Concerns raised 6 Lack of mandatory suicide prevention and mental health awareness training for academic staff View source Lack of a policy enabling pastoral tutors to exchange mobile numbers with students View source Failure to respond flexibly and proactively to welfare concerns through personal engagement View source Failure of the welfare case management system to ensure follow-up of safeguarding alerts View source Insufficient consideration of notifying families to mobilize student support networks View source Lack of staff awareness and understanding of information-sharing policy thresholds View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
HARRY JOSEPH PENGELLY ARMSTRONG EVANS · 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
Harry Joseph Pengelly Armstrong Evans died by hanging on 24 June 2021 during an acute mental health crisis, following academic pressures and concerns about his wellbeing. The report identified concerns about the university’s lack of proactive personal engagement, failures in safeguarding alert follow-up, insufficient staff awareness of information-sharing policies, and reliance on email and online forms to access welfare 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. The report was sent to University of Exeter; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory suicide prevention and mental health awareness training for academic staff
Wider context from the report “1) Training
The evidence that indicated an absence of mandatory training for academic staff on suicide prevention and mental health awareness .
The University is invited to review the provision of training for academic staff upon information sharing (see below), mental health awareness and suicide prevention.
” 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 University of Exeter; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy enabling pastoral tutors to exchange mobile numbers with students
Wider context from the report “4) Pastoral support
The evidence indicated that if Harry’s pastoral tutor had known Harry’s mobile number, he may have called him. The court heard that there was no policy for pastoral tutors exchanging mobile numbers with students .
The university is invited to review whether pastoral tutors should offer to exchange mobile numbers with their students, and to consider whether pastoral tutors should have a work mobile to facilitate a proactive approach in the event that there are concerns for wellbeing.
” 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 University of Exeter; that does not assign responsibility.
PFD Monitor interpretation Failure to respond flexibly and proactively to welfare concerns through personal engagement
Wider context from the report “2) Responding proactively
The evidence indicated that nobody from the university attempted to speak to or visit Harry despite numerous concerns being raised regarding his wellbeing . There was a total absence of personal engagement .
The court heard that research has consistently shown that most students and staff who experience poor mental health do not access formal support.
The university response was entirely by email and can be characterized as reactive . The evidence indicated a marked reluctance to respond flexibly and proactively to concerns .
The university is invited to review their policy as regards their response to welfare concerns and whether the current approach is sufficiently flexible and proactive. Specifically, whether there is an over-reliance on email responses and students themselves completing online application forms to access support .
” 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 University of Exeter; that does not assign responsibility.
PFD Monitor interpretation Failure of the welfare case management system to ensure follow-up of safeguarding alerts
Wider context from the report “5) Welfare services case management system
The court heard evidence that systems failures led to safeguarding alerts not being followed up and the case marked closed .
The university is invited to review whether the welfare case management system is fit for purpose, whether it is sufficient to capture and ensure actions on welfare concerns raised by students or third parties.
” 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 University of Exeter; that does not assign responsibility.
PFD Monitor interpretation Insufficient consideration of notifying families to mobilize student support networks
Wider context from the report “3) Sharing information
The university policy allows sharing of information with consent in circumstances involving a concern for wellbeing, and without consent in exceptional circumstances. This necessarily would have involved a conversation with Harry and failing that a consideration whether exceptional circumstances applied for sharing information with his parents.
The evidence revealed a lack of staff awareness regarding university policy on information sharing. There was evidence of a misunderstanding of policy which specifically allowed the sharing of information in cases of concern, subject to discussion with Harry, and then in exceptional circumstances without his consent. Witnesses referred to a blanket ban on sharing or alternatively to sharing only if they perceived imminent risk to life.
The evidence indicated that there was insufficient consideration given to notifying Harry’s parents of the extent of his exam failure, in order to fully mobilize Harry’s support network . There was no evidence of the ‘Think Family’ approach adopted by the university following previous suicides .
The University is invited to review the thresholds for sharing information and staff awareness of those thresholds, and the implementation and understanding across academic and welfare staff of the Think Family approach.
” 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 University of Exeter; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness and understanding of information-sharing policy thresholds
Wider context from the report “3) Sharing information
The university policy allows sharing of information with consent in circumstances involving a concern for wellbeing, and without consent in exceptional circumstances. This necessarily would have involved a conversation with Harry and failing that a consideration whether exceptional circumstances applied for sharing information with his parents.
The evidence revealed a lack of staff awareness regarding university policy on information sharing . There was evidence of a misunderstanding of policy which specifically allowed the sharing of information in cases of concern, subject to discussion with Harry, and then in exceptional circumstances without his consent. Witnesses referred to a blanket ban on sharing or alternatively to sharing only if they perceived imminent risk to life .
The evidence indicated that there was insufficient consideration given to notifying Harry’s parents of the extent of his exam failure, in order to fully mobilize Harry’s support network. There was no evidence of the ‘Think Family’ approach adopted by the university following previous suicides.
The University is invited to review the thresholds for sharing information and staff awareness of those thresholds, and the implementation and understanding across academic and welfare staff of the Think Family approach.
” 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 Review risk-assessment procedures to ensure family contact is routinely considered in safety planning.
Verbatim wording from the response “The University recognises that such clarity is essential to ensure best standards of safe practice in the management of students with complex needs. In addition, the University has reviewed its risk assessment procedure to ensure contact with family is routinely considered in safety planning.” Source location Response from Vice-Chancellor's
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 Consolidate staff mental-health training courses and clarify attendance requirements for student-facing roles.
Verbatim wording from the response “The University currently offers a range of mental health awareness training courses for academic and Professional Services colleagues who are in student facing roles. Following receipt of the Report, the University has undertaken a detailed review of this provision. Part of this review has identified the need to consolidate the courses offered and to provide clarity on who should attend, to ensure that everyone in student facing roles has the awareness and information to support students who are struggling. This work is already underway.” Source location Response from Vice-Chancellor's
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 Formalise the trusted-contact framework in university policies and standardise its use across student-facing services.
Verbatim wording from the response “The University has considered the Report alongside wider sector publications including the UUK Report into Suicide Prevention. The University has been operating using the guidelines of a ‘trusted contact’ framework since 2020, taking a risk-based approach to determine when this is invoked, and allowing us to contact students’ families or guardians or trusted contacts in times of crisis. A trusted contact framework considers whether in times of crisis or ill health the University could contact their nominated person to provide additional support to a student or to raise concerns for a student’s wellbeing.” Source location Response from Vice-Chancellor's
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 Procure and integrate a replacement welfare case-management system for operation during the 2023/24 academic year.
Verbatim wording from the response “As was noted during the Inquest, following Harry’s death the University had already undertaken a robust review of its current Case Management System (“CMS”). Steps had already been taken to identify technical issues and options for mitigation. All relevant colleagues have been made aware of the potential weaknesses in the existing system and appropriate mitigations are in place to minimise, as far as is possible, repeat issues occurring before the new system is implemented as soon as possible in 2023 with a view to the system being operational within the Academic Year 2023/24. These mitigations include:” Source location Response from Vice-Chancellor's
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 Provide staff and students with information about strengthened out-of-hours support and its access routes.
Verbatim wording from the response “The University has invested significantly in out of hours support to ensure there is a team of trained members of staff who can proactively support students in need. The Out of Hours provision is being further reviewed for additional investment, however, the University has already taken the opportunity to strengthen its Out Of Hours provision and to provide additional detail and information for all staff and students regarding the availability of this resource. This means wherever a member of staff has concerns about a student they can immediately reach out to these teams to ask for support. Additional information and details of the available support is also included on the University’s website.” Source location Response from Vice-Chancellor's
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 academic-staff awareness of out-of-hours support and contact details for proactive student outreach.
Verbatim wording from the response “Whilst the University will not be asking staff to exchange mobile numbers with their students, and nor will work mobiles be provided for this purpose, the University has increased its awareness raising for academic staff on the availability of access to people who can provide support to students outside of the working day and the associated contact details so they can arrange for proactive reach outs. We will play an active part in sector discussions on this issue and will keep our position under review to ensure we continue to be fully aligned with the sector.” Source location Response from Vice-Chancellor's
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 Conduct a practice review of academic support for students and consider and implement its findings.
Verbatim wording from the response “University Response: Supported by the enhanced training provision described above, Personal Tutors will be able to reach out to students who they feel are struggling, and identify support available, including referral to expert Wellbeing support, with the ability to check and review how the support has been received. Furthermore, we have set up a practice review on academic support for students and we will consider and implement its findings carefully.” Source location Response from Vice-Chancellor's
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 Expand out-of-hours provision to provide 24-hour telephone emergency support for students in crisis across all campuses.
Verbatim wording from the response “As was set out during the Inquest, concerns have been flagged by academic colleagues, professional services and sector representatives with regards to the proposed sharing of mobile numbers. The concerns include that this approach could have potential safeguarding implications, severe impacts on colleague wellbeing, and may mean students requiring urgent support do not use the appropriate Out Of Hours support service. With this in mind, the University is expanding its out of hours provision to ensure emergency support is available via phone for students in crisis twenty four hours a day across all our campuses. Advice is available to all staff out-of-hours (via our Estate Patrol team in the first instance) where there are serious student mental health concerns.” Source location Response from Vice-Chancellor's
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 a phased, role-appropriate suicide-prevention and mental-health training programme for staff, including mandatory introductory training.
Verbatim wording from the response “Further to the review of staff training, the University wishes to embed good practice in suicide safety and adopt a whole university approach to suicide prevention. This will involve a phased roll-out of training for all staff that is (a) appropriate to their personal/emotional capacity (it may not be appropriate for some colleagues) and (b) relevant and proportionate to their institutional role. The training will be separated into four levels ensuring the level of training taken is based on training needs assessment, role and individual skills and expertise, as follows:” Source location Response from Vice-Chancellor's
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 Review student-distress responses and existing processes for the January assessment period.
Verbatim wording from the response “A review has been undertaken of our response to students in distress and, in the short term, we are also carefully reviewing existing processes for the upcoming January assessment period.” Source location Response from Vice-Chancellor's
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 case-management mitigations, including welfare tracking, safe voicemail referral storage, staff reminders, procedural guidance and individual training support.
Verbatim wording from the response “As was noted during the Inquest, following Harry’s death the University had already undertaken a robust review of its current Case Management System (“CMS”). Steps had already been taken to identify technical issues and options for mitigation. All relevant colleagues have been made aware of the potential weaknesses in the existing system and appropriate mitigations are in place to minimise, as far as is possible, repeat issues occurring before the new system is implemented as soon as possible in 2023 with a view to the system being operational within the Academic Year 2023/24. These mitigations include:” Source location Response from Vice-Chancellor's
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 Existing out-of-hours support is considered sufficient, so staff will not exchange mobile numbers or receive work mobiles for student contact.
Verbatim wording from the response “As was set out during the Inquest, concerns have been flagged by academic colleagues, professional services and sector representatives with regards to the proposed sharing of mobile numbers. The concerns include that this approach could have potential safeguarding implications, severe impacts on colleague wellbeing, and may mean students requiring urgent support do not use the appropriate Out Of Hours support service. With this in mind, the University is expanding its out of hours provision to ensure emergency support is available via phone for students in crisis twenty four hours a day across all our campuses. Advice is available to all staff out-of-hours (via our Estate Patrol team in the first instance) where there are serious student mental health concerns.” Source location Response from Vice-Chancellor's
Open published response
14 Dec 2015 William Jeffrey MASKELL · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 3 Insufficient capacity for timeous intervention for students in distress View source Failure to prioritise welfare over student privacy in urgent intervention decisions View source Lack of a clear protocol for agency and police involvement View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
William Jeffrey MASKELL · 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
William Jeffrey MASKELL, who had Bipolar Disorder, was found collapsed in his university room after ingesting a fatal quantity of Venlafaxine and Lamotrigine. He was taken to hospital but was declared deceased. Concerns included the lack of a clear protocol for involving relevant agencies and the Police, delays in attending and forcing entry, and a risk of future deaths from untimely intervention.
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 University of Exeter; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity for timeous intervention for students in distress
Wider context from the report “3. There is a real risk of future deaths of students in distress for lack of timeous intervention because of the current restraints .
” 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 University of Exeter; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise welfare over student privacy in urgent intervention decisions
Wider context from the report “2. The respect for the autonomy of the student in running his/her private life appeared to take precedence over a real concern for welfare , resulting in delays in attendance at the scene and a reluctance to take the decision to force entry .
It appears that the Students Union’s opposition to any erosion of the students’ human rights (to privacy) was a factor.
” 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 University of Exeter; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear protocol for agency and police involvement
Wider context from the report “1. The decision to go to William’s room was hampered by the lack of a clear protocol for the involvement of the relevant agencies and the Police .
” 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 Clarify the accommodation agreement regarding emergency entry after consulting the Students’ Guild.
Verbatim wording from the response “As a result of this review, we can however see a benefit to all in further clarifying our current practices to staff, students and parents to aid their understanding as to the remit of the Wellbeing Service. We will therefore work to make more explicit and transparent all of our current procedures and practices around student welfare support. These actions will include:” Source location William-Maskell-Response
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 Conduct an independent external review of out-of-hours welfare support and crisis-management practices, including duty-of-care, legal, resourcing and infrastructure requirements.
Verbatim wording from the response “Separately to the review conducted following receipt of the Regulation 28 Report, the University had already undertaken to engage an independent third party to review its practices around out-of-hours welfare support and crisis management, taking into consideration the University’s duty of care and legal responsibilities as well as resourcing and infrastructure requirements. This review forms part of the University’s ongoing commitment to ensuring best practice in the industry. We anticipate this external review will be completed by May 2016.” Source location William-Maskell-Response
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 Complete a full review of processes for supporting students in crisis and deciding whether emergency entry to university accommodation is needed.
Verbatim wording from the response “The University, in line with your recommendations, has conducted a full review of its processes and procedures in respect of students in crisis, and in particular how the Wellbeing Service decides whether (and how) emergency entry should be gained to a student’s room. The review” Source location William-Maskell-Response
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 Publish and disseminate standards for responding to reported imminent high risk to life, including engagement with emergency services.
Verbatim wording from the response “As a result of this review, we can however see a benefit to all in further clarifying our current practices to staff, students and parents to aid their understanding as to the remit of the Wellbeing Service. We will therefore work to make more explicit and transparent all of our current procedures and practices around student welfare support. These actions will include:” Source location William-Maskell-Response
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 room-entry decision was not hampered by absent agency protocols or privacy taking precedence over welfare; the student was assessed as low risk.
Verbatim wording from the response “Having conducted the above referenced review the University does not agree that the decision to enter Mr Maskell’s room was hampered either by lack of protocols with partner agencies or by a consideration that personal privacy should take precedence over a concern for welfare. Whilst the latter was a consideration, this was because Mr Maskell was classified as being at low risk of self-harm. As the Coroner rightly identified, students often miss appointments with the Wellbeing Service and it is not reasonable to have an escalation policy in place for those classed as being at low risk of self-harm. Had Mr Maskell been classed as being at risk to himself, the Management of students at risk policy and procedure would have been followed.” Source location William-Maskell-Response
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 Immediate room entry for a student assessed as low risk would exceed the University’s legal responsibilities and duty of care.
Verbatim wording from the response “In the absence of an assessment raising his risk classification or specific knowledge of information which would place him in a higher risk category, immediately seeking entry to the room would have been acting beyond normal practice in the higher education sector. Furthermore, we believe that to have” Source location William-Maskell-Response
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations