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Investigation and inquest
On 16 December 2019, I commenced an investigation into the death of Daniel HALL. The investigation concluded at Inquest on 2 November 2021.
The medical cause of death provided by pathologist, Dr. ████████, Royal Glamorgan Hospital was:
████████
and
████████
The Coroner’s short-form conclusion was that of “suicide”.
The family’s concern at inquest related to the University’s long waiting list for Mental Health Adviser support; a failure to expedite Daniel for mental health support knowing that he had expressed suicidal ideation and suffered ASD; and the lack of safeguarding by the University.
Circumstances of the death
These were recorded as :-
Daniel Hall 20 years was a 2nd year student at the University of South Wales studying a BSc in Computer Games Development. He suffered from Autistic Spectrum Disorder (previously k/a Asperger’s Syndrome) and had successfully completed his 1st year studies. Fellow student, ████████ was his good friend and with whom he shared accommodation. Together they had travelled throughout Europe. He was aware of Daniel’s depression and kept a watchful eye over him. Upon commencing his 2nd year, Daniel had made enquiries about benefiting from the Disabled Student Allowance (DSA) and his application was being progressed by the University.
On 29 September 2019 and 23 October 2019 Daniel had face to face meetings with Nurse Adviser, ████████ as a part of his DSA Needs Assessment. On both occasions he expressed suicidal thoughts.
████████ signposted Daniel to the ‘Request for Support’ form and the Samaritans. Following completion of these forms Daniel received confirmation on 17 and 22 October 2019 that his name had been placed on a waiting list to see a Mental Health Adviser. Due to ill-health and absences of the University’s three Mental Health Advisers, there were ~200 students awaiting mental health support. Daniel was 16th on the waiting list to be seen.
Daniel was prescribed antidepressant medication by his GP on 30 October 2019 but failed to attend his follow-up appointment on 27 November 2019. ████████, noting this failed appointment arranged for Daniel to be seen by the GP on 29 November 2019 and again on 11 December 2019. His antidepressant was providing little ‘mood elevating’ cover.
On 15 November 2019 a referral was made for Specialist Mentor support and ████████ was allocated to support Daniel on 21 November 2019 and she introduced herself to him at a meeting on 3 December 2019. There is no attendance note of this meeting or arrangements made for further contact.
On 18th November 2019, Daniel purchased a ████████. In spite of continued support from his sister and friends, Daniel, ████████ 9 December 2019 at his student accommodation. During the 7-week period between expressing suicidal thoughts to Nurse Adviser, ████████ and completing his suicide plan, Daniel had contact with a number of University administrative, teaching, nursing and medical staff yet he lacked receipt of any meaningful mental health support or any ‘one to one’ safeguarding.
Coroner’s concerns
Lengthy delays for students at the University of South Wales to access mental health support services even when suicidal ideation has been expressed on more than one occasion and when risk factors (ASD) are known.
Information checked against the published report and official responses