A Royal Marine Commando who died from a drug overdose after suffering post traumatic stress disorder, did not receive treatment for his illness, an inquest heard.
David O’Sullivan died on October 29 2012 at the University Hospital of North Staffordshire, hours after being found unconscious at his best friend’s house on Abbey Road, Abbey Hulton, Stoke-on-Trent.
Ian Smith, senior coroner for Stoke-on-Trent and North Staffordshire, concluded the 25-year-old died after “a number of failings” over his treatment.
He was deployed on a six-month tour of Afghanistan in 2010 which the coroner described as a ‘pivotal experience’.
During his time in Afghanistan, David witnessed four near-death events and a friend died in his arms.
The inquest heard he did not have access to a consultant psychiatrist while he was suffering from mental health problems.
Mr Smith added: “I am satisfied on the balance of probabilities that had David received the treatment identified the outcome would have been very different.”
Surgeon Commander Rik Coetzee, head of psychiatry for the Royal Navy, told the inquest that there was a “breakdown in communication” and “poor record keeping throughout”.
He said: “It was a difficult system David was put into.”
The inquest also heard that David’s care plan was “fractured and ineffective” and he was showing symptoms of PTSD for some time, but he was not formally diagnosed until shortly before he died.
David’s death was a “catalyst”, according to Surgeon Commander Coetzee, who conducted a review into the case and found there were insufficient staff and resources to deal with him.
He told the hearing major changes had been made in response to the review.
The inquest also heard about devastating effects of post traumatic stress disorder.
Surgeon Commander Coetzee added: “PTSD is like a chameleon – it hides.
“It is like a fire that creates a lot of smoke and people get so blinded by the smoke that they don’t see the fire.”
It can be caused by traumatic life events or experiences, and is common among service personnel following experiences in battle.
It can cause loss of sleep, nightmares, flashbacks and changes in personality.
The inquest heard David had been using heroin for five months before his death.
Surgeon Commander Coetzee added: “What David achieved with the heroin was to wave the smoke away from the fire but the smoke was still there.
“He became reliant on a painkiller.”
David’s use of heroin was not detected by professionals until he was admitted to the Edith Cavell Unit in Cambridgeshire, just 12 days before his death.
Paying tribute to his son, John O’Sullivan said: “David was a hero to our family, he was a nice, kind young man who we all loved, a true gentleman.
“He was a brave and respected Royal Marine and he loved being a Royal Marine.
“We are in agreement with what the coroner has said.
“We feel he didn’t get the help he deserved with PTSD.
“If he had received the treatment he would not have turned to drugs, he was not that kind of young man.”
His widow Tracey O’Sullivan, who he wed just days before he deployed to Afghanistan, said: “He was just such a lovely guy, it was love at first sight.”
Tracey, a soldier in the Army, added: “We do not want anyone else to go through it again.”
Coroner Mr Smith said: “There were a number of failings but they have been acknowledged which hopefully will mean nobody else will suffer David’s fate and that those in the military who do suffer from PTSD will receive appropriate and timely treatment.
“David was a fine young man who suffered emotionally from what he experienced in Afghanistan.
“He was not killed by the Taliban… but ironically the drug which is produced there.”