Video report by Granada Report's Tasha Kacheri
More should have been done to engage with a young army veteran suffering from mental health issues after 'numerous traumas', an inquest has heard.
Ben Riches, 30, was found at his home in Fleetwood, Lancashire, on 11 April 2019, after he had been out with friends.
He had previously made several attempts to take his own life, including walking into traffic and walking into the sea while intoxicated.
His family say more should have been done to help the veteran, and they believe there is a stigma around asking for help with mental health in the armed forces.
Kevin Riches, Ben's father, said: "We tried to get him to engage, to see his GP and phone any mental health services.
"He was of a very strong mind that it was a sign of weakness to ask for help and I have found this is the same with everyone who served in the forces, they all seem to have that mindset.
"I think that is something if we're going to move forward in veteran suicide prevention we have to persuade these people that there is nothing wrong with talking to your GP, there is nothing wrong with making that telephone call, they will feel better when they start talking."
Ben, who joined the army aged 16, serving in Iraq and Afghanistan, was discharged on medical grounds in 2014 after an explosion damaged his hearing.
An inquest into his death at Preston Coroner's Court was told the former Kingsman of the Duke of Lancaster’s Regiment had served as a sniper and with bomb disposal teams during his time in the British Army.
In a statement read to the court, his brother, Stephen Riches, who also served alongside him, said Ben was "very proud of his job", saved lives, and was promoted to Lance Corporal for his work In Iraq and Afghanistan.
During Ben's tours, he faced several life-threatening actions and hostile engagements including being a victim of a roadside bomb - the incident which eventually led to hearing loss.
A number of his friends were also killed during his tour in Afghanistan, the inquest was told.
Stephen said his brother's behaviour started to change after he was involved in a battle where he killed someone, something he said "weighed heavy on his mind".
He said Ben became unreliable, taking more risks, while heavy drinking led to "erratic behaviour" and being demoted at work.
Ben had self-referred to the Army's mental health service, the Department of Community Mental Health (DCMH), after his sister received a worrying message from him saying goodbye to her and her children.
The family then contacted the Ministry of Defence (MOD) to inform them they thought Ben was suffering from Post-traumatic stress disorder (PTSD).
Sergeant Captain Darren Marshall, defense consultant psychiatrist from The Ministry of Defence (MOD) - the highest ranking psychiatrist in the MOD - said Ben's medical records from when he was still in the army, show he had subclinical symptoms of PTSD and an alcohol misuse problem.
Ben was taken off normal duties for six months while he worked with the DCMH, and by the end of the six-month period Ben had halved his drinking and his PTSD symptoms were no longer present, the inquest heard.
The soldier was discharged from the army in 2014 on medical grounds after an IED attack gave him permanent hearing loss, the court heard it was "a traumatic time for him".
Ben was further traumatised by a fire at his house in 2015 which left him with severe burns on his head, neck, back, and hands.
He was in a coma for weeks and spent months in hospital.
When asked, the inquest heard, the veteran told clinical psychiatrist Julie Wisely a specialist at Wythenshawe Hospital's burns unit he did not need any support for past trauma he identified.
Ms Wisely said she referred him for support anyway, but added that Ben did not report any symptoms of PTSD.
The inquest was told after each of Ben's attempts to take his own life he was taken to hospital under The Mental Health Act for an assessment.
But, each time the mental health professional in charge discharged him a few hours later, stating they had no grounds to detain him.
Many of Ben's attempts were made while under the influence of alcohol, the inquest heard, but, once sober, doctors said he was no longer agitated, had future plans and had no desire to take his own life - sometimes even denying efforts of suicide.
After Ben attempted a second time to take his own life by walking into the sea, he was called by mental health nurse Helen Bailey from the Home treatment and crisis team.
He denied thoughts of suicide on the call, but accepted he needed support for his drinking, which had been an "issue" and had "made him impulsive".
He also said he thought he had not addressed any trauma, but, Ms Bailey said, it was mainly the PTSD which he had eluded to in the conversation.
Ms Bailey said Ben had no suicidal thoughts so she referred him to a mental health triage service called Single Point of Access and gave him information on how to seek further help.
But, her referral was never picked up as the email was sent to an unmanned, deactivated email address.
Throughout the inquest, the court heard from Ben's Family and other healthcare professionals that he reported symptoms of PTSD.
HM Senior Coroner Dr James Adeley asked expert witnesses Professor Eilish Gilvarry, a consultant psychiatrist and professor of Addiction Psychiatry at Newcastle University, and Dr Sarah Troughton, an Addiction Psychiatrist with expertise in treating veterans if they thought Ben had PTSD.
Dr Sarah Troughton said Ben did not meet the full criteria for a PTSD diagnosis, but went on to say the impact of his leaving the military had been underestimated.
She said the loss of identity, his network, and his friends would have had a significant impact on him.
She added the house fire would have been another traumatic time in Ben's life, and in 2019 he was diagnosed with sarcoidosis, a lung condition that would have been a further impact on Ben as he lost the ability to lead an active lifestyle.
Both professionals acknowledged Ben may have minimised his symptoms as "veterans tend to minimise symptoms" due to stigma, fear, shame, and loss of control.
Both experts pointed to depression related to leaving the army, and Ben's increased drinking as well as his multiple traumas.
Dr Sarah and Professor Eilish said it would have been illegal to detain Ben on all occasions he was assessed in hospital after attempting to take his own life as he was capable of making decisions, even wanting to follow up and access help.
However Professor Eilish said there should have been more effort to engage with Ben after his phone call with Ms Bailey as he had already had "six significant episodes of contact, all had significant suicidal ideations".
She said there should have been more discussions with Ben's family.
Lancashire and South Cumbria Foundation Trust (LSCFT), who looked after Ben on all occasions, has done a review into Ben's care.
It said their referral system has now changed as Ben was referred to Single Point of Access, but that referral did not go anywhere.
Julie McLardy-Smith, from LSCFT, told the inquest there had been significant changes to how referral systems worked.
She added that Single Point of Access will be replaced with a referral system that meant the Trust could refer patients instead of them having to self-refer for help.
Ms McLardy-Smith said LSCFT now had a veterans service and veterans with mental health issues were now fast-tracked for support.
Coroner Dr Adeley concluded Ben took his own life at his home on 11 April 2019.
He went on to say: "Ben's death is a tragedy for both himself and his family".
He continued: "The fact that so many family members have attended [the] entirety of this inquest indicates how much Ben was loved and is still missed."
Ursula Martin, Executive Director of Improvement & Compliance at Lancashire and South Cumbria NHS Foundation Trust (LSCft), said: “We fully accept the Coroner’s findings following the conclusion of the inquest into the death of Mr Ben Riches.
“We carried out a review into the care given to Mr Riches in 2019 and have since made a number of improvements following learning from this sad incident. This includes the implementation of a policy and procedure to ensure any referrals of veterans are expedited, so that they are assessed as quickly as possible.
“The Trust has introduced a dedicated Veterans Team to provide specialist mental health care and support for a range of conditions including post-traumatic stress disorder. We remain fully committed to supporting the Armed Forces Covenant to ensure appropriate care is provided to the veteran community.
“We once again offer our sincere condolences to Mr Riches’ family and friends.”