PFD report

Daniel Alexander Jeremiah BOWEN · Prevention of Future Deaths report

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Issued 1 Feb 2019•Brighton and Hove

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
15

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to maintain communication links between healthcare providers and student support services
    Part of recurring concern: Inadequate university mental-health support systems for studentsPart of recurring concern: Unreliable inter-agency information sharing for coordinated carePart of recurring concern: Unreliable multi-agency communication procedures
  2. Failure to effectively use academic advisors to support students under academic pressure
  3. Imposition of penalties for late academic work without adequate regard to student vulnerability
    Part of recurring concern: Failure to adapt academic decisions and support to student vulnerability
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. Action

    Review late-submission and penalty clauses in examination and assessment regulations, with specific consideration of potential changes.

    Stated by University of SussexStated plannedThe respondent said that this action was planned when they made their response on 23 February 2024.
  2. Action

    Implement a university-wide support pilot around assessment-result releases, including weekday release and the “We are Here” academic-advice campaign.

    Stated by University of SussexStated plannedThe respondent said that this action was planned when they made their response on 23 February 2024.
  3. Action

    Roll out an improved academic-advising system following evaluation.

    Stated by University of SussexStated plannedThe respondent said that this action was planned when they made their response on 23 February 2024.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

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

Wider context from the report

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

Is this part of a recurring concern?

Yes — Inadequate university mental-health support systems for students; Unreliable inter-agency information sharing for coordinated care; Unreliable multi-agency communication procedures.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to effectively use academic advisors to support students under academic pressure

Wider context from the report

“(1) Academic Advisor – Better use should be made of the person in this post for each school. There was a wasted opportunity for the academic advisor to be involved in face to face meetings with Daniel and help him when he was struggling to get his work in on time and to deal with his academic pressures. In the circumstances I heard that if work was late a penalty would be imposed. This seems ridiculous; why hit a man when he is already down? ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Imposition of penalties for late academic work without adequate regard to student vulnerability

Wider context from the report

“(1) Academic Advisor – Better use should be made of the person in this post for each school. There was a wasted opportunity for the academic advisor to be involved in face to face meetings with Daniel and help him when he was struggling to get his work in on time and to deal with his academic pressures. In the circumstances I heard that if work was late a penalty would be imposed. This seems ridiculous; why hit a man when he is already down? ”

Is this part of a recurring concern?

Yes — Failure to adapt academic decisions and support to student vulnerability.

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 late-submission and penalty clauses in examination and assessment regulations, with specific consideration of potential changes.

Verbatim wording from the response

“Regulatory & procedural monitoring and review The University regularly reviews its academic regulations and procedures, including the Principles underpinning this governance. As is general practice across the higher education sector, the University sets deadlines for submission of coursework. When a student is late or misses a submission for a deadline a penalty can be applied. When there are known reasons for late submission, a student may submit a request for exceptional circumstances, with evidence (e.g. medical), where appropriate. Students with reasonable adjustments in place due to a disability or specific learning difference have an additional seven days to submit work without penalty. When the University is unaware of such circumstances, a penalty will be applied.”

Source location

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

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Implement a university-wide support pilot around assessment-result releases, including weekday release and the “We are Here” academic-advice campaign.

Verbatim wording from the response

“From Summer 2019 a university-wide pilot system of support will be in place. Release of assessment and examination results will now be at the start of the week rather than just before the weekend. This will facilitate a ‘We are Here’ Campaign whereby key academic staff will be available during the week following release of results in order to ensure that”

Source location

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

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Roll out an improved academic-advising system following evaluation.

Verbatim wording from the response

“Academic Advising System The University accepts that improvements to the academic advising system are required; consequently, the University is reviewing its delivery model for the academic advisory system. An alternate delivery pilot is already taking place this academic year (September 2018 to July 2019) in one school to improve the current offer to students. An evaluation of this pilot model will take place in the Summer with further work, and additional pilots taking place during the 2019-20 academic year. Following evaluation, roll-out of an improved academic advising system is expected from 2020-21 academic year onwards.”

Source location

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

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

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

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review the academic-advising delivery model and evaluate the alternate delivery pilot.

Verbatim wording from the response

“Academic Advising System The University accepts that improvements to the academic advising system are required; consequently, the University is reviewing its delivery model for the academic advisory system. An alternate delivery pilot is already taking place this academic year (September 2018 to July 2019) in one school to improve the current offer to students. An evaluation of this pilot model will take place in the Summer with further work, and additional pilots taking place during the 2019-20 academic year. Following evaluation, roll-out of an improved academic advising system is expected from 2020-21 academic year onwards.”

Source location

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

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Conduct further academic-advising work and additional pilots during the 2019–20 academic year.

Verbatim wording from the response

“Academic Advising System The University accepts that improvements to the academic advising system are required; consequently, the University is reviewing its delivery model for the academic advisory system. An alternate delivery pilot is already taking place this academic year (September 2018 to July 2019) in one school to improve the current offer to students. An evaluation of this pilot model will take place in the Summer with further work, and additional pilots taking place during the 2019-20 academic year. Following evaluation, roll-out of an improved academic advising system is expected from 2020-21 academic year onwards.”

Source location

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

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

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

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

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

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

Verbatim wording from the response

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

Source location

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

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Identify vulnerable repeating or resitting students and contact each by telephone with academic advice and support offers.

Verbatim wording from the response

“Immediate Action Taken”

Source location

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

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Open the commissioned Student Centre as the primary face-to-face and digital access point for student services.

    Stated by University of SussexStated plannedThe respondent said that this action was planned when they made their response on 23 February 2024.
  2. 2

    Use learning analytics and business-intelligence software to provide real-time data for targeted interventions.

    Stated by University of SussexStated plannedThe respondent said that this action was planned when they made their response on 23 February 2024.
  3. 3

    Pilot the “Enlitened” student-engagement and well-being app with the School of Psychology.

    Stated by University of SussexStated in progressThe respondent said that this action was in progress when they made their response on 23 February 2024.
  4. 4

    Launch the Imminent Risk Protocol for rapid expert case meetings and safeguarding action.

    Stated by University of SussexStated plannedThe respondent said that this action was planned when they made their response on 23 February 2024.
  5. 5

    Create a university-wide Well-being and Mental Health Strategy.

    Stated by University of SussexStated plannedThe respondent said that this action was planned when they made their response on 23 February 2024.

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

Open the commissioned Student Centre as the primary face-to-face and digital access point for student services.

Verbatim wording from the response

“Student Centre A purpose built Student Centre has been commissioned and the building is scheduled to open in January 2021. The Centre will be the primary location for students accessing services face to face, and will be the main access point for information, advice and guidance. It will enable students to access friendly, consistent and professional student focused services across campus and digitally.”

Source location

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

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Use learning analytics and business-intelligence software to provide real-time data for targeted interventions.

Verbatim wording from the response

“The Learn to Transform Strategy includes a series of pertinent actions as outlined below with timelines:”

Source location

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

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Pilot the “Enlitened” student-engagement and well-being app with the School of Psychology.

Verbatim wording from the response

““Enlitened” Pilot In recognition of the increasing usage of digital platforms, social media and smart phone applications (apps) by current and future student population; the University is taking part in a prototype pilot of an app on smartphones/tablets. Designed by an external partner, this App is designed to encourage positive student engagement and well-being and is designed to enhance a sense of belonging and connection from a digital platform. The App has been piloted with the School of Psychology since March 2019 and, subject to a positive evaluation of this pilot, it will be rolled out across the University from September 2019.”

Source location

Response from University of Sussex
Page 5 · response
Published 23 February 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Launch the Imminent Risk Protocol for rapid expert case meetings and safeguarding action.

Verbatim wording from the response

“Imminent Risk Protocol An Imminent Risk Protocol has been developed as an additional safeguarding measure to enable expert staff to initiate an immediate case meeting (within 2 working hours) if they consider or anticipate that a student will be at serious risk of harm to themselves or others within a 24-48 hour period. The protocol is time specific and action based, and designed to ensure protective factors are in place as well as mitigate risk as far as it is reasonably possible to do so. This Protocol will be launched on 29th April 2019.”

Source location

Response from University of Sussex
Page 5 · response
Published 23 February 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Create a university-wide Well-being and Mental Health Strategy.

Verbatim wording from the response

“The Learn to Transform Strategy includes a series of pertinent actions as outlined below with timelines:”

Source location

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

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026