On 30 September 2013 commenced an investigation into the death of William Jeffrey MASKELL. The investigation concluded at the end of the Inquest on 3rd December 2015. The details of how the death occurred were: Sometime after 21.18 hours on the 25 September 2013 the Deceased, who suffered from Bipolar mental illness, ingested a fatal quantity of Venlafaxine and Lamotrigine in Room H53, Birks Grange Village, Exeter University_ The conclusion of the Inquest was Mr MASKELL "Took his own life while the balance of his mind was disturbed"

William Jeffrey MASKELL had a history of ongoing Bipolar Disorder: He had previously had to withdraw from University courses because of his mental health problems and on arrival at Exeter on 12 September 2013 (for the second time) , he had a large support network including the University Wellbeing Team and Community Mental Health Services (STEP and CRISIS) and his family who had moved to be close by in initial six weeks_ We were told he was assessed as Low risk for self-harm: Despite this, concerns were raised for his welfare by Rachel Bragg, University Care Coordinator and Wellbeing Consultant; when he did not attend a planned appointment at 12.00 hours on 26 September 2013. The Community Mental Health STEP and CRISIS teams (Devon Partnership NHS Trust) were informed and attempts made to contact William without success_ Eventually (Head of Wellbeing) notified Elizabeth Murphy (Head of Student Support Services) at 17.30 hours on 26 September 2015 and having evaluated the situation (it is common for students to miss appointments) Estates Control were contacted between 18.00 18.15 hours and they went to William's room at Birks Grange. The door was locked on the inside so another updated monitor keylfob had to be obtained to enter the room William was found breathing, but collapsed on the bed; Despite immediate resuscitation attempts, attendance of emergency services (called at 18.24 hours, arrived 18.34 hours) and transfer to hospital, he was declared Deceased, The Cause of Death was la. Venlafaxine and Lamotrigine Overdose_

In my opinion action should be taken to prevent future deaths and believe that Exeter University Wellbeing Services, Devon Partnership NHS Trust (for STEP and CRISIS teams) and Students Union have the power to take such action: It is accepted that if a student is not on campus it may not be possible for "rescues" to be effected but this does not preclude review of systems within the University Halls of Residence_ the