Even with the benefit of hindsight, it's hard to identify what more could have been done to prevent the self-inflicted death of a commando suffering PTSD, one of his supervisors has told an inquest.
Sergeant Ian Turner died in his Sydney home in July 2017, after longstanding difficulties with post-traumatic stress disorder and substance abuse.
He had completed seven deployments in East Timor, Afghanistan and Iraq, including two after he was diagnosed with mental health problems.
The inquest has heard his downward spiral began in earnest after a close friend was killed in combat in 2013.
He turned to alcohol and drugs to cope, began abusing his wife and harming himself, the counsel assisting the coroner told the inquest in her opening address last year.
After a suicide attempt in March 2017, Turner was referred to the Human Performance Wing of his regiment.
The inquest will consider whether the defence force, in particular the HPW, appropriately managed his welfare in the lead-up to his death.
The unit was set up to "help commandos rehabilitate back to work or recalibrate into the civilian world", then HPW head Sergeant Matthew Cardinaels told the inquest on Monday.
Turner's estranged wife has previously told the inquest "it's somewhere people go when they broken in the eyes of the army", a suggestion that Sgt Cardinaels rejected.
He said the unit aimed to ensure Sgt Turner stayed physically active, socially connected and had intellectual stimulation while he recovered from his mental problems and decided what to do next.
He was assigned "battle buddies" - fellow servicemen who kept an eye on him and transported him to and from appointments - and was given a welfare plan.
However, in the time he was in the HPW, Sgt Turner was not permitted to travel to Tasmania to visit family, not supported in his desire to undertake PhD study and was frustrated with his welfare plan which a friend complained was "gym and guitar for four hours and nothing to do for the other 20", counsel assisting the coroner and lawyers acting for his family suggested.
He was left without contact from his battle buddies the weekend of his death, despite recently breaking up with his on-and-off girlfriend and needing almost 24-hour supervision the weekend before.
But Sgt Cardinaels contended Sgt Turner's case was incredibly complex, and that so many people had been doing their best to look after him.
Even many of his battle buddies - who were close friends - felt overwhelmed and fatigued, and had to be frequently rotated to preserve their own health.
He pointed to cumulative effects of Sgt Turner's prolonged untreated mental health issues, substance abuse, work stress, his turbulent relationship with his girlfriend, concerns over proceedings with his estranged wife and fear of being cut off from his children.
When prompted by Deputy State Coroner Harriet Grahame to consider the benefit of hindsight, Sgt Cardinaels still said he could not identify things to do better in future.
"There is so many contributing factors to Ian's case," he said.
"It's hard to say if we had have done that, or someone had done that, then this wouldn't have happened.
"I can't say that."
The inquest comes as a royal commission into veteran suicides is set to begin, to probe why the rates of suicide for ex-serving men and women are much higher than in the broader Australian population.
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