Recurring concern

Inadequate university mental-health support systems for students

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First reported 1 Feb 2019•Latest report 31 Jan 2025

Definition

What this concern includes

Includes failures in university mental-health support arrangements, including national or institutional service requirements, welfare-staff competence, specialist liaison, identification and engagement, referral, access, safeguarding and coordination of support for students with significant mental-health needs.

Not included

  • Excludes generic student welfare, pastoral or academic-support deficiencies where no student mental-health support condition is identified.
  • Excludes clinical mental-health assessment or treatment after a university has reliably connected a student to an appropriate service.
  • Excludes general mental-health service shortages outside universities unless the assertion directly concerns university responsibility for student support.
  • Excludes isolated communication, training or engagement failures that are not part of the university mental-health support system.
Reports
8

Distinct published reports

Individual concerns
11

A report can raise multiple concerns

Date range
2019–2025

First to latest report issue date

Stated actions
26

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department for Education2
Arts University Bournemouth1
Cardiff University1
Cheshire and Wirral Partnership NHS Foundation Trust1
Department of Health and Social Care1
Devon Partnership NHS Trust1
Dorset Healthcare University NHS Foundation Trust1
Greater Manchester Mental Health NHS Foundation Trust1
Health and Safety Executive1
NHS England1
Universities UK1
University of Reading1
University of Southampton1
University of South Wales1
University of Surrey1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Dorset

    AI-generated summary

    Alexander Channing · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Alexander Channing, known as Alec, was found suspended by a ligature in his university halls of residence on 27 January 2022 and was pronounced dead at the scene. The report records concerns about delays in transferring his mental health care, discharge planning without Home Treatment Team involvement, postponed assessment, limited proactive attempts to obtain consent to share information, and a lack of relevant training and policies.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of training for wellbeing services regarding students diagnosed with Emotionally Unstable Personality Disorder

    Wider context from the report

    “i. There is no training provided to the wellbeing services at the Arts University Bournemouth in relation to students diagnosed with Emotionally Unstable Personality Disorder. ”

    Source location

    Alexander Channing · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver full-day training on emotionally unstable personality disorder and personality disorders to Student Services staff, including wellbeing practitioners and counsellors.

    Verbatim wording from the response

    “I confirm to HM Coroner that a full day training session on EUPD and personality disorders was delivered to 17 members of Student Services staff, including Wellbeing Practitioners and Counsellors, on Monday 6 January 2025.”

    Source location

    Response from Arts University Bournemouth
    Page 1 · response
    Published 31 January 2025

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The delivered EUPD and personality-disorder training is considered to fully address the concern, so no further work is identified as necessary.

    Verbatim wording from the response

    “I confirm to HM Coroner that a full day training session on EUPD and personality disorders was delivered to 17 members of Student Services staff, including Wellbeing Practitioners and Counsellors, on Monday 6 January 2025.”

    Source location

    Response from Arts University Bournemouth
    Page 1 · response
    Published 31 January 2025

    Open published response
  2. Berkshire

    AI-generated summary

    Benjamin Faux · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Benjamin Faux was a taught research Master's student at the University of Reading who had severe mental health difficulties, disengaged from his studies, and took his own life in his student accommodation on or around 5 August 2023. The concerns included inadequate pastoral support and monitoring, the absence of a process to ensure completion of study-suspension arrangements, unclear responsibility for resolving his academic situation, and a lack of University contact with him before his death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Risk of vulnerable taught research students being overlooked, isolated, or left in academic limbo

    Wider context from the report

    “(6) The primary responsibility to meet acute mental health needs when they arise lies with mental health care services. I acknowledge that Reading University have engaged with and are continuing to implement lessons learned process since Ben’s death. However I consider that circumstances at Reading University continue to present a risk to vulnerable graduate students on taught research courses who struggle with their work and develop mental health issues. The risk is of being overlooked until a crisis is reached, or becoming isolated, or of being left in academic limbo, as Ben was, with tragic results. ”

    Source location

    Benjamin Faux · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide every Master’s by Research student with two academic points of contact and monthly meetings throughout the programme.

    Verbatim wording from the response

    “This change was an institutional decision made to reflect the view that it was more appropriate for academic staff to focus on providing academic and general pastoral support, with trained professionals providing more specialist welfare support where required. | 1. Strengthen support system for MbR programmes to ensure that all MbR students have monthly meetings with two academic points of contact.”

    Source location

    Response from Reading University
    Page 1 · response
    Published 29 July 2024

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement an SDAT notification process using regular staff reminders, engagement reports and SSC-provided templates.

    Verbatim wording from the response

    “We recognise there is a need for further pro-active follow-up with students whose non-engagement has been identified. To address this, the University will introduce a new process for MbR programmes whereby the relevant School Director of Academic Tutoring (“SDAT”) emails relevant academic staff at regular intervals to request reports of any significant engagement concerns back to the SDAT (who would then follow up appropriately).”

    Source location

    Response from Reading University
    Page 2 · response
    Published 29 July 2024

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Circulate guidance instructing welfare officers on prescriptive escalation, clarifying welfare information, and promptly sharing high-risk concerns with SDATs.

    Verbatim wording from the response

    “5a | In response to this Concern, the University has circulated new guidance to key staff. This has included:”

    Source location

    Response from Reading University
    Page 3 · response
    Published 29 July 2024

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Professional welfare support from central teams, alongside academic pastoral support, is considered more appropriate than restoring specialist welfare duties to Academic Tutors.

    Verbatim wording from the response

    “1 | The Academic Tutor role was revised a number of years ago, with a stronger provision of professional welfare support made available within the central student services teams.”

    Source location

    Response from Reading University
    Page 1 · response
    Published 29 July 2024

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The organisation lacks regulatory authority to mandate specific mental-health actions by member universities.

    Verbatim wording from the response

    “UUK represents 141 autonomous universities across the United Kingdom. However, it is important to note that our organisation does not represent all higher education providers nor possess the regulatory authority to mandate specific actions by our member institutions. Each university operates independently, with its own governance and procedures.”

    Source location

    Response from Universities UK
    Page 2 · response
    Published 29 July 2024

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Individual universities are responsible for their own governance, procedures and decisions on specific mental-health actions.

    Verbatim wording from the response

    “UUK represents 141 autonomous universities across the United Kingdom. However, it is important to note that our organisation does not represent all higher education providers nor possess the regulatory authority to mandate specific actions by our member institutions. Each university operates independently, with its own governance and procedures.”

    Source location

    Response from Universities UK
    Page 2 · response
    Published 29 July 2024

    Open published response
  3. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Matthew George WICKES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Matthew George WICKES died in hospital on 30 June 2022 after jumping from a road bridge in Southampton during an acute anxiety crisis. Concerns included university staff awareness and training on student mental health and neurodiversity, gaps between academic assessment and pastoral support, difficulties in effectively reaching struggling students, and inadequate recording of academic meetings and agreed support.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient academic staff awareness and understanding of student mental health

    Wider context from the report

    “1. Matthew was neurodiverse. It was accepted that this condition was not known by the university at the relevant time, as he was diagnosed after his commencement on his course and did not disclose his condition to the university. In the circumstances, appropriate actions and case specific assistance which might otherwise have been available to and assisted Matthew were neither implemented in response nor accessed by him. Notwithstanding Matthew’s neurodiversity – which of itself was a barrier to him being able to reach out or to seek help - I am concerned about the level of awareness, understanding and curiosity of academic staff around the mental health of students, particularly in the post-pandemic climate, where interruptions to their study and dysregulated student life have had a significant impact on their mental health. Whilst it was explained to me that all staff are offered training on mental health management and are provided with guidance on how to support students, I am concerned that aspects of this are not made compulsory for academic staff. Where a myriad of training options are made available to staff and often required of them, with very little practical time available in which to do it, there is a risk that modules and aids with regard to mental health will not be prioritised, followed through or accessed. There is as I understand it no evident monitoring in respect of which staff have viewed or undertaken what training or indeed in respect of who has completed the modules on offer. It remains unclear as to who or how many staff have actually viewed or undertaken the online training around student mental health. Although the process of ‘raising a concern’ by academic staff is a means by which such matters can be considered and is a process set up and encouraged through the student hubs, I am concerned that in not ensuring that academic staff are at least armed with the ability to spot or to know when to make initial enquiries of students or are clearly guided on how best to do so (particularly with regard to an understanding of the needs and skills required to liaise with students with neurodiversity), there is a risk that an over-focus on academic policies and procedures will endure and that those students who are struggling to adhere to them will be missed or overlooked. ”

    Source location

    Matthew George WICKES · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  4. South Wales Central

    AI-generated summary

    Daniel HALL · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Daniel Hall was a 20-year-old student at the University of South Wales who expressed suicidal thoughts on two occasions while awaiting mental health support. He died at his student accommodation on 9 December 2019, and the coroner’s short-form conclusion was suicide. The principal concern was lengthy delays in accessing mental health support despite expressed suicidal ideation and known autism spectrum disorder, together with a lack of safeguarding.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in student access to mental health support services

    Wider context from the report

    “Lengthy delays for students at the University of South Wales to access mental health support services even when suicidal ideation has been expressed on more than one occasion and when risk factors (ASD) are known. ”

    Source location

    Daniel HALL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Commission an independent external review of wellbeing, health and safeguarding policies, procedures and interventions.

    Verbatim wording from the response

    “Further, as part of our ongoing commitment to continuous enhancement of our provision, we will be commissioning a specialist independent external review of policies, procedures and interventions around wellbeing, health and safeguarding to ensure that our service continues to provide the very best support for our stakeholders. The Terms of Reference for the review will include benchmarking how we operate against best practice across the Higher Education sector and will inform future enhancements to the established service the University provides.”

    Source location

    2021-0381-Response-from-University-of-South-Wales_Published
    Page 1 · response
    Published 18 November 2021

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce specialist Wellbeing practitioner roles and increase team staffing capacity.

    Verbatim wording from the response

    “Since the 2019 Autumn term, the University has introduced new specialist Wellbeing practitioner roles to our existing Wellbeing services and increased the overall number of staff in the team by 37%, which has significantly reduced waiting time for students. Wellbeing Advice and Specialist Provision appointments are monitored weekly by the Service Manager, who may increase or alter provision to meet student need.”

    Source location

    2021-0381-Response-from-University-of-South-Wales_Published
    Page 2 · response
    Published 18 November 2021

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Enhance processes for rapid specialist Wellbeing responses, including immediate risk assessment, action planning and referral where needed.

    Verbatim wording from the response

    “USW processes, which enable rapid response specialist Wellbeing services, have been enhanced since March 2020. Direct and early conversation with a Wellbeing practitioner is facilitated by Student Wellbeing appointments which are booked online. During the Wellbeing Advice Appointment, the trained Wellbeing practitioners, together with the student, assess need and risk there and then, agreeing and initiating a plan of action. Any expression of suicide will be referred rapidly, if the assessment of individual need and risk by the Wellbeing practitioner identifies a need for access to specialist support. Referrals may be made internally and/or to a GP or other Secondary Care mental health services.”

    Source location

    2021-0381-Response-from-University-of-South-Wales_Published
    Page 2 · response
    Published 18 November 2021

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reserve daily internal specialist support capacity for urgent referrals following Wellbeing Advice Appointments.

    Verbatim wording from the response

    “The existing availability of internal specialist support including Counsellors, Mental Health Advisers and Nurse Advisers has been adapted to ensure we have daily availability reserved for urgent referrals following Wellbeing Advice Appointments.”

    Source location

    2021-0381-Response-from-University-of-South-Wales_Published
    Page 2 · response
    Published 18 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Pilot direct referral pathways linking students in mental health crisis with local primary and secondary mental health services.

    Verbatim wording from the response

    “We are piloting a service for students in mental health crisis for direct referral to local Primary and Secondary mental health services. In Autumn 2021, the South East Wales Mental Health Partnership¹, established this pilot for enhanced collaboration between university support services and local mental health services in cases where students are presenting as particularly high risk or significantly unwell. The pilot will introduce a new ‘University Liaison Service’ (‘ULS’) hosted by Primary Care in the NHS, but based within the participating universities, to support the student needs between the universities, GPs and NHS Mental Health Services. The University is applying lessons learnt through this pilot to its operating principles with other Local Health Board partners.”

    Source location

    2021-0381-Response-from-University-of-South-Wales_Published
    Page 2 · response
    Published 18 November 2021

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review communication links and expectations with the on-campus GP practice, including consent-based information sharing about interventions.

    Verbatim wording from the response

    “Other examples of collaboration with external services includes the University’s long-running partnership with a GP practice to deliver services to students on campus at Trefforest. In 2022, we will be reviewing the communication links and expectations of this relationship, drawing on the learning and standardised measures of mental health severity from the Health Board collaboration. The aim will be to include a requirement for primary care services to inform (with individual consent) University support services of interventions in order that University supplementary support can be synchronized.”

    Source location

    2021-0381-Response-from-University-of-South-Wales_Published
    Page 4 · response
    Published 18 November 2021

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete a review of wellbeing and safeguarding policies, practices and interventions to improve service connectivity and consider systematic wellbeing monitoring.

    Verbatim wording from the response

    “To manage the enhancement of our Wellbeing services, the University has created a Wellbeing, Health and Safeguarding project under the governance of our Equality and Diversity Steering Group with Executive level sponsorship and oversight. The Wellbeing, Health and Safeguarding project strands incorporate:”

    Source location

    2021-0381-Response-from-University-of-South-Wales_Published
    Page 4 · response
    Published 18 November 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The University does not provide prescriptions or act as a first-response, primary-care, emergency clinical, or domiciliary service.

    Verbatim wording from the response

    “Prescriptions and pharmaceutical remedies are not provided within University services. However, we recognise the benefits of tailoring our services to complement external”

    Source location

    2021-0381-Response-from-University-of-South-Wales_Published
    Page 3 · response
    Published 18 November 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    GPs, NHS mental-health services, and other public services are responsible for emergency, clinical, and domiciliary support.

    Verbatim wording from the response

    “The University recognises it is not a first response organisation nor is it a primary care agency and should not be expected to provide emergency or clinical services nor domiciliary visits. Those services are provided by GP, NHS and other public services. Our services, as outlined above, have been devised to ensure the University can take action when we are made aware of suicidal and other high-risk intentions. This includes referring the matter to external clinical and specialist services best qualified to support the student.”

    Source location

    2021-0381-Response-from-University-of-South-Wales_Published
    Page 5 · response
    Published 18 November 2021

    Open published response
  5. Surrey

    AI-generated summary

    Sarah Margaret Clarke · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sarah Margaret Clarke, a 23-year-old university student with significant mental health difficulties, was found deceased in her university accommodation on 21 November 2019 after sending an email indicating that she intended to end her life. The concerns included inadequate follow-up after she became extremely distressed, insufficiently robust systems for managing and safeguarding students at high risk of self-harm, and failure to implement relevant national guidance or provide adequate oversight and learning.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficiently robust systems for managing, treating and safeguarding high-risk students with mental health problems

    Wider context from the report

    “3. The organisation and systems at the CWB were insufficiently robust to appropriately manage, treat and safeguard students known to have mental health problems and be at high risk to themselves on a background of a lack of national guidance of what are the basic requirements for universities to provide such services. ”

    Source location

    Sarah Margaret Clarke · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to implement national guidance to reduce student suicide

    Wider context from the report

    “4. National guidance issued in September 2018 to reduce the incidence of suicide in the student population had not been implemented by CWB at the time of Sarah’s death. ”

    Source location

    Sarah Margaret Clarke · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of national guidance on basic university mental health service requirements

    Wider context from the report

    “3. The organisation and systems at the CWB were insufficiently robust to appropriately manage, treat and safeguard students known to have mental health problems and be at high risk to themselves on a background of a lack of national guidance of what are the basic requirements for universities to provide such services. ”

    Source location

    Sarah Margaret Clarke · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement enhanced safeguarding processes, including a safeguarding policy, broader training access and consideration of all students as potential safeguarding concerns.

    Verbatim wording from the response

    “With regards to safeguarding, since 2019 the University has updated its safeguarding policy, which all staff are required to follow. In addition, the University has improved access to safeguarding training, considers all students in the service as potential safeguarding concerns, and refers to the safeguarding policy if required. The CWB team’s experience and that of the Designated Safeguarding Lead is called upon to ensure referrals and follow ups are robust.”

    Source location

    Response from University of Surrey
    Page 5 · response
    Published 1 December 2022

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement student concern reporting, repeated follow-up and escalation processes, including escalation to health, security or police services when appropriate.

    Verbatim wording from the response

    “b. Staff who are concerned about students can now expect a smoother process and a robust follow up. They can submit a new ‘report a concern’ or ‘safeguarding concern’ form, and for”

    Source location

    Response from University of Surrey
    Page 3 · response
    Published 1 December 2022

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Increase out-of-hours mental health support when the Centre for Wellbeing is closed.

    Verbatim wording from the response

    “more immediate issues, can directly contact CWB duty advisors. Out of hours support has also been increased for when the CWB is closed”

    Source location

    Response from University of Surrey
    Page 4 · response
    Published 1 December 2022

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide personalised, student-led action plans for students at risk to support individual safety needs and risk management.

    Verbatim wording from the response

    “d. Students at risk are now supported with a personalised action plan to help them understand and manage their own risk. This action plan is student-led and is designed to support a student’s individual safety needs whilst encouraging autonomy”

    Source location

    Response from University of Surrey
    Page 4 · response
    Published 1 December 2022

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Strengthen case management through caseload monitoring, daily advisor check-ins, structured handovers and cross-service information sharing for students of concern.

    Verbatim wording from the response

    “e. In the CWB, closer case-load monitoring, daily check-ins with all advisors and structured handovers between duty advisors has improved case management and coordination, especially for ‘high risk’ cases. Information about students at risk is also now shared across key services at the University (Disability, CWB, Security and Residential Life) to ensure a joined-up approach to students of concern. Where consent is provided, information is also shared with trusted adults, such as family or friends. All information about individual students is sensitively managed.”

    Source location

    Response from University of Surrey
    Page 4 · response
    Published 1 December 2022

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use risk assessments as working documents with students to mitigate risk, establish action plans, support follow-up and enable earlier escalation or information sharing.

    Verbatim wording from the response

    “c. Although risk assessments in their basic form are not supported by NICE guidelines, the CWB has changed its use of risk assessments. They are now used as a working document between advisor and student to try, where possible, to mitigate risk and ensure that an action plan is in place. This helps to make sure that support is being received and any escalation can be actioned appropriately. It also provides a lower threshold for sharing of information and robust follow up, sooner.”

    Source location

    Response from University of Surrey
    Page 4 · response
    Published 1 December 2022

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish internal oversight through governance groups, policy reviews, a Centre for Wellbeing risk register, performance indicators and committee reporting.

    Verbatim wording from the response

    “The University oversees and monitors the services provided by the CWB through the following:”

    Source location

    Response from University of Surrey
    Page 6 · response
    Published 1 December 2022

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with the Surrey Suicide Prevention Partnership on university suicide-safety policy, guidance, staff training and student mental health support.

    Verbatim wording from the response

    “d) The University has a working relationship with the Surrey Suicide Prevention Partnership (“SSP”), which involves Surrey County Council, the Police and NHS Trust, working together. The SSP team is supporting the University to improve awareness and mental health training for University student-facing staff. In addition, the CWB is providing direct input into the SSP’s own policy and guidance on suicide safety”

    Source location

    Response from University of Surrey
    Page 7 · response
    Published 1 December 2022

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The CWB is a pastoral university service, not an emergency, medical or statutory mental health provider, and cannot replicate NHS services.

    Verbatim wording from the response

    “It is important to note that CWB is not an emergency service provision and should not be considered as replicating or replacing formal NHS and local mental health care services. For emergencies, students are informed and expected to contact the emergency services via 999, or the University’s Security team. Members of the Security team are available 24/7 and can contact the local mental health crisis line, escort the student to a place of safety such as the local hospital A&E or Safe Haven, signpost to external sources of support such as Samaritans, PAPYRUS and other mental health charities.”

    Source location

    Response from University of Surrey
    Page 3 · response
    Published 1 December 2022

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    NHS and other professional mental health services are responsible for actively diagnosing and treating students’ mental health.

    Verbatim wording from the response

    “The University of Surrey strives to be a welcoming and caring community for its students and staff. Sarah’s tragic death prompted a period of reflection and reform. There are necessary limitations to the support that any university’s wellbeing services can provide students. They do not and cannot replicate the services of the NHS and other professional mental health services that have regulatory oversight from the Care Quality Commission. We will champion the need for greater clarity from Government and the Office for Students on this point so that there is no more confusion about the role of universities in supporting students’ wellbeing. It is the responsibility of services within the NHS to actively diagnose and treat students’ mental health.”

    Source location

    Response from University of Surrey
    Page 11 · response
    Published 1 December 2022

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The University had a suicide safety policy and had adopted the national recommendations, except for a planned round-table event.

    Verbatim wording from the response

    “4. National guidance issued in September 2018 to reduce the incidence of suicide in the student population had not been implemented by CWB at the time of Sarah’s death.”

    Source location

    Response from University of Surrey
    Page 5 · response
    Published 1 December 2022

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    There are no defined acceptable standards or regulatory service levels applicable to the CWB because it is not statutory mental health provision.

    Verbatim wording from the response

    “So far as the University is aware, there are no “acceptable standards” to which the CWB must be held to account. The support services provided by the CWB are not statutory mental health provision, such as those provided by local NHS mental health services. Instead, they are stand-alone services provided by the University to support students in a pastoral way to help them to succeed at university.”

    Source location

    Response from University of Surrey
    Page 7 · response
    Published 1 December 2022

    Open published response
  6. Manchester South

    AI-generated summary

    Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient mental health training and specialist liaison for university welfare staff

    Wider context from the report

    “7. The inquest was told by the clinical lead for Eating Disorders of the high risk of Eating Disorders in high achieving students on courses such as medicine. In such cases, the inquest was told universities need to be alert to early signs of anxiety that risk leading to eating disorders developing. As part of this understanding by universities the inquest was told of the need to recognise early signs of mental health issues and listen carefully from an early stage. The skill set/training of academics in welfare roles in relation to mental health was described as key and specific work with Eating Disorder services and training of those involved in welfare programmes supporting students can be effective; ”

    Source location

    Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of universities to identify early signs of anxiety and mental health issues in students

    Wider context from the report

    “7. The inquest was told by the clinical lead for Eating Disorders of the high risk of Eating Disorders in high achieving students on courses such as medicine. In such cases, the inquest was told universities need to be alert to early signs of anxiety that risk leading to eating disorders developing. As part of this understanding by universities the inquest was told of the need to recognise early signs of mental health issues and listen carefully from an early stage. The skill set/training of academics in welfare roles in relation to mental health was described as key and specific work with Eating Disorder services and training of those involved in welfare programmes supporting students can be effective; ”

    Source location

    Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  7. South Wales Central

    AI-generated summary

    Jack Liam May · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jack May, a 20-year-old nursing student with a longstanding history of mental health problems, died in the River Taff on 25 October 2018; the inquest concluded that his death was suicide. The report raised concerns about the adequacy and accessibility of Cardiff University’s emergency, counselling, wellbeing and pastoral support services for students experiencing mental health or other personal difficulties.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate provision of counselling and wellbeing services for students

    Wider context from the report

    “(1) Provision of sufficient services within Cardiff University to provide emergency help and support for students. Evidence suggested that there may be inadequate provision of counselling and wellbeing services, with long waits being experienced by attendees, also that after 4 appointments, students must reapply. This presents obvious difficulties for students with longer term needs; ”

    Source location

    Jack Liam May · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Invest in and develop the Centre for Student Life as a future home for Student Support Services.

    Verbatim wording from the response

    “2.1 The University has sought to take a lead nationally in debates around student mental health and the development of innovative approaches to supporting students. Our Director of Student Support and Wellbeing, ████████, was a member of the Universities UK Mental Health in HE Group which oversaw the initial development of the Universities UK’s Stepchange¹ strategic approach to mental health. Working with Student Minds UK, the University of the West of England, the University of York and Universities UK, the University is a pilot site for the Stepchange framework and later in 2019 we will launch a new strategy and action plan for mental health, founded on the Stepchange approach, which has been in development over the past 18 months. We are investing in a substantial new building, the Centre for Student Life, which from 2021 will be the home of our Student Support Services.”

    Source location

    2019-0078-Response-by-Cardiff-University
    Page 2 · response
    Published 9 June 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Allocate additional investment for posts supporting risk assessment, triage and management of student crises.

    Verbatim wording from the response

    “4.10 In recent years we have seen a substantial growth in students presenting to our services in crisis, and therefore not a state suitable for counselling. This is an issue we are currently seeking to alter our approach to in response to this presenting change. We are reviewing and improving a range of policies, including in particular our ‘Fitness to Study Procedure’, to make them more accessible and supportive; we are in the early stages of developing a new approach managing risk assessment and intervention where students are experiencing a crisis. We have recently allocated around £150,000 additional investment for new posts to risk assess, triage and manage these situations. This in turn will release staff time back to our counselling provision as the growth in this type of work has, to this point, been reactively managed by our counselling staff.”

    Source location

    2019-0078-Response-by-Cardiff-University
    Page 9 · response
    Published 9 June 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Increase staff time allocated to student counselling and wellbeing services.

    Verbatim wording from the response

    “4.8 At the University Counselling Service management aims for a maximum wait of three working weeks for a combined assessment counselling session (90 minute Therapeutic Consultation); this is normally followed by a four week purposeful gap for the student to explore goals set at that consultation, and a date agreed for the student to re-engage with the service. The service aims for a maximum four week wait for ongoing counselling. Our Wellbeing Team aim for a maximum two weeks wait for assessment and four weeks for ongoing sessions.”

    Source location

    2019-0078-Response-by-Cardiff-University
    Page 8 · response
    Published 9 June 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The University disputes that its counselling and wellbeing provision is inadequate for the purposes its services are intended to fulfil.

    Verbatim wording from the response

    “Matters of Concern 5 (1): “Provision of sufficient services within Cardiff University to provide emergency help and support for students. Evidence suggested there may be inadequate provision of counselling and wellbeing services, with long waits being experienced by attendees, also that after 4 appointments students must reapply. This presents obvious difficulties for students with longer term needs;””

    Source location

    2019-0078-Response-by-Cardiff-University
    Page 7 · response
    Published 9 June 2019

    Open published response
  8. Brighton and Hove

    AI-generated summary

    Daniel Alexander Jeremiah BOWEN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Daniel Alexander Jeremiah BOWEN took his own life, as recorded in the inquest conclusion. Concerns included insufficient use of academic advisors to support him with late work and academic pressures, and flawed communication between university departments, his GP or counsellor, and student support services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to maintain communication links between healthcare providers and student support services

    Wider context from the report

    “(2) With regard to communication – this appeared to be deeply flawed amongst the huge number of University departments and units. The health clinic incorporating amongst other things a pharmacy and the counselling service, was excellent offering free access to students. The system failed – Daniel was not in the link between his GP/counsellor and the student support unit. If this link had been complete I do not believe Daniel would have died when he did. ”

    Source location

    Daniel Alexander Jeremiah BOWEN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce an online student-support tool providing 24/7 access and oversight of vulnerable or at-risk students.

    Verbatim wording from the response

    “Activity/Action | Timeline for completion Creation of a Well-being and Mental Health Strategy | September 2019 Introduction of an online student support tool to offer all students 24/7-year-round access and oversight of vulnerable or at-risk students | September 2020 (expedited to Jan 2020) Fundamental review of assessment and feedback mechanism to ensure inclusive practice, effective learning experiences and achievement of fair outcomes | June 2021 Utilise learning analytic and business intelligence software to provide real time data, informing practices and allowing for targeted interventions. | September 2021”

    Source location

    Response from University of Sussex
    Page 3 · response
    Published 23 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reconfigure pastoral support from separate teams into coordinated thematic services with streamlined processes and clarified responsibilities.

    Verbatim wording from the response

    “Reconfiguration of pastoral support The University is reconfiguring its student support provision from separate teams into thematic areas. The objectives of this reconfiguration are:”

    Source location

    Response from University of Sussex
    Page 3 · response
    Published 23 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Improve professional-service data sharing, case-note access, links and active referrals across student support services.

    Verbatim wording from the response

    “Communication and Data Sharing Following Daniel’s death, the University has reviewed and improved its data sharing and appropriate access to case notes and systems to improve the flow of information across the professional service areas. Professional service staff have improved access to necessary information, links and active referral between constituent areas such as: the Student Support Unit (that works with disabled students and those with specific learning differences and mental health conditions), Student Life and the Counselling Service, to facilitate more cohesive support to students and remove barriers to service access.”

    Source location

    Response from University of Sussex
    Page 3 · response
    Published 23 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue working with the GP practice to improve data sharing about student patients and support risk mitigation.

    Verbatim wording from the response

    “The University is also continuing to work with the GP’s Practice towards improving data sharing about patient/student service users, to ensure pertinent information and knowledge is available to expert practitioners, working together to support students and mitigate the risk of serious self-harm as far as it is possible to do so.”

    Source location

    Response from University of Sussex
    Page 4 · response
    Published 23 February 2024

    Open published response
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Data last updated 7 September 2026