A 'first class' pharmacy student was found dead on the morning of an exam he was feeling 'anxious' about, an inquest has heard.
Ben Trueman insisted on studying at the University of Manchester so he could be nearby to his girlfriend - who had moved to Salford from their hometown of Worcester a year earlier.
The 19-year-old student was doing well in his university work, and teaching staff were not concerned about Mr Trueman's mental health, an inquest at Manchester Coroners Court heard on June 1.
But having experienced 'low mood' for five years - followed by the breakdown of his relationship - Mr Trueman was found hanged in his room at Unsworth Park university halls, on Fallowfield Campus.
His father Dr Laurence Trueman appeared via video from the family home, and told the inquest that his son claimed he wanted to 'kill himself' on occasion as a younger teenager.
However, his family thought such comments were being said due to 'teenage bravado' as opposed to any genuine intention.
Mr Trueman completed his GCSEs and A-levels, improving his grades in the second year of sixth form.
Dr Trueman said he had suggested his son tried to apply for universities in clearing that summer, but he instead took a gap year so he could move to Manchester the following year, to be closer to his girlfriend.
"He thought it was a good idea," said Dr Trueman.
"But what actually happened was he spent most of that year pining after his girlfriend. He spent a lot of time in his bedroom, in the dark. We encouraged him to get dress and go out with friends who were still in the area but he really spent much time in his bedroom."
The court heard Mr Trueman secured a place to study pharmacy from September 2019.
Whilst he had a room of his own at Unsworth Park, he spent much of his time living with his girlfriend in Salford.
But Dr Trueman explained that the relationship was struggling, and he received a text from Mr Trueman's girlfriend stating he had been 'in a black mood' and was making threats to kill himself.
Dr Trueman said: "They may have been very much in love, but it was quite obvious that the physical act of living together was not as easy as they had anticipated."
Dr Trueman told the court that in October, while Mr Trueman was at home in Worcester, his son stood at a motorway bridge and had to be talked down.
By December, Mr Trueman's relationship had further broken down.
On December 1, the court heard his girlfriend phoned Dr Trueman, warning that his son was on the roof garden above her flat and he was suggesting he would jump off.
In a call with his parents, Mr Trueman said he had self harmed. His parents rushed up to Manchester and informed the police, who told the family to take him to Manchester Royal Infirmary.
While at the hospital, Mr Trueman admitted to having 'low mood for five years'.
The court heard Mr Trueman had previously self harmed and had taken drugs on occasion - but there was no record of him being asked about either by Abayomi Omolawon, the mental health practitioner who saw him.
Mr Omolawon admitted he 'should have' discussed it and believed he did, but no records were available to prove it, while a review carried out by Greater Manchester Mental Health NHS Trust (GMMH) admitted faults in Mr Omolawon's record keeping.
Coroner Nigel Meadows described it as a 'failure' and confirmed he would write a letter of concern to the trust.
Mr Trueman returned to Worcester over the Christmas period and was 'down in mood'.
The court heard Mr Trueman was sick overnight after Boxing Day and admitted to his family days later that it followed an attempt to hang himself.
He also suffered after a disagreement during a night out for New Year's Eve when his group of friends bumped into his ex-girlfriend, before he was told to 'go away'.
However, Dr Trueman said that his son's mood seemed to have improved in the days that followed, and he was determined to go back and complete his studies in Manchester.
"He sat downstairs with us watching telly, his phone was upstairs which was very unusual," said Dr Trueman. "He was talking about the future, he said to us that his main focus in life was his degree."
Dr Trueman said his son seemed to have enjoyed his first week back in Manchester, but his mood declined the following week and he was feeling 'anxiety' about his upcoming exam on January 22.
The day before, the pair spoke by text, and Mr Trueman told his dad he would 'give it a go'.
But on the morning of January 22, police received a call with concerns for Mr Trueman's welfare.
Greater Manchester Police informed the university and a student accommodation officer visited Mr Trueman's room, where he was found dead.
Police inspecting the scene found a note penned in Mr Trueman's handwriting on his desk.
A toxicology report found a number of drugs in Mr Trueman's system, including cannabis and cocaine, while drug paraphernalia was found by police at the scene.
Dr Simon Merrywest, director for student experience at the University of Manchester, told the inquest that the university had never been warned about Mr Trueman's mental health and his tutors had no concerns.
He described Mr Trueman as a 'gifted student' who was achieving 'first class marks' in his early work, and coroner Mr Meadows accepted: "The university could not have done any more."
Concluding, Mr Meadows ruled Mr Trueman's death had been caused by hanging and was the result of suicide.
"Ben was clearly an intelligent young man and a complicated person," he said.
Mr Meadows added: "He clearly was a very much-loved son and had he carried on with his studies he would have ended up being very successful. The true extent of his mental health problems was never ultimately fully diagnosed."
Following the inquest, Dr Trueman told the Manchester Evening News : "We would like to say that despite all these issues, Ben was a wonderful, bright and handsome young man. We feel that he had a lot to offer in life and that it is tragic that the promise of things to come will not be able to blossom and flourish.
"Although we are heartbroken, we were privileged to have our son and we will always treasure the near 20 years that he was a part of our lives. He was and always will be, a deeply loved member of our family."
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