A "loveable" Liverpool University student was found dead after suddenly running off into the night.
Yousif Kadhim, 22, died after being hit by a train at Hythe Station in Colchester in the early hours of August 21, 2021.
His father Dr Abbas Kadhim said: "Yousif was a polite, respectable, intelligent, sociable, perfectionist person. He was loveable, supportive, kind, and loved music and theatre. He was looking forward to finishing university and finding the right job in the future.
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"He liked reading and writing, he liked music and art, especially musical theatre."
Yousif, who lived on Hartington Road, Toxteth, had been visiting friends in the area when he fell into a depressed state and started having thoughts of self harm at around 11.45pm on August 20.
His friends called NHS 111 for help - but during the call, Yousif ran off into the night without his coat or shoes, and his friends were told to call back when he returned.
Instead, they called police and searched for Yousif, but were unable to locate him.
At around 6.20am the following morning, officers found the body of a man on the tracks at Hythe Station, which they were able to identify as Yousif.
The train driver, Steven Wigfield, said he had no idea his train had been involved in an incident until after Yousif's body was found.
At his inquest today, October 6, coroner Anita Bhardwaj heard that the East of England Ambulance Service introduced new rules in September last year instructing staff to contact police when an at-risk patient absconded during a call, instead of simply dropping the report.
She said: "When it was known that Yousif had run off, it would have been good practice for the ambulance service to contact the police, as this could have been a missed opportunity. However, fortunately his friends contacted the police themselves."
Business student Yousif, who was born in Libya and moved to England when he was three, had a history of anxiety and depression, and had been provisionally diagnosed with bipolar disorder.
In 2018, he told Liverpool University student services that he had a number of ongoing mental health issues, and that he was taking antidepressants. In 2019, he told his father that he had been suffering from anxiety, stress and insomnia.
He approached Mersey Care NHS Foundation Trust in early 2020, where he told nurses he had "never felt happy" and that he "felt like an outsider." The service made arrangements for blood tests and an ECG scan to be carried out to assess what medication he should be put on, however, he was reluctant to have these tests carried out, and so the assessment was not completed.
He missed two appointments, and when the Trust contacted him in March 2021 he told them "his needs were being met, he didn't need anything else and he was fine."
On August 10, Yousif spoke to Dr Markos Bakalis at his GP surgery, Brownlow Health, who changed his twice-daily dose of antidepressants to a single large daily dose, and recommended beta blocker medication for his anxiety.
He said: "He told me that over the last two months he had deteriorated, with no specific trigger. He told me he was very low, struggled to go out, was not eating well, and was anxious. He admitted having suicidal thoughts, but he clearly was not suicidal when I spoke to him."
Dr Diane Exley, who spoke to Yousif at a follow-up appointment on August 18, also did not believe he posed a serious risk to himself.
Handing down a conclusion of suicide, Coroner Bhardwaj said: "I'm of the view it's more likely than not that Yousif placed himself before an oncoming train with the intention of taking his own life."
- The Samaritans helpline can be reached 24/7 on 116 123. If you prefer to write down how you're feeling, or if you're worried about being overheard on the phone, you can email Samaritans at jo@samaritans.org.
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