Recurring concern

Failure to reliably identify and support students with emerging mental-health needs

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First reported 24 Jul 2019•Latest report 10 Jul 2024

Definition

What this concern includes

Includes university processes for identifying students whose academic absence, performance changes, work difficulties, neurodiversity or other circumstances indicate possible emerging mental-health need; proactive outreach and engagement; initial enquiry; referral or connection to support services; and coordination of ongoing support where these controls directly concern student mental-health safety.

Not included

  • Excludes general student mental-health service capacity or waiting-time deficiencies where the failure is not the university's identification, outreach or connection-to-support process.
  • Excludes generic academic performance monitoring, pastoral support or staff-training deficiencies unless they directly impair identification or support of students with emerging mental-health needs.
  • Excludes clinical mental-health assessment or treatment failures after a student has been reliably identified and connected to an appropriate service.
  • Excludes neutral descriptions of student mental-health prevalence, academic pressure or neurodiversity without an asserted failure of identification, engagement or support arrangements.
  • Excludes failures belonging to a separately named statutory, clinical or specialist mental-health pathway when that pathway provides the more specific supported boundary.
Reports
4

Distinct published reports

Individual concerns
7

A report can raise multiple concerns

Date range
2019–2024

First to latest report issue date

Stated actions
8

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.

Cheshire and Wirral Partnership NHS Foundation Trust1
Department for Education1
Department of Health and Social Care1
Greater Manchester Mental Health NHS Foundation Trust1
Health and Safety Executive1
Universities and Colleges Admissions Service1
Universities UK1
University of Reading1
University of Southampton1
University of the Arts London1

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. 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

    Failure to maintain contact with vulnerable students during unresolved academic situations

    Wider context from the report

    “(5) By March 2023 Ben’s department at Reading University knew that Ben was a student with severe mental health concerns linked to management of his academic work, who had not taken any exam and had not completed sufficient research to file a dissertation and by late June they also knew that he had not completed paperwork to suspend his studies and yet: a. The University staff who knew this did not appear to appreciate what it meant for Ben and his continuing risk of vulnerability; and b. There was no individual who was given or took responsibility for what should happen next with regard to resolving Ben’s academic situation; and c. Apart from brief further contact from the Student Support Centre the suspension forms, no-one from the University contacted Ben between 24 April 2023 and when he took his life on or around 5 August 2023; ”

    Source location

    Benjamin Faux · 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

    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

    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

    Flag vulnerable students discussing withdrawal or suspension to relevant Student Support Centres and Student Wellbeing Services teams.

    Verbatim wording from the response

    “3 | There will be a range of circumstances in which students, outside of our formal fitness to study process, may need to consider the possibility of suspending their studies. Our system for supporting students through to the conclusion of such discussions, is a weakness that the Coroner has correctly identified.”

    Source location

    Response from Reading University
    Page 2 · response
    Published 29 July 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

    Assign SDATs responsibility for ensuring Master’s by Research student-support processes are completed.

    Verbatim wording from the response

    “5b and 5c | The University has clarified that the student support in place for MbR students should be aligned as far as possible with those on taught programmes. Therefore, it is the relevant SDAT who is responsible for ensuring that student support processes are seen through to completion for these students. | 1. New notification system to be implemented whereby the SDAT emails reminders to relevant academic staff at regular intervals to monitor and report engagement of MbR students. SSCs to provide”

    Source location

    Response from Reading University
    Page 3 · response
    Published 29 July 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

    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

    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

    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

    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 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

    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

    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

    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

    Open published response
  2. 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

    Failure to equip academic staff to identify and appropriately engage students with neurodiversity

    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 2 · 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

    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

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Gap between academic assessment and pastoral support for students

    Wider context from the report

    “2. It was evident to the Court that very positive steps have already been undertaken in planning towards an early warning system for students in the academic year 2023/24. This will allow triggers to be identified and set for academic absence and changes in study or support behaviours (as is to be trialled in 2023/24). Such steps are to be commended and I hope will proceed at pace. However, I do have concerns that there is and remains an evident gap between the academic assessment of students and the pastoral support that they receive. I hope this will be addressed and filled – in part in the development of staff training and understanding around mental health and in what circumstances concerns should be raised (as above). Where academic absence or performance issues are identified, I am not convinced, on the evidence heard at this inquest, that enough has yet been done to also consider how ‘reaching out’ to such students can be most effectively achieved. It was evident that much of the group-focused approaches offered by the university or the initiatives where the onus is placed on the student to come forward, may not work. Practically, how best can students – especially those with neurodiverse needs – be compassionately and empathically approached and engaged with to ensure they receive the help and validation that they probably desperately require? ”

    Source location

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

    Open source report
  3. Inner North London

    AI-generated summary

    Julius Jake Little · 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

    Julius Jake Little, a 20-year-old undergraduate living in university halls, was found unresponsive on 7 June 2019 with a ligature around his neck and was pronounced dead despite resuscitation efforts. The report raised concerns about how universities use disclosed mental-health information, including limited student responses to support offers and the lack of communication of disclosure information to tutors and halls staff.

    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 secure engagement with mental health support invitations

    Wider context from the report

    “In the course of hearing an inquest at Poplar Coroner's Court on 9/10/19 into the death of Julius Jake Little, evidence was considered in relation to available support services offered to undergraduates at UAL who have a history of mental health problems. The Dean of Students at UAL ████████, gave evidence that applicants to UAL make an online application to the admissions organisation UCAS. The application invites them to disclose any history they have of mental health problems, upon being accepted on a course of study this information is provided to the admitting university. ████████ indicated that the mental health disclosure information is used to target students that may require support, and at UAL emails are sent to undergraduates, inviting them to register with the university's support services. Regrettably, it would appear that of UAL's cohort of students that disclosed mental health problems to UCAS, only 66% of undergraduates responded to the email invitation offering mental health support. The remaining 33%, a total of some 200 students, did not respond to the offer. I asked ████████ whether the identity of students who had made a mental health disclosure in their UCAS application was communicated to tutors and halls of residence staff at the university. I was informed that this information was not so disseminated as it would be breach of data protection legislation, this appears to be a missed opportunity. I cannot suggest a solution to this problem, however it does appear to be a lost opportunity to secure this valuable information but not to utilise it effectively. ”

    Source location

    Julius Jake Little · 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

    Initiate pre- and post-enrolment email campaigns encouraging students with disclosed mental health conditions to engage with support services.

    Verbatim wording from the response

    “For the 2019/20 academic year we have made improvements to our processes for engaging disabled students, including those with long-term mental health conditions, with our support services. At the point that the information in respect of mental health conditions is shared with the university by UCAS, a pre- and post-enrolment email campaign is initiated, asking students to engage with support services. Our Disability Advisers make contact with students who have declared a disability and are requesting support. In addition, Disability Advisers are now actively following up on those students who have not engaged with support services. This has enabled us to significantly reduce the number of students who declared a long-term mental health condition prior to enrolment and are not engaging with support services from 33% in 2018 to 4% in 2019.”

    Source location

    2019-0371-Response-by-UAL
    Page 1 · response
    Published 13 December 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

    Have Disability Advisers contact students who disclose disabilities and request support.

    Verbatim wording from the response

    “For the 2019/20 academic year we have made improvements to our processes for engaging disabled students, including those with long-term mental health conditions, with our support services. At the point that the information in respect of mental health conditions is shared with the university by UCAS, a pre- and post-enrolment email campaign is initiated, asking students to engage with support services. Our Disability Advisers make contact with students who have declared a disability and are requesting support. In addition, Disability Advisers are now actively following up on those students who have not engaged with support services. This has enabled us to significantly reduce the number of students who declared a long-term mental health condition prior to enrolment and are not engaging with support services from 33% in 2018 to 4% in 2019.”

    Source location

    2019-0371-Response-by-UAL
    Page 1 · response
    Published 13 December 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

    Have Disability Advisers actively follow up students who have not engaged with support services.

    Verbatim wording from the response

    “For the 2019/20 academic year we have made improvements to our processes for engaging disabled students, including those with long-term mental health conditions, with our support services. At the point that the information in respect of mental health conditions is shared with the university by UCAS, a pre- and post-enrolment email campaign is initiated, asking students to engage with support services. Our Disability Advisers make contact with students who have declared a disability and are requesting support. In addition, Disability Advisers are now actively following up on those students who have not engaged with support services. This has enabled us to significantly reduce the number of students who declared a long-term mental health condition prior to enrolment and are not engaging with support services from 33% in 2018 to 4% in 2019.”

    Source location

    2019-0371-Response-by-UAL
    Page 1 · response
    Published 13 December 2019

    Open published response
  4. 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

    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
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Data last updated 7 September 2026