His comments follow the publication of an interim report into out-of-hours GP care by the Care Quality Commission (CQC), prompted by Mr Gray's death, which found primary care trusts may be failing to spot patient safety issues because of a lack of scrutiny.
He concluded that on the balance of probabilities, the deaths of Ptes Benton, James and Gray were self-inflicted, but he offered no conclusion on the death of Pte Collinson, whose inquest returned an open verdict earlier this month.