After a number of reported student suicides at Cambridge University between March and June 2022 and the high profile death of Bristol student Natasha Abrahart, Higher Education (HE) providers are understandably concerned about what can be done to support student welfare and what the implications might be for HE providers who do become involved in the inquest process.

What is the purpose of an inquest?

In an inquest, the Coroner has a duty to discern who has died, when and where they have died, and how they have died. As you might imagine, establishing how an individual has died is the most pivotal factor in an inquest. Coroners themselves are not permitted to apportion blame; an inquest is a purely fact finding procedure, however admitted failings can be recorded by the Coroner.

Additionally, where the Coroner has a concern that circumstances creating a risk of death will occur or persist in the future, an organisation can be issued a Prevention of Future Death report (PFD). Such reports can be issued at any point in an inquest; they do not set out what action should be taken, only that action should be taken. Recipients of PFDs have 56 days to respond with an outline of the action they propose to take. PFDs are key in establishing lessons learned in an inquest and in improving the quality of the services an organisation delivers.

For example, Cardiff University student Mared Foulkes died by suicide the morning she received examination results to say she had not successfully completed the year. This was subsequently incorrect once the University’s ratification process had occurred. The Coroner in this case issued a PFD to Cardiff University to review their examination results communication process, as well as their ratification process. Measures were put in place to address these concerns leading to a more streamlined and improved examination results process for those students at the university.

 How might an education provider be involved in an inquest?

If a student were to take their own life while studying, it is likely that the Coroner would want to establish what the deceased’s academic situation was to fully ascertain the circumstances surrounding their death. Particular focuses of an inquest may include:

  • Whether or not the student’s mental health was impacted by their studies.
  • Whether or not the HE provider was aware of any of the student’s mental health issues and what support was in place for them during their studies.
  • What procedures the HE provider has in place to support vulnerable students more generally.
  • Whether or not the HE provider has a robust multi-agency approach to refer vulnerable students to wider support services.

In relation to this, the HE provider might be asked to provide witness statements, correspondence, and evidence of their internal policies. Where it is suggested that an act or omission of the HE provider may have contributed to the death, they may be deemed an ‘interested person’. This means they are able to play a more active role in the inquest process generally.

What preventative steps to take?

What has become clear from recent cases of student deaths is that it is imperative for HE providers to have a robust, linked up multi-agency approach to safeguarding which will enable them to be aware, as far as possible, of what mental health challenges a student might be facing. This will allow HE providers, to put in place the appropriate academic and welfare support. 

If they haven’t already, HE providers might consider:

  • Implementing a suicide prevention strategy to put in place a framework to help to understand student suicide, mitigate risk, to intervene when required and to respond to an adverse incident.
  • Appropriately training staff to look out for and identify safeguarding issues among students, so students can be swiftly referred to appropriate internal or external services.
  • Ensuring that adequate internal wellbeing services are in place where possible, for example counselling or Mindfulness services.
  • Where there is a significant waiting time expected for internal wellbeing services, ensuring that students can be signposted to external wellbeing services such as local counselling charities, the GP, or A&E.
  • Maintaining a good relationship with local GP surgeries and having dialogues with them to ascertain what precisely what they are and are not able to do with regards to treating and diagnosing mental health conditions and how their referral processes work; communicating this to students in a transparent manner may make them more receptive to the idea of seeking support in this way.
  • Ensuring every student has a pastoral point of contact they can speak with about any wellbeing issues or exacerbating factors they might be dealing with so the HE provider is kept in the loop.
  • Signposting all relevant wellbeing services as part of a student’s induction into an HE setting and frequently advertising these throughout their time studying.
  • Allowing all students the opportunity to discuss whether they need a support plan in place for either mental health or academic support and being transparent about what evidence is needed to approve such a plan.
  • Being as supportive as possible in helping students procure evidence for a support plan.
  • Ensuring, as far as possible, that any internal extenuating circumstances application policies do not entail unfavourable treatment of students until they are approved.
  • Being clear and transparent about extenuating circumstances procedures and what evidence is required for an application to be approved.

Cambridge University’s pro-Vice Chancellor has stated that: “Nothing is more important to the university and colleges than the safety of our students. We are committed to delivering a comprehensive set of actions that are designed to help keep students safe”. We are sure this is a sentiment echoed by other HE providers and highlights the importance of ensuring multi-agency working when supporting student welfare.

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