A coroner has called on the Ministry of Defence (MoD) to review its care for vulnerable soldiers after he ruled that bullying, the "lingering" mental effects of an alleged rape, "work-related despair" and a romantic break-up were all factors in the death of a soldier who committed suicide in an Army barracks.
Nicholas Rheinberg concluded that Corporal Anne-Marie Ellement hanged herself at Bulford Barracks in Wiltshire, two years after she alleged that two soldiers raped her while she was stationed in Germany.
But Mr Rheinberg said at the inquest in Salisbury that, although the care given to Cpl Ellement in the aftermath of the allegation had been of "high quality", the transfer of information when she returned to the UK had been "unforgivably bad".
He said he would be recommending to the MoD that it review its Suicide Vulnerability Risk Assessment procedures and ensure that medical personnel are regularly given refresher training.
In a statement read outside court, Cpl Ellement's family said they welcomed the coroner's conclusions and recommendations.
Her sister, Sharon Hardy, said: "The family are delighted with this verdict we have today.
"The coroner has confirmed what we have always known - that Anne-Marie was treated appallingly and let down by the Army.
"She was never able to recover from the allegation of rape she made in Germany.
"She then suffered bullying by the Army and was subjected to unacceptable work practices.
"Victims of sexual abuse in the Army need proper support, which the coroner has recognised, and we are delighted with his recommendations."
Cpl Ellement, 30, was found dead at Bulford Barracks near Salisbury in Wiltshire on October 9, 2011.
The three-week inquest heard that Cpl Ellement alleged she had been raped by two soldiers in November 2009, while she was posted in Germany but had been left "absolutely devastated" by the decision taken by military investigators not to prosecute them.
Mr Rheinberg said: "It is not the function of this inquest to make a determination whether Anne-Marie was raped, that may be for another court to determine, nevertheless I find as fact that Anne-Marie believed she was raped and was deeply affected by what for her was a deeply humiliating experience."
He ruled that although the MoD had a policy in place for caring for victims of alleged sexual assaults within the Army, a review was needed to ensure that all steps were taken to support the victims, particularly in cases where the allegation was made against a colleague.
He explained that although Cpl Ellement was placed on the Army's sexual vulnerability risk assessment register, this information was not transferred to her medical professionals when she was brought to the UK.
He said: "I find the welfare provided in Germany was good but the transfer of information unforgivably bad."
He added: "I have concerns in relation to the support and welfare support given to a soldier following an allegation of sexual assault.
"There is an existing code of practice on services to be provided by the armed forces to victims of crime and sexual assault, I ask that that code of practice be reviewed."
However, Mr Rheinberg said that he felt this issue was not a significant factor in Cpl Ellement's death because she had shown an improved state of mind upon her arrival at Bulford.
Mr Rheinberg ruled that there were two periods when he believed that Cpl Ellement had been subjected to bullying.
The first was by the girlfriend of one of her alleged rapists who Mr Rheinberg said directed her anger at the incident at Cpl Ellement.
He said: "I find as a fact that deliberate action was taken to make Anne-Marie's final days in Germany uncomfortable and the actions and that deliberate action was harassment."
He said it was "unduly optimistic" of her superiors to keep Cpl Ellement and those who accused her of lying about the rape within the same accommodation block without trouble occurring.
The other incident of bullying that Mr Rheinberg identified was in 2011 at Bulford when Cpl Ellement's superior officer, Staff Sergeant Julian Clark, made a posting on Facebook deriding the quality of work that he was inspecting.
He said that Cpl Ellement believed this criticism identified her shortcomings to her colleagues and was something that troubled her "again and again".
He said: "I find it was inappropriate for a senior NCO (non-commissioned officer) to make a posting about a junior NCO on a social media website and further inappropriate to have friends who were junior NCOs able to read the posting.
"Although not imbued with evil intent, it resulted in bullying."
Mr Rheinberg said that the other factors involved in Cpl Ellement's suicide was her perception that she was over-worked.
He said that although she reported that she had been working up to 90 hours in a nine-day period in the weeks prior to her death, she was liable to "exaggeration".
He explained although he did not feel the MoD had over-worked her, Cpl Ellement was feeling stressed about her job and was suffering from "work-related despair".
Mr Rheinberg said the other significant factor was a recent relationship breakdown with her sending messages speaking of her sense of betrayal to her former boyfriend on the day that she committed suicide.
Mr Rheinberg also explained how Cpl Ellement had suffered sexual abuse and bullying as a child including being raped at the age of 18.
He said that she continued to complain of bullying both in civilian life and when she joined the Army, which had been a lifelong ambition.
He said that she suffered "poor body image and low self-esteem" and their was a "correlation between her physical and mental health".
Mr Rheinberg explained that she was diagnosed as suffering from depression in 2009 and was prescribed anti-depressants.
A previous inquest in March 2012 recorded a conclusion that Cpl Ellement, originally from Bournemouth in Dorset, took her own life.
But last August, the High Court ordered a fresh hearing, which began in Salisbury on February 3.
During the inquest, Cpl Ellement's family claimed she had felt bullied by colleagues and without support in the Army.
Her sister, Sharon Hardy, 44, a married mother-of-four from Christchurch, Dorset, told the inquest: "When she died, my immediate thoughts were the Army, the rape, the bullying and the overwork."
The hearing was adjourned last week after the court heard an inventory listing items including three mobile phones and a pink diary found in Cpl Ellement's room had been discovered by the MoD.
But in a statement given to the court, Cpl Ellement's father confirmed that he had received the items including the diary and five mobile phones.
He said that he had passed on the diary to Cpl Ellement's mother Alexandra Barritt and he had disposed of most of the mobile phones because of their age but had held on to her iPhone.
Following the inquest, Brigadier John Donnelly, director of personnel services for the MoD, said: "The Army deeply regrets the tragic death of Cpl Anne-Marie Ellement and although there were aspects of her care that were praised, I want to apologise to her family for the failures that the coroner has identified.
"This second inquest has been an extremely thorough investigation by Her Majesty's coroner and Anne-Marie's family has shown great dignity throughout. We now have a clear understanding of the complex circumstances surrounding her death and where the Army needs to learn lessons.
"Our priority is to study the coroner's conclusions and then identify what further steps can be taken, to help prevent a recurrence of this kind of tragedy in the future. At present, however, our thoughts and sympathy lie with Anne-Marie's family and her friends at this difficult time."
Emma Norton, legal officer for human rights charity Liberty and the lawyer representing Cpl Ellement's sisters, said: "Soldier or civilian, your human rights require protection.
"Yet the Army failed this vulnerable, traumatised woman at every stage: an incompetent rape investigation coupled with a chain of command that repeatedly overlooked serious bullying and ignored her suffering.
"As long as the military investigates itself, this risks happening again. The coroner recognised the terrible failings in Anne-Marie's case. Now we need real reform."