A talented student nurse killed himself just a day after two of his tutors had twice taken him to hospital.
Lugh Shelley, 22, took a fatal overdose before being discovered by a friend who had realised he had not been to class.
But it emerged that the Staffordshire University student had been taken to hospital by tutors on September 4 and 5 last year, an inquest heard.
A consultant has revealed that Royal Stoke University Hospital carried out its own investigation into whether Lugh's death could have been prevented.
Lugh, who was from Lowestoft, Suffolk, was studying nursing practice - specialising in mental health - at the town's Centre of Excellence in Healthcare Education.
He had been identified with bipolar disorder in 2018 and anxiety in April 2019. The inquest heard Lugh had discharged himself on September 4.
In a report, Royal Stoke consultant Doctor Pradep Sundaralingham said: "My investigation was to see if we missed an opportunity to prevent this tragedy.
"On September 4, Lugh turned up to class late and tutors stated he was walking oddly and had slurred speech. The hospital suspected a stroke but a scan of the brain showed it was normal.
"Lugh was brought into County Hospital's emergency department the following day by tutors concerned about his drowsiness. He was complaining of unsteadiness and pain across his lower back.
"Examinations and blood tests were all normal. Lugh said he had no intention to self-harm or end his life.
"He said he was looking forward to completing his mental health degree and helping others. He declined to accept help and his tutors also noted the university could help in terms of counselling.
"He was advised to see his GP and given a number to talk to if he felt suicidal."
Friends last saw Lugh after taking him home from hospital on the evening of September 5.
PC Joe Weaver, from Staffordshire Police, said: "I attended the scene of Lugh's death, there was no suspicion of third-party involvement.
"A friend went to the house on the morning of September 6 after realising he had not turned up to class and she was concerned knowing of his recent hospital visits.
"His door was unlocked and slightly ajar, he was on his bed unresponsive." The inquest heard Lugh had last been seen by his mother 10 days before his death."
She told the inquest: "It's my belief that this was unintentional, I know I think that because I'm his mum, but I think he took one more risk. I'm really unhappy with how he was dealt with at the hospital.
"I saw him 10 days before he died - I feel very lucky to have seen him. He seemed to me overworked, he said he had worked 76 hours in one week because of money, apart from that he seemed well. I actually said to somebody he seemed like a man instead of a boy.
"He was really enjoying himself at Stafford, I'm devastated he didn't have the chance to go on." The cause of death was given as codeine toxicity. South Staffordshire coroner Andrew Haigh ruled that Lugh took a 'self-overdose of medication while unwell'."
He added: "The family cannot accept that Lugh has deliberately taken his life, but I deal with the balance of probabilities, and I feel Lugh has taken his life.
"If I was satisfied it was a cry for help I could record that but I'm not satisfied it was."
In a message to his family, Mr Haigh added: "You didn't anticipate this would happen and I'm very sorry it has."
Staffordshire University has reaffirmed that the mental wellbeing of its students is one of its top prirorities.
Following the inquest, Dr Ann Ewens, dean of the school of health and social care, said: "This was a very sad case and following Lugh's death we put in place additional support for students affected by the tragic news.
"Mental health is a priority for our university and we are working with Keele University, local colleges, NHS trusts and other partners to make sure all students are given access to the support they need."
Following the inquest, Royal Stoke chief nurse Michelle Rhodes said: "We offer our sincere condolences to Lugh Shelley's family at this very sad time and we would, of course, be willing to discuss any aspects of his care while he was with us."
If you're struggling and need to talk, the Samaritans operate a free phoneline open 24/7 on 116 123.
Alternatively, you can email jo@samaritans.org or visit the site to find your local branch.
