Coroner Emma Brown warned more veteran suicides would follow unless changes are made in the way mentally ill military personnel are treated.
She said Dave Jukes, who served in Iraq and Afghanistan, had not undergone an adequate assessment of his mental health, despite being in the care of the NHS.
In a report seen by the Daily Star Sunday, she wrote: “It is possible that a full assessment would have prevented Mr Jukes’ death.”
The Coroner for Birmingham and Solihull added: “In my opinion there is a risk that future deaths will occur unless action is taken.”
The report states that West Midlands Police, who were aware that Dave was suicidal, failed to pass on vital information to a mental health team.
The report lists errors and failings by the police, NHS and mental health teams which ended with him taking his life in October 2018.
He was found hanged at his family home. Police and the NHS involved in the dead veteran’s care now have to respond to the criticism in the coroner’s report within 56 days.
Dave, 49, was a lance corporal in the Staffordshire Regiment and served in Iraq, Afghanistan, Bosnia and Northern Ireland.
He struggled with PTSD after coming back to the UK. After leaving the forces he had flashbacks, nightmares and survivors’ guilt over comrades killed in Iraq.
Since January last year at least 138 veterans and service personnel have taken their own lives.
His widow Jo, 48, said: “The attitude of some of the people who were supposed to be responsible for Dave’s care was appalling.
“The Coroner recognised this. So I have very mixed emotions.”
Less than a month before his death, Dave had sent an email to the NHS Veteran’s Mental Health Transition, Intervention and Liaison (TIL) Service, saying that he felt “out of control”.
His email said: “I seem to be getting worse and it’s starting to worry me. I think I need to be put away before I lose it and do something I don’t want to do.
“I’m finding it so hard to control my thoughts about hurting myself. I love my family but I hate my life. I’m scared and it hurts. I need help.”
Shortly before his death he smashed up his home in Birmingham and barricaded himself in the attic.
Daves’ local NHS trust, Birmingham and Solihull Mental Health NHS Foundation Trust, said: “We undertook a thorough review, alongside the other organisations involved in Mr Jukes’ care, into the circumstances leading up to his death.
“As a result we have already taken a number of actions, including to address issues around record-keeping and communication between agencies and we will respond fully to the further concerns raised by the Coroner.”
A spokesman for West Midlands Police said: “We are satisfied that correct police procedure was followed and acknowledge and respect the findings the Coroner has made.”