A senior coroner told the University of Southampton 'more could have been done' to support a promising student who killed himself on the day his exam results were due to be released.
Engineering student Matthew Wickes - who was autistic - fell 'further and further into crisis' before taking his own life because he was worried he'd failed his third year, it was heard.
The 'highly intelligent' 21-year-old had been on track for a first class degree before his academic scores saw a 'big drop off' and a 'ticking time bomb' countdown began in his head until his results were published.
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The inquest heard Matthew, who was studying electrical engineering and may have been suffering from long covid, missed several meetings with his project supervisor and then submitted work he felt 'did not cut the mustard'.
Thinking he would not have enough credits to pass the year and with an 'innate fear of failing', Matthew, who was captain of the university's archery team, did not sit his two summer exams.
On the eve of results day, he left his girlfriend's accommodation before jumping from a bridge in Southampton.
Despite the best efforts of emergency services, Matthew was tragically pronounced dead at Southampton General Hospital in the early morning of June 30 last year.
At Winchester Coroner's Court, Hants, senior coroner Christopher Wilkinson concluded a verdict of suicide and said he would issue a Regulation 28 'prevention of future deaths' report to prevent other students falling 'between the stalls'.
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Mr Wilkinson suggested it was necessary to develop an 'early warning system' to help identify struggling, vulnerable students.
The inquest heard Matthew's autism diagnosis only came in November 2019 - while already at Southampton - so the university did not know of his condition.
Originally from Carnforth, Lancs, 'highly intelligent' Matthew initially coped well with university life, according to his father, Stuart Wickes, despite not telling the university of his neurological condition.
In a statement read out to the court, Mr Wickes said: "Unfortunately it came too late to register on his UCAS form.
"Despite experiencing social anxiety he showed a strong independent streak and seemed to like operating independently."
His parents said their fears were 'put at rest' as he appeared to be 'thriving' and was looking to pursue a career in AI or robotics.
However, his second and third years were blighted by Covid and resultant lockdowns, leading to a 'lowering' in social confidence which he had helped build up in his first year.
When Matthew 'avoided' answering questions about his third year summer exams and had not applied for student finance, his parents' concerns grew.
Mr Wickes said the looming results day would have been a 'ticking time bomb' for Matthew, as he had seen a 'big drop off' in his score.
The inquest heard Matthew missed meetings with his project supervisor in January and March before further meetings and exams in May - but only received email correspondence as a form of contact.
The hearing was told Matthew 'struggled with tiredness' after recovering from Covid which he and his girlfriend Niambh Jones caught in March 2022.
Ms Jones described him as a 'kind and thoughtful person', and told the inquest: "It was quite difficult to manage things because of low energy levels. I think it was since then his mental health took a decline.
"He found it exhausting being in his own brain and he found it difficult to manage his thoughts."
On his exam stress, she said: "He and his friends take a lot of pride in their brains - they're high achievers.
"There must have been some sort of pressure about not getting those grades, not wanting to admit to failing or doing badly."
Professor Tim Norman, head of school at the University of Southampton, said Matthew wouldn't have known for sure he had failed until results were published on June 30, but accepted he would have had an idea.
Giving evidence, Prof Norman admitted the university could 'join the dots' better between academic progress and pastoral care after Matthew's non-attendance was flagged in April by student support but not followed up.
Delivering a verdict of suicide, Mr Wilkinson said a 'number of factors' had developed in Matthew's third year of university.
He said: "Firstly, Matthew succumbed to a Covid infection in March 2022, which affected him quite significantly with difficulty sleeping, excessive tiredness - it is more likely than not that he suffered from long Covid."
The coroner said this caused 'brain fog' and affected his ability to perform academically.
"Despite no clear indication from the university or tutors he was failing, I believe Matthew - being the intelligent person he was - had started to put two and two together and realised the project was not going to reach the mark he required."
He said he believed Matthew had an 'innate fear of failure' and fell 'further and further into crisis' before taking his life.
On the university being unaware of Matthew's autism, he continued: "In not knowing that condition, the university were at a loss to knowing if he had a specific disabilities and could have provided help.
"That said, with the benefit of hindsight more could have been done to Matthew to follow up on evident falling behind and failures to attend meetings and examinations.
"I have taken on board the academic process but that human side should have indicated a student in need and perhaps should trigger a means in which somebody reaches out to them.
"That is something that could and should change."
While he said he was 'heartened' by steps already taken by the university since Matthew's death, he said he would issue a Regulation 28 report 'to give focus and impetus' to services already in play.
He recommended developing an early warning system so other students don't 'fall between the stalls' and a 'simple, pragmatic way' that will allow contact with an absent student, even just to say 'are you okay?'.
Mr Wilkinson also highlighted need for staff awareness and training as well as rigorous record keeping of third year major project meetings.
In response, Professor Deborah Gill, Vice-President of education at the university, said: “We were deeply saddened by Matthew’s death. The death of a young person is always a tragedy, and our thoughts remain with his family, his friends, and all those who knew and loved him.
“We are fully committed to providing our students with the best possible support during their time here. This includes providing mental health training for our staff, providing 24/7, 365-day access to in-person support so that students can reach out themselves, or on behalf of their friends, and working closely with local NHS partners and charitable organisations to facilitate access to specialist support.
“Plans are already in place for the start of the academic year for a new system to identify changing patterns of attendance at timetabled taught sessions, with the aim of providing further opportunity to identify and support students.
“We will take on board the coroner’s comments and his acknowledgement that the University is continually taking steps to evolve the wellbeing support we provide. We will of course reflect on and respond to any formal guidance once any further report has been received.
“Above all, we will continue to give our students the encouragement and confidence to reach out, as there is a huge array of support we can put in place immediately.”
Call Samaritans on 116 123 for support.
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