The body of a man described as "a beautiful soul" was discovered in a park by horrified fellow students, an inquest has heard.

Fakhar Zaman, aged 29, was found dead in woodland in Maindy Park, Cardiff. He had been grieving the death of his mother and was stressed about his university work, his brother Kumar Zaman said.

The University of South Wales MA student had been in touch with university counselling services, his GP, the NHS emergency phone service for urgent mental health help and been seen by A&E mental health nurses at the University Hospital of Wales between May and August 2024 when he died. But he was not deemed at immediate risk, the hearing at Pontypridd Coroner's Court on December 11 was told.

Although he told services he had suicidal thoughts, and later that he had attempted to take his own life twice, he said he would not go through with it.

His brother Kumar accused mental health services of "negligence" saying they should have taken his brother's mental health symptoms, including claims of two previous suicide attempts as well as suicidal thoughts, more seriously.

Fakhar, an international student from Pakistan, who had no family in Cardiff, told mental health services that his religion forbade suicide and he would also not do it because of the effect it would have on his brother.

Witnesses from USW mental health services and the Cardiff and Vale University Health Board, told the hearing that while he reported barely sleeping, low mood and panic attacks he also presented normally. Although he was anxious he had capacity, knew where to seek help and engaged.

After being in touch with services and being seen at the University Hospital of Wales in May the international student, who worked in software engineering in his home of Pakistan, before coming to Cardiff to study, made no contact at all with health or emergency services throughout June 2024.

He also missed a face to face USW counselling appointment in June, the university's mental health adviser David Kukiewicz told the inquest. Fakhar later contacted his GP, 911 and press 2 - the emergency mental health line - and mental health services in July 2024.

Attending the inquest virtually from his home in the Netherlands, Kumar Zaman, Fakhar's older brother by 11 years, questioned whether the outcome would have been different if services had taken his brothers symptoms more seriously and done more.

Describing his close bond with Fakhar he said his younger brother meant everything to him. Growing up in Pakistan their father had died in a car accident when Fakhar was a baby and he formed a strong bond with his mother. He was devastated when she died 10 days after he arrived in Cardiff to study in 2023, Kumar said.

He said: "Me and my brother were very close. I was there to support him, We were very close. Fakhar was always a happy person, laughing and joking with friends from primary and college."

But that changed when their mother died and Fakhar returned from the funeral in low spirits. "He became quiet and stopped laughing. I don't think he got over it. He told me he was stressed working for his university course. He told me he got panic attacks and in March 2024 was stressed about exams," said Kumar.

In evidence read to the hearing Sher Baz, a friend of Fakhar's in Cardiff, told how he had seen him hours before his death walking on City Road and had given him a lift home around 8.30pm on August 18.

"He was a beautiful soul," he said. "When I dropped him off he was smiling and there was nothing of concern." Kumar agreed and said the last time he spoke to his brother by phone at 6pm the night before he died he had sounded "happy and normal".

Addressing questions about the help Fakhar received during those months Emma Lamorte, community team nurse manager from Cardiff and Vale University Health Board, said they had drawn up a "lessons learned" report which identified five issues to work on. These included the inability of nursing staff to access 911 notes, referral to the NHS-run Mental Health University Liaison Service and delays in meeting 28-day waits for appointments.

Coroner Andrew Morse concluded that while there were delays, Fakhar was correctly assessed as at risk, but not immediate risk, of self harm or suicide by accident and emergency staff at University Hospital of Wales, the USW counselling service, his GP and the NHS emergency mental health helpline "911 and press 2".

The coroner found that while the student had not been told by the "911 and press 2" operator that he could self refer for face to face services with the local NHS run Mental Health University Liaison Services (MHULS), this is now being addressed with extra training.

And when the student went to accident and emergency at the University Hospital of Wales in May 2024 there had also been issues with the mental health nurse team being unable to access 911 notes but this sharing of records more easily is also being looked at.

"It was clearly identified that Mr Zaman was struggling with his mental health for reasons of bereavement, stress at university studies, lack of sleep and suicidal ideation. Mr Zaman and his brother reported all those," the coroner said.

"It is clear Mr Zaman knew how to access services. He contacted 911 and the university and went to a GP seeking medication. What follows over months is missed appointments by him, so a degree of lack of follow up, but from his own choice."

And he added: "Mr Zaman was a man with capacity. He could make his own choices." However, he noted there was a delay when on July 17, 2024 Fakhar had spoken to a Cardiff and Vale University Health Board duty clinician, explained his low mood and was given a face to face appointment but not until September 17. That was outside the health board's 28-day target to be seen.

Recording a short form conclusion of suicide, with the cause of death being hanging, the coroner noted also that toxicology reports showed no sign of drugs or alcohol in his body.

He said it was not evident that had delays in appointments not happened, the outcome would have been different. The coroner found services correctly assessed the level of risk to the student as not being immediate.

"Whilst he had suicidal thoughts and was at risk he was not at immediate risk. Was the delay in appointment causative in this case? If there had been no delay it may have changed the outcome.

"The months that passed between the initial revelation of suicidal ideation thoughts, without that taking place, as an indication that assessment of level of risk was appropriate.

"While delay was of concern to Mr Zaman I cannot go further than to say it may have changed the outcome. But that is not sufficient to say it would have changed the outcome."

Extending his condolences to Kumar and their extended family Mr Morse added: "There was an opportunity for Mr Zaman to be referred earlier to the MHULS, run by the NHS, timing has been improved on that. There were opportunities where matters could have been escalated but I cannot say, on balance, that would have altered the outcome."

For emotional support, you can call the Samaritans 24-hour helpline on 116 123, email jo@samaritans.org , visit a Samaritans branch in person or go to the Samaritans website.