PFD report

William Jeffrey MASKELL · Prevention of Future Deaths report

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Issued 14 Dec 2015•Exeter and Greater Devon

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
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
11

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. Insufficient capacity for timeous intervention for students in distress
    Part of recurring concern: Insufficient student mental-health support capacity
  2. Failure to prioritise welfare over student privacy in urgent intervention decisions
  3. Lack of a clear protocol for agency and police involvement
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.7

  1. Action

    Work with the university to develop a procedure for consulting statutory bodies about unconfirmed, non-high-risk deterioration in student mental health or wellbeing.

    Stated by Devon Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 December 2015.
  2. Action

    Consider developing jointly agreed, student-specific contingency plans covering responses, roles and accommodation access during deterioration in mental health or wellbeing.

    Stated by Devon Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 December 2015.
  3. Action

    Obtain university room-access information and ensure STEP and CRISIS staff can accurately advise wellbeing staff and signpost appropriate agencies.

    Stated by Devon Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 December 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The room-entry decision was not hampered by absent agency protocols or privacy taking precedence over welfare; the student was assessed as low risk.

    Stated by University of ExeterDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

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. ”

Is this part of a recurring concern?

Yes — Insufficient student mental-health support capacity.

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 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. ”

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

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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Work with the university to develop a procedure for consulting statutory bodies about unconfirmed, non-high-risk deterioration in student mental health or wellbeing.

Verbatim wording from the response

“The Trust has had further discussions with the University with a view to identifying specific action that can be taken to improve the joint working between us; we have nominated our Adult Directorate Practice Lead for the Community to work with colleagues from the University to progress the following actions:”

Source location

William-Maskell-Response2
Page 1 · response
Published 14 December 2015

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

Consider developing jointly agreed, student-specific contingency plans covering responses, roles and accommodation access during deterioration in mental health or wellbeing.

Verbatim wording from the response

“The Trust has had further discussions with the University with a view to identifying specific action that can be taken to improve the joint working between us; we have nominated our Adult Directorate Practice Lead for the Community to work with colleagues from the University to progress the following actions:”

Source location

William-Maskell-Response2
Page 1 · response
Published 14 December 2015

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

Obtain university room-access information and ensure STEP and CRISIS staff can accurately advise wellbeing staff and signpost appropriate agencies.

Verbatim wording from the response

“The Trust has had further discussions with the University with a view to identifying specific action that can be taken to improve the joint working between us; we have nominated our Adult Directorate Practice Lead for the Community to work with colleagues from the University to progress the following actions:”

Source location

William-Maskell-Response2
Page 1 · response
Published 14 December 2015

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

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
Page 2 · response
Published 14 December 2015

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
Page 3 · response
Published 14 December 2015

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
Page 1 · response
Published 14 December 2015

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
Page 2 · response
Published 14 December 2015

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
Page 2 · response
Published 14 December 2015

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
Page 2 · response
Published 14 December 2015

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.4

  1. 1

    Share the coroner’s findings with the involved service and across the wider Trust.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
  2. 2

    Complete the action arising from the Root Cause Analysis investigation.

    Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
  3. 3

    Publish and disseminate standards for missed Wellbeing Service appointments and Wellbeing Service support.

    Stated by University of ExeterStated plannedThe respondent said that this action was planned when they made their response on 14 December 2015.
  4. 4

    Consult statutory bodies on developing a procedure for potential deterioration in mental health or wellbeing not confirmed as high risk.

    Stated by University of ExeterStated plannedThe respondent said that this action was planned when they made their response on 14 December 2015.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The existing policy sufficiently safeguards students classified as at risk and aligns with practice at other higher education institutions.

    Stated by University of ExeterExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. 2

    No reasonable policy or procedural changes would have prevented the death.

    Stated by University of ExeterNo action considered necessaryThe respondent said that no further action was needed.

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

Share the coroner’s findings with the involved service and across the wider Trust.

Verbatim wording from the response

“Thank you for your letter of 14 December 2015 which we received on the 17 December 2015 following the inquest into the death of William Maskell. As an organisation we are committed to learning from these tragic events and have since receiving your report and recommendations taken the opportunity to share your findings with the service involved as well as across the wider trust.”

Source location

William-Maskell-Response2
Page 1 · response
Published 14 December 2015

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 the action arising from the Root Cause Analysis investigation.

Verbatim wording from the response

“The Trust has undertaken a Root Cause Analysis Investigation following the death of William; the report was shared at the inquest and we were able to confirm that the action resulting from the report had been completed. It is clear following review of your report and consideration of your recommendations that there are continued improvements that can be made to prevent future deaths of this nature.”

Source location

William-Maskell-Response2
Page 1 · response
Published 14 December 2015

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 missed Wellbeing Service appointments and Wellbeing Service support.

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
Page 2 · response
Published 14 December 2015

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

Consult statutory bodies on developing a procedure for potential deterioration in mental health or wellbeing not confirmed as high risk.

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
Page 2 · response
Published 14 December 2015

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 existing policy sufficiently safeguards students classified as at risk and aligns with practice at other higher education institutions.

Verbatim wording from the response

“The most relevant policy in place at the University is the ‘Management of students at risk’ policy which sets out the actions to be taken in the event that a student is classified ‘at risk’ following engagement with the Wellbeing Service. When a student is classified ‘at risk’ (as opposed to no, or low risk), the policy details appropriate next steps to be followed by the Wellbeing advisor. The University’s review has shown that this policy is sufficient in safeguarding students at risk and is in line with practice at other higher education institutions.”

Source location

William-Maskell-Response
Page 2 · response
Published 14 December 2015

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

No reasonable policy or procedural changes would have prevented the death.

Verbatim wording from the response

“Our review has concluded that no reasonable changes to our policies or procedures would have prevented this.”

Source location

William-Maskell-Response
Page 3 · response
Published 14 December 2015

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