27 Jan 2022 Finnian Gabriel Denney Kitson · Prevention of Future Deaths report Manchester City
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Concerns raised 1 Failure to provide a separate, explicit option to disclose mental health illness on application forms View source
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Finnian Gabriel Denney Kitson · 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
Finnian Gabriel Denney Kitson, who had been diagnosed with anxiety and prescribed medication, took his own life in student accommodation on 8 October 2020, shortly after commencing studies at The University of Manchester. The report’s principal concern was that the UCAS application process did not refer separately and explicitly to mental health illness, which could discourage applicants from disclosing diagnoses and limit access to support when starting university.
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. The report was sent to Universities and Colleges Admissions Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a separate, explicit option to disclose mental health illness on application forms
Wider context from the report “The option for applicants to disclose a mental health illness should be considered separately to them confirming whether they have any ‘disability’ or ‘special needs’. It is likely that the majority of applicants will consider evidence of a disability or special needs to refer to physical illness, not mental health illness. Moreover, those who suffer from mental health illness (irrespective of its severity) will often not consider themselves to have a ‘disability’.
Omitting to refer specifically (and explicitly) to mental health on the form could, in my judgment, discourage applicants from disclosing information about their mental health diagnosis , and thus provide them with support at the point they commence their studies.
” Open source report
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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 revised application health-question wording, help text and categories with greater emphasis on mental health for the 2023 entry cycle.
Verbatim wording from the response “In July 2019, UCAS held a cross-sector roundtable discussion to review this question, with a particular focus on the needs of students sharing a mental health condition. The group, which comprised representatives from sector bodies (such as Universities UK and Advance HE) and expert organisations (such as NADP, UMHAN and Student Minds), concluded that the format of the question remained fit for purpose, but a significant update to the wording of the question, help text and categories was needed – including a greater emphasis on mental health. Work to review the language was subsequently completed by autumn 2019 and the full revisions – outlined below – will be introduced in May 2022 for the 2023 entry cycle. The full text can be found in Annex A.” Source location 2022-0023-Response-from-UCAS_Published
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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 Update the application health question’s help text and on-screen wording to broaden coverage of conditions and impairments.
Verbatim wording from the response “In the period between the agreed changes and implementation, we made a number of interim adjustments: in November 2019, we updated the help text to reflect the broader range of conditions and impairments captured and, in May 2021, we made further improvements to the on-screen question text, as follows:” Source location 2022-0023-Response-from-UCAS_Published
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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 Convene a summer 2022 event to revisit the UCAS application question and reassess whether the existing approach remains appropriate.
Verbatim wording from the response “As part of our ongoing commitment to ensuring students receive the best experience possible, we regularly review our products and services to ensure that they are fit for purpose. Student mental health is at the forefront of these commitments, and a matter UCAS takes very seriously. Cognisant of the changes to the landscape since we held our original roundtable in 2019, we have committed to convening another event in summer 2022 whereby we will revisit our discussion about the UCAS application and check our original decision remains the best approach. We are also currently undertaking a review of the reference section, which allows teachers and advisers – with the permission of the applicant – to flag any mitigating circumstances, such as a mental health condition.” Source location 2022-0023-Response-from-UCAS_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The UCAS question format was considered fit for purpose, although its wording, help text and categories required updating.
Verbatim wording from the response “In July 2019, UCAS held a cross-sector roundtable discussion to review this question, with a particular focus on the needs of students sharing a mental health condition. The group, which comprised representatives from sector bodies (such as Universities UK and Advance HE) and expert organisations (such as NADP, UMHAN and Student Minds), concluded that the format of the question remained fit for purpose, but a significant update to the wording of the question, help text and categories was needed – including a greater emphasis on mental health. Work to review the language was subsequently completed by autumn 2019 and the full revisions – outlined below – will be introduced in May 2022 for the 2023 entry cycle. The full text can be found in Annex A.” Source location 2022-0023-Response-from-UCAS_Published
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28 Oct 2019 Julius Jake Little · Prevention of Future Deaths report Inner North London
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Concerns raised 2 Failure to secure engagement with mental health support invitations View source Failure to effectively disseminate mental health disclosure information to tutors and halls of residence staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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. The report was sent to Universities and Colleges Admissions Service; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Universities and Colleges Admissions Service; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively disseminate mental health disclosure information to tutors and halls of residence staff
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.
” Open source report
25 Jul 2019 Owen Arron Wynne Williams · Prevention of Future Deaths report West Yorkshire (West)
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Concerns raised 4 Delays in staff support availability after unexpected A level results View source Delayed UCAS availability after educational institutions release student results View source Lack of national agreement on the timing and manner of A level results release View source Lack of national requirement for advance direct parental communication about A level results release and potential unexpected results View source See 1 more concern
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Owen Arron Wynne Williams · 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
Owen Williams was found unresponsive, suspended by a rope tied to a tree in a secluded wooded area, after accessing A level results that did not meet the grades required for his intended university course; his death was confirmed later that day. The report identified concerns about the lack of national consistency in how and when A level results are released, delays before support is available, UCAS opening later, and the absence of a national requirement to inform parents in advance about the results-release system and potential impact of unexpected results.
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. The report was sent to Universities and Colleges Admissions Service; that does not assign responsibility.
PFD Monitor interpretation Delays in staff support availability after unexpected A level results
Wider context from the report “I heard evidence from the Principal of the college that Owen attended that there is wide variance both locally and nationally of the timing and way in which colleges release A level results, some release results electronically as early as 6.00 am and later the same morning provide a facility within the school and college to provide support to students, some colleges / schools require the students to physically attend to obtain their results, when at the same time support by staff members is immediately on hand.
I understand UCAS is available from 8.00 am onwards, once again some hours after some students have obtained their results.
In particular, from the evidence presented to me it appears:-
1. That there is no national agreement across all educational institutions to the timing and manner in which A level results are released.
2. That there can be a significant time lag between results being released by some schools and colleges and the timing of when there is the availability of staff to provide support to those students that may have received unexpected results.
3. That UCAS is presently available some hours after some educational institutions have released student results.
4. That there is no national requirement for educational establishments to communicate directly to parents in advance of results day and explain the system in place for the release of the A level results at the educational establishment that their child is attending and to alert them to the potential that unexpected results can occur and to be alert to the impact that this may have upon their child.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Universities and Colleges Admissions Service; that does not assign responsibility.
PFD Monitor interpretation Delayed UCAS availability after educational institutions release student results
Wider context from the report “I heard evidence from the Principal of the college that Owen attended that there is wide variance both locally and nationally of the timing and way in which colleges release A level results, some release results electronically as early as 6.00 am and later the same morning provide a facility within the school and college to provide support to students, some colleges / schools require the students to physically attend to obtain their results, when at the same time support by staff members is immediately on hand.
I understand UCAS is available from 8.00 am onwards, once again some hours after some students have obtained their results.
In particular, from the evidence presented to me it appears:-
1. That there is no national agreement across all educational institutions to the timing and manner in which A level results are released.
2. That there can be a significant time lag between results being released by some schools and colleges and the timing of when there is the availability of staff to provide support to those students that may have received unexpected results.
3. That UCAS is presently available some hours after some educational institutions have released student results.
4. That there is no national requirement for educational establishments to communicate directly to parents in advance of results day and explain the system in place for the release of the A level results at the educational establishment that their child is attending and to alert them to the potential that unexpected results can occur and to be alert to the impact that this may have upon their child.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Universities and Colleges Admissions Service; that does not assign responsibility.
PFD Monitor interpretation Lack of national agreement on the timing and manner of A level results release
Wider context from the report “I heard evidence from the Principal of the college that Owen attended that there is wide variance both locally and nationally of the timing and way in which colleges release A level results, some release results electronically as early as 6.00 am and later the same morning provide a facility within the school and college to provide support to students, some colleges / schools require the students to physically attend to obtain their results, when at the same time support by staff members is immediately on hand.
I understand UCAS is available from 8.00 am onwards, once again some hours after some students have obtained their results.
In particular, from the evidence presented to me it appears:-
1. That there is no national agreement across all educational institutions to the timing and manner in which A level results are released.
2. That there can be a significant time lag between results being released by some schools and colleges and the timing of when there is the availability of staff to provide support to those students that may have received unexpected results.
3. That UCAS is presently available some hours after some educational institutions have released student results.
4. That there is no national requirement for educational establishments to communicate directly to parents in advance of results day and explain the system in place for the release of the A level results at the educational establishment that their child is attending and to alert them to the potential that unexpected results can occur and to be alert to the impact that this may have upon their child.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Universities and Colleges Admissions Service; that does not assign responsibility.
PFD Monitor interpretation Lack of national requirement for advance direct parental communication about A level results release and potential unexpected results
Wider context from the report “I heard evidence from the Principal of the college that Owen attended that there is wide variance both locally and nationally of the timing and way in which colleges release A level results, some release results electronically as early as 6.00 am and later the same morning provide a facility within the school and college to provide support to students, some colleges / schools require the students to physically attend to obtain their results, when at the same time support by staff members is immediately on hand.
I understand UCAS is available from 8.00 am onwards, once again some hours after some students have obtained their results.
In particular, from the evidence presented to me it appears:-
1. That there is no national agreement across all educational institutions to the timing and manner in which A level results are released.
2. That there can be a significant time lag between results being released by some schools and colleges and the timing of when there is the availability of staff to provide support to those students that may have received unexpected results.
3. That UCAS is presently available some hours after some educational institutions have released student results.
4. That there is no national requirement for educational establishments to communicate directly to parents in advance of results day and explain the system in place for the release of the A level results at the educational establishment that their child is attending and to alert them to the potential that unexpected results can occur and to be alert to the impact that this may have upon their child.
” Open source report
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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 Jointly host a roundtable with education-sector representatives to explore consistent school practice, embargo timing, student support and alternative higher-education choices.
Verbatim wording from the response “On receipt of your letter, we contacted the Department for Education (DfE) and (JCQ) to discuss our own concerns about the time at which students can access their results without support from their school or college – and the inconsistency in approach. We believe improvements could be made to the process, and we are keen to work with DfE, JCQ, awarding organisations, schools, and colleges to improve the overall experience for students. In order to take this forward, we will jointly host a roundtable with DfE to explore how we can support students throughout the examination and results periods, particularly those who do not receive the grades they had hoped for.” Source location 2019-0250-Response-by-UCAS
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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 Provide telephone and social-media support through the Customer Experience Centre during the Confirmation and Clearing period.
Verbatim wording from the response “Most importantly, our Customer Experience Centre offers support via telephone and social media during the Confirmation and Clearing period, ensuring students have access to the right information and advice for their needs.” Source location 2019-0250-Response-by-UCAS
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2 May 2019 Benjamin James Charles MURRAY · Prevention of Future Deaths report Avon
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Concerns raised 2 Failure to ensure that mental health disclosure is de-stigmatised and does not deter university admission View source Lack of post-death investigation reports for student deaths View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Benjamin James Charles MURRAY · 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
On 5 May 2018, Ben was found beneath the Clifton suspension bridge after walking onto the bridge, climbing onto the buttress wall and propelling himself forward. The inquest concluded that his death was suicide. The report raised concerns about mental health disclosure by university applicants, the pastoral role of universities during transition to higher education, and the absence of university investigation reports following a student 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. The report was sent to Universities and Colleges Admissions Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that mental health disclosure is de-stigmatised and does not deter university admission
Wider context from the report “2. For UCAS, The Department of Education and The Minister for Suicide Prevention
The concern over mental health disclosure either on the UCAS application form or indeed to a prospective University.
I am told that currently such disclosure is at 37%. There needs to be a move towards de-stigmatising mental health and ensuring that students are made aware that by disclosing mental health problems on their UCAS form or to their prospective University that it will not affect getting a place at University.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Universities and Colleges Admissions Service; that does not assign responsibility.
PFD Monitor interpretation Lack of post-death investigation reports for student deaths
Wider context from the report “3. For Bristol University, The Department of Education and The Minister for Suicide Prevention
The transition from home to University can be a challenging time for some students and Universities clearly have the primary role of education however this inquest has demonstrated they also carry out an important pastoral role.
It is not the role of the Coroner to investigate Ben’s journey through University in light of the circumstances of his tragic death and the limited scope. That said as a Coroner has a duty to consider prevention of future deaths it was appropriate in this case that aspects of Ben’s progress were investigated by me.
In addition currently the University sector does not carry out an investigation report (such as a root cause analysis or sudden untoward investigation) after a death of a student. Such a written report usually affords an opportunity to review what happened; what was done well/the good practice points; areas of concern, if there are any, and importantly what lessons can be learned often with a formal written action plan. Such a document is also very helpful to the Coroner when considering and discharging this duty. Such a formal process and document most importantly assists in preventing future deaths.
” Open source report
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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 Redesign the undergraduate application’s questions and supporting help text about disability, special needs and mental health information.
Verbatim wording from the response “As part of a wider programme of business change, we are redeveloping our online application for undergraduate students. This affords us the opportunity to work with organisations such as Student Minds and the UMHAN to redesign how we ask for information about disabilities, special needs, or mental health issues – and the help text that supports this. To understand the most appropriate and effective way in which to redesign this question, we’re holding a roundtable discussion on 30 July with representatives from sector bodies and expert organisations, the result of which will be in place in 2020, for the 2021 entry cycle.” Source location 2019-0155-Response-by-UCAS
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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 Explore using the UCAS Hub to strengthen application and transition messaging and signpost support services and experts.
Verbatim wording from the response “Alongside the new application service, we have developed the UCAS Hub – a new online information and advice tool to support students through every step of their decision-making journey, which surfaces the right information at the right time, based on their expressed preferences and interests. The first version of this will go live this autumn. We are exploring how the UCAS Hub could help strengthen the messaging about all aspects of applying and going to university, to alleviate anxiety during the application process, as well as regularly signposting the support services and experts who can offer help once they have made the transition.” Source location 2019-0155-Response-by-UCAS
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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 Continue collaborating with student organisations to keep declaration content up to date and distribute it to applicants appropriately.
Verbatim wording from the response “Applicants are encouraged to declare if they have a disability, special need, or mental health concern, so that universities’ student support teams are aware and offer additional help. However, we understand from our work that it can be difficult for young people to self-declare this type of personal, sensitive information. To address this, we have worked with organisations such as Student Minds and the University Mental Health Advisers Network (UMHAN) to develop additional content that reinforces the importance of declaring a mental health concern, explains the benefits of doing so, and clarifies how this information is used by UCAS and the university or college. We will continue to work with such organisations to ensure that our content is up-to-date, and reaches our applicants in a timely and appropriate manner.” Source location 2019-0155-Response-by-UCAS
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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 Hold a sector and expert roundtable to determine the most appropriate redesign of mental health-related application questions.
Verbatim wording from the response “As part of a wider programme of business change, we are redeveloping our online application for undergraduate students. This affords us the opportunity to work with organisations such as Student Minds and the UMHAN to redesign how we ask for information about disabilities, special needs, or mental health issues – and the help text that supports this. To understand the most appropriate and effective way in which to redesign this question, we’re holding a roundtable discussion on 30 July with representatives from sector bodies and expert organisations, the result of which will be in place in 2020, for the 2021 entry cycle.” Source location 2019-0155-Response-by-UCAS
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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 Provide content explaining the importance and benefits of declaring mental health concerns and how UCAS and providers use that information.
Verbatim wording from the response “Applicants are encouraged to declare if they have a disability, special need, or mental health concern, so that universities’ student support teams are aware and offer additional help. However, we understand from our work that it can be difficult for young people to self-declare this type of personal, sensitive information. To address this, we have worked with organisations such as Student Minds and the University Mental Health Advisers Network (UMHAN) to develop additional content that reinforces the importance of declaring a mental health concern, explains the benefits of doing so, and clarifies how this information is used by UCAS and the university or college. We will continue to work with such organisations to ensure that our content is up-to-date, and reaches our applicants in a timely and appropriate manner.” Source location 2019-0155-Response-by-UCAS
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations