Olivia Perks, 21, was found dead at the elite military training school in Berkshire on 6 February 2019.

Coroner Alison McCormick said the army missed an opportunity to get Ms Perks seen by a doctor after the Falklands Ball on 1 February 2019, after which she slept in a colour sergeant's room.

The inquest at Reading Town Hall heard Ms Perks fell victim to a "complete breakdown in welfare support" during her time at the academy.

The coroner said the chain of command missed an opportunity to get Ms Perks seen by a doctor after the ball.

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.

After the inquest, her mother Louise Townsend described the last four years as the "hardest and most difficult journey" and that the story presented by the Ministry of Defence was "very different" to the coroner's conclusion.

'Possible that measures put in place could have prevented death'

Ms McCormick 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."

The inquest heard Ms Perks had felt an "overwhelming sense of embarrassment" after an incident at a ball five days before she died and was scared she was going to be kicked out of the college.

It also heard she had previously attempted to end her life in July 2018 but was deemed low risk of reoccurrence.

The inquest heard no one in the chain of command was shown a risk assessment, which warned she may be dealing with a "severe level" of stress and be too embarrassed to seek help.

Ms Perks was warned at the time she could face the sack if her behaviour was repeated and returned to duties two days after the incident.

Coroner's findings were 'very different' from MoD's story

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.

Ms 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 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 army said it is "deeply sorry" for the "systematic and individual failings" at Sandhurst which led Ms Perks's death.

The academy's commandant Major General Zac Stenning added: "Much more should and could have been done to support her. As an organisation we should have been better."

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