An inquest heard how a "kind, gentle and caring man" unexpectedly ended his own life by walking into the sea at Exmouth shortly after sending a heartbreaking message to his wife.

The hearing, at Exeter Coroner's Court and presided over by coroner Alison Longhorn, examined the circumstances surrounding the untimely death of 47-year-old Ben Weir, from Chudleigh Knighton, on the evening of September 18, 2023, at Orcombe Point. Ms Longhorn noted that Mr Weir was born in Birmingham and was a security operation team leader at the Royal Devon and Exeter Hospital.

She noted that he had been seen by NPAS Exeter police helicopter walking along the beach after concerns for his welfare were raised by his family. The Coastguard and RNLI were called to the scene after he was seen entering the water and swimming out some distance. He was later recovered from the water and brought to shore but despite the efforts of medical personnel, he passed away at the scene.


Ms Longhorn read out a statement from Mr Weir's wife, Elisabeth, who stated that they met in 2008 and he took on her two children as his own. They lived in Worcestershire and she described him as a "wonderful dad". They had a son together in 2011 and Mr Weir left work to look after the children.

At one point, he studied at a local college as he wanted to become a mental health nurse. The couple moved to Devon in 2016 and he began working at the Royal Devon and Exeter as a security officer, quickly gaining a promotion.

She described him as a "kind, gentle and caring man" who "genuinely wanted to help people". She said he would stop and check on everyone, asking nurses and doctors how they were and people thought highly of him.

She said people were shocked at his passing and no-one was aware of any changes in his behaviour or personality in the weeks leading up to his death. In addition, despite working in mental health services herself for over a decade, she did not see anything which suggested he was struggling.

She noted he had suffered from flu-like symptoms in late August, feeling lethargic, but that it was not Covid. He was off work for a few weeks, but returned to work on September 9. She said he remarked how "busy" he was at work on September 15 and felt tired but a few days later on he took their son to the cinema.

On September 18 he was up early, dressed and washed and helped their son to his school taxi, chatting to the driver for a few minutes. He then urged his wife to get some more rest, saying he was going to visit the gym.

Mrs Weir explained that the couple were frequently in contact with each other every day and it was not uncommon for him to text or message her during the day, including when he was at the gym, letting her know when he arrived or left. However, after not hearing from him, she became concerned, especially when he did not reply to her messages.

She became increasingly worried after calling the gym and his workmate friends, eventually ringing local hospitals and by the afternoon, she rang police. She said police later came to her house but appeared to show "no sense of urgency", despite her husband's silence being very out of character.

At 5.03pm she received a text message from her husband which confirmed her very worst fears as he wrote how he loved her, but then apologised, suggested his family would be "better off" without him, before claiming he had failed as a partner and father while she was "always an amazing wife".

He claimed he "did not deserve such amazing kids", calling them "awesome" and adding "I love you all". However, his message went on to reveal that he intended to end his life, and he apologised, before again stating how much he loved her and their children.

Understandably distraught, Mrs Weir informed police who raised the low-risk missing person status of Mr Weir to high risk. By this stage, she had contacted his workmate and close friend Julian Marks who went searching some of the places the pair would walk their dogs and he found Mr Weir's car at Exmouth beach.

Mrs Weir criticised the police, saying they were ignoring her pleas to find her husband and were not responding to Mr Marks, saying he had heard that a man had been seen walking along the beach and entering the water as the tide came in. She said that the police had told Mr Marks over the phone to stay by Mr Weir's car and that he told her officers were "standing around and doing nothing".

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Another workmate and friend of Mr Weir's had arrived at Exmouth beach at this point and he told Mrs Weir that it was claimed her husband had walked into the sea "and nobody had stopped him, nobody talked to him or helped him".

She added: "This was completely unnecessary and he could have been saved". She learned through his two workmates that her husband had been picked out of the water by the lifeboat and "people were working on him", but that the police told her nothing.

She wrote: "I knew he died. I felt him die, but nobody told me anything." She wrote that a police officer on the beach refused to speak to her on the phone and officers at her home similarly would not talk to her. She said she believed that his death was "preventable".

She recounted how the next day she was called to a police station where she was told to collect her husband's belongings, including his still-wet clothes. She said she was told to collect his car "by 5pm or we would be charged". She said as she left the station with her daughter, clearly sobbing and breaking down, nobody offered her any sympathy and instead they shut the door behind her.

In his statement Mr Marks wrote how Mr Weir was "exceptionally" good at his job, which sometimes included helping medical staff with violent or difficult patients. Mr Marks explained that Mr Weir - like most of the security team - understandably did not enjoy certain aspects of the work, such as having to help staff physically restrain violent children with learning difficulties or where they had eating disorders and had to be given food.

Mr Marks said that he never saw any signs of sadness or depression in Mr Weir but did say that the loss of his dog Sam in 2023 "hit him hard" and he was "totally devastated" and "tearful" at the loss of his pet. He said Mr Weir was a "very likeable character, very sociable, kind, caring, a loyal and helpful friend", adding that he was a "loving father and a great friend".

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He explained how after the worried call from Mrs Weir, he drove to Exmouth beach where he found Mr Weir's car about 200m past the lifeboat station. Inside he found a 24-hour parking ticket, with a start time of 2.27pm. He said he was asked by police over the phone to download the what.three.words app to show the exact location but had difficulty due to connectivity issues.

The police helicopter arrived and was seen hovering over the water towards Sandy Bay and Mr Marks stated he saw the lifeboat, more police and paramedics, who set up along Queens Drive as Mr Weir was pulled from the sea.

He wrote: "I still don't understand why Ben's dead. Everyone loved Ben. His death has had an enormous impact on his colleagues, friends and family."

Mr Weir's GP stated that the he only had three entries on his report, all for minor issues and none for depression or mental health matters.

A statement from a police tactical flight officer who explained how the NPAS Exeter helicopter was first at the scene. The officer stated that the helicopter was deployed to the area between Orcombe Point and Sandy Bay as the missing person was thought to know the area well and may be there. He said he was sent a picture of Mr Weir and at 6.25pm saw him walking along the beach towards Exmouth, around 100m east of Orcombe Point.

He added that zooming in on the helicopter's camera he could see the man's clothes were wet and covered in sand. Just three minutes later he saw the man walk towards and then into the water, fully clothed and continued to walk and then swim away from the shore.

The flight officer immediately called for the RNLI lifeboat and Coastguard to attend the scene as the police helicopter did not have any form of rescue capabilities such as a winch. The officer's statement noted how the man was swimming further and further out with his face down in the water adding that he appeared to be "actively trying to drown himself".

He said the helicopter remained hovering over the man to help direct the lifeboat to that location but "unknown to us the Exmouth lifeboat was already committed on another rescue in Topsham, Exeter".

Another RNLI crew attended on foot and at 6.58pm an RNLI crew member swam out to Mr Weir and turned him over in the water. At the same time the Exmouth lifeboat arrived and placed him on board the boat. By this time, the flight officer estimated Mr Weir had spent 24 minutes face down in the water. He wrote how he saw RNLI crew performing CPR as the boat went to the shore where HART paramedics were waiting.

A statement from the Coastguard revealed that at the time Mr Weir was ashore with paramedics in the ambulance he was still alive but despite their best efforts he passed away and CPR was stopped at 7.27pm.

Inspector Rachel Manifield, Devon and Cornwall Police's Force Information Manager on duty at that time, gave evidence in court, explaining that her role was to co-ordinate officers involved in the search for Mr Weir, which included a large number of officers, enhanced crisis communicators and specialist surveillance techniques.

Inspector Manifield revealed that a police dog handler had been able to make it to the beach, which was difficult to reach at that point due to the tide coming in and the rocks, but noted that by this stage the information was that Mr Weir was between 150m and 200m out at sea. The inspector said that officer said she "felt compelled" to go into the water to get Mr Weir but that Inspector Manifield had made the "commander's decision" to stop the officer. She said she needed to take into account a number of key factors, including that it was getting dark, it was open sea, Mr Weir had been in the water for some time, the officer was in full uniform, the dog handler kept losing sight of Mr Weir, she was not equipped to carry out a sea rescue, particularly at such a distance and adding that by this stage the RNLI was just minutes away.

A further report from another officer who attended the scene and co-ordinated the emergency response, including the setting up of a base, noted that there were a number of difficulties in accessing the beach area due to the incoming tide and rocks, with some parts of the beach being inaccessible.

A toxicology report found no evidence of drink or drugs in Mr Weir's blood and a Home Office pathologist stated that the medical cause of death was drowning.

In conclusion, Ms Longhorn noted that Mr Weir had no history of depression or low mood and there had been no noticeable change in his behaviour. However, she also noted the despairing message sent by Mr Weir to his wife, intimating that he intended to take his own life.

She also said she had to note how he had had walked into the water, swum out some distance and was seen to repeatedly put his face into the water. She also considered how he may have specifically chosen that location as he knew the area fairly well and "chose that particular location at that particular time because of the difficulty it would present for the emergency services in getting to him should they become aware of his location".

As such she recorded a conclusion of suicide. Ms Longhorn offered her condolences to Mr Weir's family, adding that this was a "particularly tragic incident and to have lost Ben in this way must have been so incredibly distressing for you all. I cannot imagine how difficult it's been to come to term with Ben's death, particularly as there was absolutely no indication that he was suffering from low mood or poor mental health. Ben was clearly very loved by his family and friends alike and I'm sure is very missed by all who knew him."