16 May 2021 Sarah Margaret Clarke · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 12 Insufficiently robust systems for managing, treating and safeguarding high-risk students with mental health problems View source Failure to verify the safety of distressed students from self-harm View source Higher incidence of student mental health difficulties, self-harm and suicide View source Failure to implement national guidance to reduce student suicide View source Failure to complete a serious incident report on CWB working practices View source Failure to undertake reflection on CWB working practices View source Lack of national guidance on basic university mental health service requirements View source Failure to secure local NHS mental health service involvement in CWB service provision View source Lack of internal oversight of CWB service provision View source Insufficient communication and learning between CWB and local NHS mental health services View source Lack of external regulatory oversight of CWB service provision View source Failure to establish robust systems confirming student safety View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 13
Action
Host a mental health round-table event with local support services to reinforce and strengthen existing relationships.
Stated plannedThe respondent said that this action was planned when they made their response on 1 December 2022. View source
Action
Deliver suicide-awareness, mental-health, distressed-student and safeguarding training, including ASIST for relevant security staff and training for personal tutors.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2022. View source
Action
Implement student concern reporting, repeated follow-up and escalation processes, including escalation to health, security or police services when appropriate.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2022. View source
Action
Strengthen case management through caseload monitoring, daily advisor check-ins, structured handovers and cross-service information sharing for students of concern.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2022. View source
Action
Implement enhanced safeguarding processes, including a safeguarding policy, broader training access and consideration of all students as potential safeguarding concerns.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2022. View source
Action
Work with the Surrey Suicide Prevention Partnership on university suicide-safety policy, guidance, staff training and student mental health support.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2022. View source
Action
Use risk assessments as working documents with students to mitigate risk, establish action plans, support follow-up and enable earlier escalation or information sharing.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2022. View source
Action
Provide personalised, student-led action plans for students at risk to support individual safety needs and risk management.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2022. View source
Action
Increase out-of-hours mental health support when the Centre for Wellbeing is closed.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2022. View source
Action
Establish internal oversight through governance groups, policy reviews, a Centre for Wellbeing risk register, performance indicators and committee reporting.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2022. View source
Action
Improve internal safety information sharing through detailed concern referrals, a student engagement platform and centralised Centre for Wellbeing documentation.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2022. View source
Action
Make internal reviews following future student suicides standard procedure.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2022. View source
Action
Develop regular working relationships with local NHS, GP, commissioning and mental health services through contacts, meetings, partnership discussions and a written responsibilities document.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2022. View source See 10 more actions Respondent positions A position is what this recipient says about the concern when it does not describe a specific action. 8
Position
The University had a suicide safety policy and had adopted the national recommendations, except for a planned round-table event.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
The University was not required to produce a serious incident report because it is not a regulated healthcare service provider.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action. View source
Position
The CWB is a pastoral university service, not an emergency, medical or statutory mental health provider, and cannot replicate NHS services.
Outside remitThe respondent said that this matter was outside its role or authority. View source
Position
CWB staff followed the internal processes then in place to reassure themselves about the student’s safety from self-harm.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
NHS and other professional mental health services are responsible for actively diagnosing and treating students’ mental health.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Position
There are no defined acceptable standards or regulatory service levels applicable to the CWB because it is not statutory mental health provision.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
The evidence does not establish that students have a higher incidence of mental health difficulties, self-harm or suicide than the general population.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
Existing University oversight arrangements, including governance groups, policy reviews, risk registers and performance monitoring, provide internal oversight of CWB services.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source See 7 more positions
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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. The report was sent to University of Surrey; that does not assign responsibility.
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.
” 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 Surrey; that does not assign responsibility.
PFD Monitor interpretation Failure to verify the safety of distressed students from self-harm
Wider context from the report “2. Sarah was known to have significant mental health difficulties exacerbated by a recent bereavement and other personal difficulties. On 19th November 2019 after Sarah hung up on the administrator and was knowingly extremely distressed, CWB staff did not take steps to reassure themselves that Sarah was safe from self-harm .
” 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 Surrey; that does not assign responsibility.
PFD Monitor interpretation Higher incidence of student mental health difficulties, self-harm and suicide
Wider context from the report “1. I heard evidence students have a higher incidence of mental health difficulties, self-harm and suicide exacerbated by multifactorial issues such as being effectively itinerant with work and other social pressures.
” 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 Surrey; that does not assign responsibility.
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.
” 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 Surrey; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a serious incident report on CWB working practices
Wider context from the report “7. There was no serious incident report completed by US as to the working practices of the CWB and no reflection has taken place and no steps have been taken to put into place by CWB to provide more robust systems to confirm the safety of students such as Sarah.
” 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 Surrey; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake reflection on CWB working practices
Wider context from the report “7. There was no serious incident report completed by US as to the working practices of the CWB and no reflection has taken place and no steps have been taken to put into place by CWB to provide more robust systems to confirm the safety of students such as Sarah.
” 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 Surrey; that does not assign responsibility.
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 .
” 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 Surrey; that does not assign responsibility.
PFD Monitor interpretation Failure to secure local NHS mental health service involvement in CWB service provision
Wider context from the report “6. There was little communication or learning between and a lack of involvement sought or offered by local NHS mental health services to ensure the service provided by CWB was within an acceptable standard.
” 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 Surrey; that does not assign responsibility.
PFD Monitor interpretation Lack of internal oversight of CWB service provision
Wider context from the report “5. There was no internal (by CWB) or external regulatory (by US) oversight as to the service provision at CWB before Sarah’s death or indeed after her death.
” 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 Surrey; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication and learning between CWB and local NHS mental health services
Wider context from the report “6. There was little communication or learning between and a lack of involvement sought or offered by local NHS mental health services to ensure the service provided by CWB was within an acceptable standard.
” 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 Surrey; that does not assign responsibility.
PFD Monitor interpretation Lack of external regulatory oversight of CWB service provision
Wider context from the report “5. There was no internal (by CWB) or external regulatory (by US) oversight as to the service provision at CWB before Sarah’s death or indeed after her death.
” 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 Surrey; that does not assign responsibility.
PFD Monitor interpretation Failure to establish robust systems confirming student safety
Wider context from the report “7. There was no serious incident report completed by US as to the working practices of the CWB and no reflection has taken place and no steps have been taken to put into place by CWB to provide more robust systems to confirm the safety of students such as Sarah.
” 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 Host a mental health round-table event with local support services to reinforce and strengthen existing relationships.
Verbatim wording from the response “At the time of Sarah’s death, the University did have a suicide safety policy which was approved by the Executive Board in September 2019. The University can confirm that all the recommendations in the UUK Suicide-Safer Universities report of 2018 have been adopted except for the University hosting a” Source location Response from University of Surrey
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 Deliver suicide-awareness, mental-health, distressed-student and safeguarding training, including ASIST for relevant security staff and training for personal tutors.
Verbatim wording from the response “f) A focus on training: Mental Health First Aid is now a substantial recommendation for all student-facing staff in professional and academic departments. The Applied Suicide Intervention Skills Training (ASIST) course is undertaken by key staff particularly in security roles. Mental health awareness, distressed student and safeguarding awareness training for all Personal Tutors is in hand.” Source location Response from University of Surrey
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 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
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 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
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 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
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 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
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 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
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 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
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 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
Open published response
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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 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
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 internal safety information sharing through detailed concern referrals, a student engagement platform and centralised Centre for Wellbeing documentation.
Verbatim wording from the response “Since Sarah’s death, there have been changes in the mechanisms for, and quality of, information sharing between departments within the University and the CWB regarding student safety and mental health, specifically:” Source location Response from University of Surrey
Open published response
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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 Make internal reviews following future student suicides standard procedure.
Verbatim wording from the response “f) Internal reviews after any future suicides will now be standard procedure” Source location Response from University of Surrey
Open published response
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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 Develop regular working relationships with local NHS, GP, commissioning and mental health services through contacts, meetings, partnership discussions and a written responsibilities document.
Verbatim wording from the response “Since Sarah’s death, the University has taken considerable steps to improve links with local mental health services e.g., Community Mental Health Recovery Services, NHS Trusts and General Practitioner (“GP”) practices. These steps include:” Source location Response from University of Surrey
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 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
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 was not required to produce a serious incident report because it is not a regulated healthcare service provider.
Verbatim wording from the response “7. There was no serious incident report completed by US as to the working practices of the CWB and no reflection has taken place and no steps have been taken to put into place by CWB to provide more robust systems to confirm the safety of students such as Sarah.” Source location Response from University of Surrey
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 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
Open published response
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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 CWB staff followed the internal processes then in place to reassure themselves about the student’s safety from self-harm.
Verbatim wording from the response “2. Sarah was known to have significant mental health difficulties exacerbated by a recent bereavement and other personal difficulties. On 19 November 2019 after Sarah hung up on the administrator and was knowingly extremely distressed, CWB staff did not take steps to reassure themselves that Sarah was safe from self-harm.” Source location Response from University of Surrey
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 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
Open published response
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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
Open published response
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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 evidence does not establish that students have a higher incidence of mental health difficulties, self-harm or suicide than the general population.
Verbatim wording from the response “1. I heard evidence that students have a higher incidence of mental health difficulties, self-harm and suicide exacerbated by multifactorial issues such as being effectively itinerant with work and other social pressures.” Source location Response from University of Surrey
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 University oversight arrangements, including governance groups, policy reviews, risk registers and performance monitoring, provide internal oversight of CWB services.
Verbatim wording from the response “5. There was no internal (by CWB) or external regulatory (by the University of Surrey) oversight as to the service provision at CWB before Sarah’s death or indeed after her death.” Source location Response from University of Surrey
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations