Overview

• The coroner recorded an open conclusion after finding no evidence to explain how Mongan died due to the advanced decomposition of his body.
• Evidence showed senior officers had shouted at and assigned punitive tasks to Mongan, behaviour the coroner said caused him distress.
• Mongan’s accommodation went unchecked over Christmas 2019, and his absence was not reported when he failed to join 77 Brigade in January.
• Forensic experts detected barbiturates in Mongan’s system but could not determine whether self-poisoning or a cardiac event caused his death.
• His widow, Beth Mongan, criticised the three-week delay in discovering his body as ‘unforgivable’ and believes bullying drove him to suicide.