Tracy Clark had understandably mixed emotions when her 18-year-old son, Connor MacKenzie Clark, packed his bags and left home to take part in a training course for the Royal Marines. “It felt nerve-racking, really awful in a way, but I was so proud of him for having the courage to chase his dream,” Tracy told the Guardian. “I thought he was physically and emotionally strong enough. He was nervous but incredibly excited.” Tracy said her son went into the four-week recruitment orientation phase (ROP) course with his eyes open, conscious he would be challenged by some aspects such as “personal administration” – keeping uniform, kit and locker in pristine order. “He said: ‘Mum, I know my ironing’s rubbish but they’ll teach me how to do it.’ I asked him: ‘Connor, are you sure about this? Are you sure of the Royal Marines?’ He said: ‘Yeah, absolutely.’ “I said to him: ‘What if it doesn’t work out?’ He said: “Oh mum, my plan B is to be a police officer, or join the fire service.’ We used to always say: ‘Don’t forget, you’ve got a plan B.’ Unfortunately, he forgot.” On 12 June 2021, 19 days into the course, Connor was found dead on a railway track two miles from the commando training centre in Lympstone, Devon. He had scaled the perimeter fence, using a duvet to get across the razor wire, and was struck by a train. Since then, Tracy has battled to unearth what she calls a “perfect storm of failings” that led up to her son’s death. During Connor’s inquest in Exeter, it emerged he believed instructors had told him he was a “failure” and the “worst recruit”. The inquest heard he and his fellow trainees were subject to “thrashings” – bouts of high-intensity physical activity dished out as punishments – and were harshly sworn at. The inquest was told that a few days before he died, Connor self-harmed, opening up a cut on his arm, and had gone to the sick bay. The medic had not flagged up what had happened to the trainers. The search for Connor when he was discovered missing from his room was flawed, with one senior officer admitting he could not understand how a recruit – a “member of our family” – had been gone for so long without an effective hunt taking place. “I was shocked and beyond hurt when I found out what happened,” said Tracy. “They call it a brotherhood. It’s easy to be a brotherhood when everything’s going right. And when everyone’s strong. A brotherhood is actually just opening your eyes and looking deeper.” Tracy described Connor as kind, generous, thoughtful and selfless. Cherished memories include him teaching Maasai children to play rugby while on a safari and sticking up for a schoolmate when she was bullied. He decided aged 13 that he wanted to join the marines. “You could have knocked me over with a feather,” Tracy said. “But he was very determined and liked to push himself.” Connor, who was from Norwich, trained hard and during the Covid lockdowns would run barefoot for 10 miles along the coast and break the ice with his mother, a cross-Channel swimmer, on the Norfolk Broads so they could take a dip. “We would warm up in the car drinking green tea and honey,” she said. Tracy felt he was ready for the physical challenges of the ROP, which marines undertake before initial training and is set up as a transition from civilian to military life, but it soon became clear he was struggling. “I talked to him probably at least every second day. He said: ‘I’m tired, I’m exhausted.’ He was staying up until one, two in the morning to do personal administration. I think because he was exhausted, he was getting more and more and more things wrong.” She did not say he was bullied and did not have a particular problem with the industrial language used by trainers but felt that they needed to be more alert to crises. “They said the door’s always open but maybe it’s the first experience away from home for some of these recruits. They may not go and seek help. It needs to be the other way around. It is a failing on their part to not have that safety net, not to check in on him.” What appears to have been a cry for help came when he self-harmed. Tracy said: “That was Connor’s way of seeking help. He should have been put in a safe place.” Surgeon commander Jon Bedford told the inquest he made a “poor and wrong” decision by not telling the training team what had happened. Clark’s roommates reported him missing at about 5.50am but it was several hours before the emergency services were called. Tracy believes the search outside the wire should have started sooner and if the emergency services had been called earlier, a go-slow could have been put on the train line. “That is really shocking,” she said. She has spent the three years since her son’s death fighting for answers. “This has to mean something. Change has to be made. I hated the marines at first but I don’t now. I’m angry at the failings. It’s a collective issue. There was a perfect storm of failings. “It keeps coming back to the duty of care. That duty of care wasn’t followed in so many ways. I entrusted my 18-year-old son to them. And they let us down.” Tracy said her overriding emotion remained pride. “I’m so proud of Connor for chasing his dream, as tragically as his dream ended.” In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counselor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org