Tri-Service
Coroner: Death Of Cheryl James Was Suicide
The death of Private Cheryl James, 18, was caused by suicide following a "self-inflicted" wound, coroner Brian Barker QC ruled at an inquest at Woking Coroner's Court.
Delivering his conclusion following a three-month inquest into her death at Deepcut barracks, Coroner Brian Barker QC said:
"The conclusion is self infliction... This was an intentional discharge by Ms James."
He added that 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'."
But he added that it was "regrettable" her death was not better investigated at the time - and praised her parents for their fight for justice.
The young private, 18, died from a fatal bullet wound at Deepcut barracks in November 1995 - one of four young recruits to die at the Army training camp in Surrey over seven years.
A fresh inquest was ordered into her death after High Court judges quashed an open verdict recorded in December 1995.
Speaking at the conclusion of the fresh inquest at Woking Coroner's Court, Coroner Brian Barker QC said:
"I begin by recognising the patience and loving fortitude of Mr and Mrs James. They have waited for far too long for the proper examination of the circumstances of their daughter's death and it is clear to all they have devoted immense energy and devotion to that end."
"This has been a long and a difficult exercise, and many events since the autumn of 1995 have had to be examined." He added:
"It is highly regrettable that the investigation of Ms James' death in 1995 was not more thorough and the scene of her death not more fully and scientifically investigated."
"Had it been, some of the inconsistencies of memory might have been avoided and the scientific evidence might have been of much better quality."
Ms James' parents, Des and Doreen - who sat in the court listening intently to the coroner, spent many years fighting for the fresh inquest to be held.
Pte James, from Llangollen, North Wales, was one of four soldiers who died at Deepcut between 1995 and 2002 amid claims of bullying and abuse.
Privates Sean Benton, James Collinson and Geoff Gray also died from gunshot wounds.
Coroner Mr Barker said several reviews and investigations into the culture at Deepcut had revealed "the many and obvious inadequacies and shortcomings" at the barracks.
But he said his findings would only look at criticisms of the culture and command at the barracks in so far as it was linked to Pte James's death. He said:
"Many witnesses had adverse experiences there, but it is outside the remit of this inquest to inquire into events concerning people other than Ms James, or to make findings about other matters."
"For this reason, I've left unexplored many alleged events and shortcomings of the Deepcut regime except where there is some basis for saying they might have been linked to Ms James's death."
Mr Barker said Surrey Police had apologised and recognised that they should have taken primacy of the initial investigation in 1995.
Pte James had been carrying out lone guard duty at Deepcut barracks when she was found dead, a situation the coroner said military rules should not have allowed. He said:
"It seems to me that lone armed guard duty is a potentially dangerous activity."
A policy was in place that meant women should not be left alone on guard duty, but Mr Barker said "there was at Deepcut a wholesale lack of awareness of that provision".
The lack of awareness of the rules was common to both officers and non-commissioned officers, he said, and suggested it was "not an isolated, individual failing".
He said it was "at least arguable" that the potential risk to women on lone guard duty "should have been identified and steps taken to reduce that risk before Ms James's death".
Deepcut barracks failed in its duty of care to its young recruits, the coroner said.
There were far too few officers to train and look after the young squaddies, who were left bored and indisciplined, Mr Barker said. He added:
"The ratio of staff to squaddies was inadequate. While some intermittent training was provided, there were too few permanent staff to deliver it and put into place a structured regime to occupy and meet a duty of care to those young men and women."
One witness told the inquest that Deepcut was like a "sausage machine that had become clogged".
Non-commissioned officers (NCOs) meted out guard duty to trainees as punishment, Mr Barker said, which was against army rules.
One senior NCO described Deepcut as the worst two-and-a-half years of his time in the army, telling the inquest he felt little care was given to recruits.
There was also overwhelming evidence of a "sexualised" atmosphere at Deepcut, Mr Barker said.
Given the "dearth" of a structured life for trainees at Deepcut, he said it was "unsurprising that trainees turned to each other for stimulation".

Deepcut failed in its duty of care to its young recruits like Cheryl James, the coroner said
While sexual relations were not prohibited between trainees, the extent to which they were able to have sex was "inappropriate", he said.
Mr Barker said it would have been "unreasonable" to think Pte James was sexually naive, with evidence showing she had a number of sexual partners from the beginning of her training.
But he said there was "no basis in the evidence" that the army or Deepcut regime sexualised her.
The coroner also found that there was evidence of inappropriate sexual relationships between commanding officers or instructors and trainees.
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."
Bored and without adequate supervision or training from their officers, the young recruits at the barracks turned to sex and drinking to occupy their time, he said.
He criticised the lack of female officers - an Army-wide problem the inquest heard - and the lack of welfare officers and support structures, saying the "haphazard provision of welfare support was insufficient".
Mr Barker said there was evidence that a sergeant, Andrew Gavaghan, shouted at Pte James and made her cry.
But amid suggestions of bullying of recruits at Deepcut, Mr Barker said it was likely that if the incident with Sgt Gavaghan bore any major relevance then others would have come forward, but none did.
Mr Barker said there was no evidence she had spoken to or written to any friends about the encounter with him, and there was "no evidence" that it had played on her mind later in November 1995.

Cheryl James was found dead at Deepcut barracks
Pte James was unhappy in the Army and often spoke about leaving and going awol.
Shortly before her death she spoke about shooting herself, but her friends thought this was just "banter", the inquest heard.
Described as "vivacious and bubbly", Pte James was caught in a love triangle with two men at the time of her death.
She had been in a relationship with Royal Engineer Simeon Carr-Minns but then started a sexual relationship with another squaddie at Deepcut, Paul Wilkinson.
Pte James was the brunt of criticism and labelled "a slag" by some at the barracks, but did not appear overly upset by the remark, the hearing was told.

Four young recruits died at Deepcut over seven years
But she was unhappy and upset by the situation she found herself in, the inquest heard.
The inquest heard a single allegation that Pte James was sexually assaulted during her time at Deepcut.
Fellow squaddie Mark Beard said Pte James was ordered by Sgt Gavaghan to have sex with another soldier, Ian Atkinson, the night before she died. The claim was strongly denied by both men.
Pte Beard told the inquest that Pte James had told him she had been ordered to go into a room with Pte Atkinson, but Mr Barker said it was an assumption that it was for them to have sex.
The coroner ruled his claim "at highest was assumption, at its lowest was fantasy", adding it was "highly unlikely" she would have only spoken to him about it rather than telling her friends or boyfriends. Mr Barker said:
"I find Private Beard's allegation to be wholly without foundation."
And he said it was "most regrettable" that claims made by Pte Beard led to newspaper headlines, with one suggesting Pte James had been a sex slave who was forced to have sex with officers. Mr Barker added:
"On the evidence heard, neither sexual harassment nor bullying were directed at Ms James on her return to Deepcut."
You can find out more about the inquest as it happened here.
Click below, meanwhile, to find out what's changed for today's recruits 20 years on from Cheryl James's death.
Forces TV's Rosie Laydon went to the Army Training Regiment in Winchester, where new recruits now go through basic training.