The Army missed opportunities to prevent the suicide of a "positive and bubbly" officer cadet at the prestigious Sandhurst military academy, an inquest has found.
Olivia Perks, 21, was found dead in her room at the elite military training school in Berkshire on February 6 2019.
Coroner Alison McCormick recorded a conclusion of suicide at the end of the inquest on Friday.
She said the army missed an opportunity to get Ms Perks seen by a doctor after the Falklands Ball on February 1 2019, after which she slept in a colour sergeant’s room.
The fact stress was a factor that placed Ms Perks at higher risk was also not passed on to the chain of command after her first term, meaning they were less likely to believe getting her seen was necessary.
The coroner said: "The risks to Olivia were not managed in accordance with the Army policy for the risk management of vulnerable people.
"There was a missed opportunity by the chain of command to recognise the risk which the stress of her situation (after the Falklands Ball) posed to Olivia and a medical assessment should have been, but was not, requested.
"It is not possible to know what the outcome would have been had a medical assessment taken place, but it is possible that measures would have been put in place which could have prevented Olivia's death.
"It is my hope that Liv’s legacy will be an Armed Forces where the welfare of everyone is properly safeguarded… by embracing those qualities that so defined Liv, of positivity, hard work and determination."
After the inquest, her mother Louise Townsend said the coroner’s findings were "very different" to the story the Ministry of Defence had told her relatives following her daughter’s death.
In a statement issued through her solicitor outside court, she said: "The maternal family of Olivia welcome the findings of the coroner's inquest into her tragic and unnecessary death.
"The last four years have been the hardest and most difficult journey we could have embarked upon: to lose our wonderful, vivacious and captivating girl, in circumstances which we now know were avoidable.
"We have been fighting for the truth of what really happened since she passed, and the story we were presented with at the start of this process by the Ministry of Defence was very different to the conclusion that has now been reached by the coroner."
The inquest at Reading Town Hall, which took place over 16 days, heard Ms Perks fell victim to a "complete breakdown in welfare support" during her time at the academy.
She tried to take her own life during a Royal Engineers visit in July 2018 but was deemed at "low risk of reoccurrence" after.
She was back on duty two days later and warned she risked losing her place at the academy if she engaged in similar behaviour again.
The inquest was told Sandhurst had an "irresponsible" lack of welfare support despite being rated outstanding by Ofsted three times before the tragedy.
It had just one welfare officer for 2,500 people according to Lieutenant Colonel Rupert Whitelegge, who was commander of the academy’s Old College at the time.
Witnesses told the hearing that during the Royal Engineers visit, Ms Perks had confessed that she wanted to kill herself.
She had been in a banned relationship with then staff sergeant Mark Easingwood, who worked as a fitness instructor for cadets, in the months before she died.
Sophie Given, whom Ms Perks had met on a dating site, told the hearing her friend told her she "may be pregnant" with a staff sergeant’s baby.
He told the hearing they "kissed once" and had "an emotional bond" but denied their relationship was sexual.
After the Falklands Ball, she spent a night in Colour Sergeant Griffith’s room.
The pair denied sexual activity had taken place, claiming the colour sergeant had invited her in out of concern for her welfare and she had slept there.
After she was seen leaving in her ball gown from the night before she was told "my office now" by the regimental sergeant major and later missed a parade.
She felt an "overwhelming sense of embarrassment" as she felt she had got the colour sergeant into trouble and feared losing her place at the academy.
In the days before her death, friends told the inquest she felt like she was "on trial" as the academy’s leaders questioned her about the incident and rumours about it spread on WhatsApp.
One staff member told her she had "had enough male company" as she was being informally questioned about that night by a largely male group.
In a letter to her mother, which was found in her room when she died, she said she "just can’t deal with the false rumours which have ruined my army career."
Speaking outside court following the inquest, the academy’s commandant, General Zac Stenning, said: "We are deeply sorry for the systemic and individual failings within the Royal Military Academy Sandhurst which led to the tragic death of Officer Cadet Olivia Perks in February 2019.
"Much more should and could have been done to support her. As an organisation we should have been better.
"I have promised to commit to a culture of continuous learning to ensure Sandhurst remains a safe and positive training environment for our future leaders.
"Nothing less is acceptable."
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