A student who suffered from bipolar disorder and anxiety took his life one day after tutors took him to hospital over concern for his wellbeing.
Lugh Shelley, 22, from Lowestoft, took a fatal overdose after his tutors took him to hospital twice in two days.
Mr Shelley was studying nursing practice and specialising in mental health at Staffordshire University.
An inquest in South Staffordshire heard he was discovered by a friend who was concerned the student was not attending lectures.
It emerged the student's tutors had taken him to hospital on September 4 and 5 of 2019. He died on September 6.
A consultant revealed Royal Stoke University Hospital carried out its own investigation into whether the death was preventable.
The inquest heard Mr Shelley suffered with mental ill health since 2018.
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 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."
Mr Shelley was last seen on September 5, when friends took him home from hospital.
The inquest heard he had last been seen by his mother 10 days before his death.
Lugh's mother 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."
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."
Following the inquest, Dr Ann Ewens, dean of Staffordshire University's 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.
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