks’ guard, but be replaced with a professional guard force had not yet been acted upon.
While it was entirely Geoff’s decision to take his own life, the above failures provided Geoff with an opportunity to go to an isolated location with a firearm where he could act as he did.”
Noting a wide range of improvements evidenced by the Army (including in guarding arrangements, training supervisory ratios, de-stigmatisation of soldiers seeking welfare support, and in Trauma Risk Management), the Coroner decided it was not necessary to make any Preventing Future Deaths Report to the Ministry of Defence, stating,
“In the light of the changes in structure, culture and practice since Geoff’s death, the evidence at this inquest has not revealed to me any area where it appears that the army have either not already taken action or are not cognisant of and already pursuing the relevant action to prevent future deaths.”
The Coroner was strongly critical of the failings in the original investigations into the death. A PFD report was issued to the Chief Coroner and the President of Royal College of Pathologists concerning the desirability of further guidance being issued on the type of post-mortem to be carried out in cases of death by gunshot wounds, even if the initial evidential inquiries point to self-infliction. In Geoff Gray’s case, a normal Coroner’s post-mortem had been carried out, not a forensic post-mortem.