The body of L/Cpl Bernard Mongan was discovered in his barracks three weeks after he went missing.
An Army investigation into the unexplained death of a British soldier has identified serious failings in its duty of care.
The decomposing body of Lance Corporal Bernard Mongan was discovered in his barracks in Catterick, North Yorkshire, on 23 January last year.
He had been missing for three weeks without anyone noticing.
The Army said the delay in discovering he was dead was “unacceptable and profoundly regrettable”.
The BBC has seen a copy of the Army’s Service Inquiry Report into his death.
The report, which has not yet been made public, says that “failings in the proper management of personnel led to the delay in the discovery of L/Cpl Mongan”.
The report also shows that L/Cpl Mongan’s complaints of bullying and concerns about his welfare had not been properly investigated or passed on. The panel which carried out the inquiry concludes that its report “makes for sobering reading”.
The Royal Signals soldier, who had served in Iraq, had been spending his Christmas leave in his room at Catterick Barracks, but was due to start an attachment with the Army’s 77 Brigade in Berkshire on 7 January 2020. But neither camp noticed that he was missing.
While duty officers in Catterick had been told to contact those remaining in the barracks over the Christmas period to “ensure they are safe and well”, the inquiry found the plan had “not been communicated and implemented as effectively as it should have”.
There was no roll call or head count at Hermitage Camp in Berkshire, when L/Cpl Mongan was meant to turn up for work in the new year. The report says it is “distressing” that his absence was not noticed by the units involved.
Before his death L/Cpl Mongan had complained that he was being bullied. He had kept a record of his “perceived mistreatment”. The inquiry panel found there had not been a proper investigation into the allegations.
Mongan was also a victim of a serious assault in Catterick in November 2018 which was being investigated by the Royal Military Police. Support for the victim was “not effective”, the report says.
There were also welfare and medical concerns surrounding the soldier which were not properly recorded or relayed. In 2016 it was reported he had made “an attempt on his own life”. While this was addressed at the time the information was not passed on.
As recently as 2019 he was described as being in an “emotional state” – with one witness saying he found him “sat on his bed… uncontrollably crying”.
The report has been seen by his wife Beth. In a statement she said “it’s clear Bernie felt bullied and his mental health suffered”. Though separated, the mother of his three children had kept in contact.
She said “he was telling people he was afraid and he was not checked properly in the days before he died”.
Emma Norton, who runs the Centre for Military Justice, said the failings bear a striking similarity to other cases. She said the death of Cpl Anne-Marie Ellement in 2011 also showed the Army’s failure to properly transfer information about her potential vulnerability.
“Despite all the reassurances to the family in that case… the Army now appears to admit that the same thing happened to Bernie,” she said.
In a statement, Brig Edward Chamberlain, head of the Army Personnel Services Group, said: “There were clearly failings in our duty of care to Lance Corporal Mongan.
“The delay in discovering he was deceased was unacceptable and profoundly regrettable. We are truly sorry that such a situation should have arisen.”
He said the wellbeing of members of the armed forces was “critical”, adding: “In this case, we fell short of the standard which our armed forces and their families are entitled to expect, and for that we apologise.”
“We will implement all the recommendations in the Service Inquiry to ensure an incident like this does not happen again.”