A much-loved musician “tormented by mental health difficulties” walked out of a hospital unnoticed and ended up in the sea, an inquest has heard.

The body of Daniel Venes was discovered washed up on the shore near Calais – 50 miles from where he was last seen in Margate on August 14, 2021.

Now a coroner has ruled that sub-standard care allowed Daniel to abscond from the town’s QEQM Hospital while awaiting a mental health referral.

He was left without proper supervision for 22 hours before he disappeared – despite his poor mental state.

Daniel, a former Herne Bay High School pupil who lived in Reed Avenue, just off Sturry Road in Canterbury, was just 31 when he was found dead on the French beach.

Family, friends, and countless strangers had spent months searching tirelessly for him following his disappearance.

An extensive police investigation also saw officers scour east Kent – sending up a helicopter on at least two occasions after possible sightings of Daniel.

However, five months later it was revealed his body had been discovered on the other side of the Channel on August 28, 2021 – just two weeks after he disappeared.

Area coroner Sarah Clarke concluded it was “unclear” how Daniel came to be in the Channel but confirmed his medical cause of death as drowning.

Daniel’s family say they have been left “devastated” by his death – and that to have lost a loved one in these circumstances will “continue to hurt forever”.

The coroner’s court at County Hall in Maidstone heard today that Daniel had a history of mental illness, including bipolar disorder and paranoid schizophrenia.

He had been taken to hospital by ambulance after being found by British Transport Police officers in distress at Sturry railway station. The inquest heard that after his admission it should have been clear that he needed constant observation and to be detained in the hospital on mental health grounds – but this was never carried out.

Area coroner Sarah Clarke said: “It was not until five hours after he was first admitted that a recommendation [to mental health services within the hospital] was made, and there are another five hours where he appears to have been observed by a mental health professional, but we don’t know how frequently as there is no paperwork to support it.”

Daniel was at the QEQM for at least 22 hours – largely unobserved – before he left the hospital grounds unnoticed.

It was not until two hours after he had last been checked on that staff realised he had disappeared, with police alerted within an hour

Shockingly, the court heard there had been a similar incident sometime before where Daniel had been brought to the hospital amid concerns for his mental wellbeing but had fled.

He was later found submerging himself in the sea.

Despite this, upon his next admission he was not automatically flagged as a flight risk or danger to himself, and so was not given appropriate observation – partly because this information was not available to staff at the time of his arrival in August 2021.

Representatives of the East Kent Hospital Trusts and Kent and Medway NHS Social Partnership Trust (KMPT) told the court that a Serious Incident Review had been carried out, and steps taken to ensure similar incidents do not happen again.

This included a reworking of the risk analysis chart to ensure a case of Daniel’s severity was properly risk assessed and graded.

The inquest heard from Jennifer McBride, a matron from East Kent Hospitals, that capacity for enhanced observation of mental health patients had been increased since Mr Venes’ death.

The inquest also heard of plans to have ‘safe houses’ for mental health patients in operation by autumn that would be attached to emergency departments to look after such patients while they await referrals.

However, Ms Clarke said she remained concerned not enough had been done to prevent people from coming to harm. She informed the court she would be making a Prevention of Future Deaths (POFD) report.

She said: “What I can say is, having read the evidence and heard it, I don’t think it will be of any surprise to those involved in Daniel’s care to hear me say that while he was in the hospital the care from the acute team and mental health nurses fell far below the care that should be expected [in the situation].

“Daniel was tormented by mental health difficulties, but with the very great support of his family was able to, at times, live a relatively normal life. He was not alone, but sometimes his mental illness made him feel like he was alone.

“This all created an endless cycle of episodes of acute psychosis, where at times he just needed the support of mental health professionals and to have people around him.

“He would self-medicate with alcohol – perhaps to drown out the voices, I don’t know. When he wasn’t acutely unwell he understood it wasn’t a good thing to do, but unfortunately his illness would take over.

“I can see a lot of records where things were done to try and help, and that things were happening to try and assist him.

“However, [during his time in hospital] not one clinician highlighted the need for him to have enhanced or indeed regular observation.

“It took five hours to make a recommendation, then there were another five hours where he appeared to be observed, but we don’t know any details because there are no records to show it.

“I have no doubt systems have improved, investigations have been undertaken on a multiagency level and lessons have been learned.

“However, there remain some concerns that I consider trigger a POFD order.”

Recording a narrative verdict, the coroner said there was "absolutely no evidence" to rule Mr Venes' death a suicide, and instead carried a narrative verdict – adding that while his date of death would be listed as the day he was found, it was "all but certain" he died before that.

"Daniel Venes was found in the English Channel having died on the 28th of August 2021, on a beach in France having been reported missing after absconding from an accident and emergency centre where he had been taken," she said.

"It was likely that he would have required hospital admission due to a relapse of a dissociative disorder. The circumstances of his entry into the sea remain unclear."

Jane Dickson, speaking on behalf of East Kent Hospitals University NHS Foundation Trust, said: “We offer our deepest condolences and sincere apologies to Daniel’s family. The safety of those we care for is our utmost priority and we accept that we did not provide the correct level of observation.

“We immediately undertook our own review into the circumstances of his death and made a number of improvements, including additional training for Emergency Department staff in bespoke mental health support and recruiting Enhanced Observation Support Workers.

“We fully accept the coroner’s conclusion and are committed to addressing any outstanding issues identified.”

Speaking after the hearing, Daniel’s uncle, Justin Venes, said the family were pleased there had been recognition of the “massive failings in the care that was supposed to be provided to Daniel”.

“[There was] recognition that there needs to be fundamental changes made because nobody with mental health issues should be forced to be left in a hospital for 22 hours without proper supervision and care,” he added.

“We’ve heard what measures have been put in place to ensure this doesn’t happen again.

“We’re relieved to hear some of those recommendations – that mental health is going to take more of a priority and be taken more seriously.”

Asked about the emotional impact of Daniel’s death on the family, he added: “It’s been devastating. It’s hard enough – it’s a big enough tragedy to lose someone.

“But to lose someone in the circumstances that we have – which could so easily have been prevented – it’s something that will continue to hurt forever.

“We now, after today’s inquest, will have to start trying to move forward.

“And part of that process will be recognising the efforts that have been put forward to ensure that mental health is taken more seriously.”

Asked how she would like her son to be remembered, Daniel’s mum Shaine Venes said: “Happy up there playing his guitar – and enjoying the sunshine, enjoying family.

“His music and his art will live on forever.

“We’re hoping to get an exhibition of his art out there sometime this year.”

Daniel’s disappearance sparked a high-profile, months-long quest to find him.

A ‘Help find Dan Venes’ page set up on Facebook amassed more than 3,500 followers, with members of the group – many of them strangers – regularly heading out at all hours to search fields and woodland across east Kent, and to check on tents following possible sightings.

Meanwhile, Kent Police continued their official search efforts.

On November 22, 2021 – 100 days after he went missing – Det Insp Louise Murphy said: “Daniel is still missing and enquiries to locate him remain ongoing.

"We are still very keen to hear from anyone who may have seen him or has any information about his whereabouts since August 14.”

In January 2022, police renewed their appeal to locate Daniel. Det Insp Louise Murphy said: “While it has been nearly six months since Daniel went missing, we have not given up hope of finding him and have been actively making enquiries to locate him.

“If anyone has any information that will assist us in our enquiries please call us.”

But unbeknown to them, Daniel’s body had been found more than five months previously.

Almost 150 days after he was discovered his heartbroken family were informed, following DNA tests that revealed his identity.

At the time, his father, Jason Joiner, from Swalecliffe, told KentOnline: “I don’t know why it’s taken this long. He was found about five months ago, but it’s taken them all this time [to identify him in France].

“They haven’t really explained it that well. All they said was they’ve got to do dental records, then they’ll release his body.

“We want him home. I miss him and I love him.”

News of Daniel’s death sparked a wave of sorrow.

Mr Joiner described his son as a “brilliant” guitar player and “a lovely, caring person”.

His close friend Ricky Twyman remembered him as a kind, private person with a profound appreciation for the beauty of the natural world around him.

The pair, who both lived in Sturry, first met a decade ago but grew especially close in the last year.

“We’d spend three, five, seven days a week together,” explained Ricky.

“Most of it just walking and talking, exploring, guitar-playing and singing.”

“Dan loved nature. He’d take walks, meditate, take photos of things other people wouldn’t even find interesting.”

Daniel was also a talented artist and musician, who had thousands of followers on Facebook pages exhibiting his work.

“He liked to make art with anything - paintings were his massive thing, but he’d literally try anything,” said Ricky.