PFD report

Benjamin Faux · Prevention of Future Deaths report

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Issued 10 Jul 2024•Berkshire

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
8

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
14

Described in 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.

Report evidence summary

Concerns raised8

  1. Failure to maintain contact with vulnerable students during unresolved academic situations
    Part of recurring concern: Failure to adapt academic decisions and support to student vulnerabilityPart of recurring concern: Failure to maintain contact with vulnerable people after initial engagementPart of recurring concern: Failure to reliably identify and support students with emerging mental-health needs
  2. Lack of follow-through for students offered suspension of studies
  3. Failure to identify students unfit to study and initiate enforced suspension
    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.9

  1. Action

    Assign SDATs responsibility for ensuring Master’s by Research student-support processes are completed.

    Stated by University of ReadingStated completedThe respondent said that this action was complete when they made their response on 29 July 2024.
  2. Action

    Implement an SDAT notification process using regular staff reminders, engagement reports and SSC-provided templates.

    Stated by University of ReadingStated plannedThe respondent said that this action was planned when they made their response on 29 July 2024.
  3. Action

    Trigger the Fitness to Study Process when a vulnerable student takes no suspension action, enabling suspension in appropriate circumstances.

    Stated by University of ReadingStated plannedThe respondent said that this action was planned when they made their response on 29 July 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Professional welfare support from central teams, alongside academic pastoral support, is considered more appropriate than restoring specialist welfare duties to Academic Tutors.

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

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 contact with vulnerable students during unresolved academic situations

Wider context from the report

“(5) By March 2023 Ben’s department at Reading University knew that Ben was a student with severe mental health concerns linked to management of his academic work, who had not taken any exam and had not completed sufficient research to file a dissertation and by late June they also knew that he had not completed paperwork to suspend his studies and yet: a. The University staff who knew this did not appear to appreciate what it meant for Ben and his continuing risk of vulnerability; and b. There was no individual who was given or took responsibility for what should happen next with regard to resolving Ben’s academic situation; and c. Apart from brief further contact from the Student Support Centre the suspension forms, no-one from the University contacted Ben between 24 April 2023 and when he took his life on or around 5 August 2023; ”

Is this part of a recurring concern?

Yes — Failure to adapt academic decisions and support to student vulnerability; Failure to maintain contact with vulnerable people after initial engagement; Failure to reliably identify and support students with emerging mental-health needs.

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 follow-through for students offered suspension of studies

Wider context from the report

“(3) Ben was appropriately encouraged to use University procedures such as ‘exceptional circumstances’ applications through to a conclusion, however there was no process for ensuring that after being offered the option to suspend his studies Ben was supported through to a conclusion of that process one way or another, and that remains the case for students in that position now; ”

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

Failure to identify students unfit to study and initiate enforced suspension

Wider context from the report

“(4) There is an established process for enforced suspension of studies and the University agreed that with hindsight Ben was clearly not fit to study and should have been identified as such and put on that pathway instead of leaving it to Ben to decide and take action to suspend his studies; ”

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 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 recognise continuing vulnerability and risk from known academic and mental health concerns

Wider context from the report

“(5) By March 2023 Ben’s department at Reading University knew that Ben was a student with severe mental health concerns linked to management of his academic work, who had not taken any exam and had not completed sufficient research to file a dissertation and by late June they also knew that he had not completed paperwork to suspend his studies and yet: a. The University staff who knew this did not appear to appreciate what it meant for Ben and his continuing risk of vulnerability; and b. There was no individual who was given or took responsibility for what should happen next with regard to resolving Ben’s academic situation; and c. Apart from brief further contact from the Student Support Centre the suspension forms, no-one from the University contacted Ben between 24 April 2023 and when he took his life on or around 5 August 2023; ”

Is this part of a recurring concern?

Yes — Failure to adapt academic decisions and support to student vulnerability; Inadequate mental health risk assessment.

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 monitor engagement and identify academic or welfare issues at an early stage

Wider context from the report

“(2) The nature of taught research courses (largely independent work) makes it more challenging to monitor students’ engagement and identify issues at an early stage. Ben’s difficulties with his academic work started after Christmas 2022 but were not addressed by the department until he raised them himself in March 2023 by which point he was at a crisis point; ”

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

Risk of vulnerable taught research students being overlooked, isolated, or left in academic limbo

Wider context from the report

“(6) The primary responsibility to meet acute mental health needs when they arise lies with mental health care services. I acknowledge that Reading University have engaged with and are continuing to implement lessons learned process since Ben’s death. However I consider that circumstances at Reading University continue to present a risk to vulnerable graduate students on taught research courses who struggle with their work and develop mental health issues. The risk is of being overlooked until a crisis is reached, or becoming isolated, or of being left in academic limbo, as Ben was, with tragic results. ”

Is this part of a recurring concern?

Yes — Failure to reliably identify and support students with emerging mental-health needs; Inadequate university mental-health support systems for students.

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 named pastoral tutors for students on taught research courses

Wider context from the report

“(1) About 5 years ago, following concerns from academic staff that they were not equipped to support students with welfare issues, Reading University stripped out the pastoral care function from the academic supervisor role, leaving only ‘academic advisors/tutors’. There is alternative provision made for welfare but it is not part of the tutor role and students on taught research courses do not have named pastoral tutors; ”

Is this part of a recurring concern?

Yes — Inadequate pastoral support systems for identifying and responding to welfare concerns.

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 individual responsibility for resolving vulnerable students’ academic situations

Wider context from the report

“(5) By March 2023 Ben’s department at Reading University knew that Ben was a student with severe mental health concerns linked to management of his academic work, who had not taken any exam and had not completed sufficient research to file a dissertation and by late June they also knew that he had not completed paperwork to suspend his studies and yet: a. The University staff who knew this did not appear to appreciate what it meant for Ben and his continuing risk of vulnerability; and b. There was no individual who was given or took responsibility for what should happen next with regard to resolving Ben’s academic situation; and c. Apart from brief further contact from the Student Support Centre the suspension forms, no-one from the University contacted Ben between 24 April 2023 and when he took his life on or around 5 August 2023; ”

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

Assign SDATs responsibility for ensuring Master’s by Research student-support processes are completed.

Verbatim wording from the response

“5b and 5c | The University has clarified that the student support in place for MbR students should be aligned as far as possible with those on taught programmes. Therefore, it is the relevant SDAT who is responsible for ensuring that student support processes are seen through to completion for these students. | 1. New notification system to be implemented whereby the SDAT emails reminders to relevant academic staff at regular intervals to monitor and report engagement of MbR students. SSCs to provide”

Source location

Response from Reading University
Page 3 · response
Published 29 July 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

Implement an SDAT notification process using regular staff reminders, engagement reports and SSC-provided templates.

Verbatim wording from the response

“We recognise there is a need for further pro-active follow-up with students whose non-engagement has been identified. To address this, the University will introduce a new process for MbR programmes whereby the relevant School Director of Academic Tutoring (“SDAT”) emails relevant academic staff at regular intervals to request reports of any significant engagement concerns back to the SDAT (who would then follow up appropriately).”

Source location

Response from Reading University
Page 2 · response
Published 29 July 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

Trigger the Fitness to Study Process when a vulnerable student takes no suspension action, enabling suspension in appropriate circumstances.

Verbatim wording from the response

“The University will take the necessary steps to ensure that:”

Source location

Response from Reading University
Page 2 · response
Published 29 July 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

Circulate guidance to SDATs and Heads of Schools reinforcing SDAT responsibility for Master’s by Research student-support processes.

Verbatim wording from the response

“2. New guidance to be circulated to SDATs and Heads of Schools in all schools with MbR students to reinforce the SDAT’s responsibilities in relation to student support processes.”

Source location

Response from Reading University
Page 4 · response
Published 29 July 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

Have Student Support Centre staff actively support vulnerable students to suspend their studies, including completing paperwork with consent.

Verbatim wording from the response

“The University will take the necessary steps to ensure that:”

Source location

Response from Reading University
Page 2 · response
Published 29 July 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

Circulate guidance instructing welfare officers on prescriptive escalation, clarifying welfare information, and promptly sharing high-risk concerns with SDATs.

Verbatim wording from the response

“5a | In response to this Concern, the University has circulated new guidance to key staff. This has included:”

Source location

Response from Reading University
Page 3 · response
Published 29 July 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

Flag vulnerable students discussing withdrawal or suspension to relevant Student Support Centres and Student Wellbeing Services teams.

Verbatim wording from the response

“3 | There will be a range of circumstances in which students, outside of our formal fitness to study process, may need to consider the possibility of suspending their studies. Our system for supporting students through to the conclusion of such discussions, is a weakness that the Coroner has correctly identified.”

Source location

Response from Reading University
Page 2 · response
Published 29 July 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

Provide every Master’s by Research student with two academic points of contact and monthly meetings throughout the programme.

Verbatim wording from the response

“This change was an institutional decision made to reflect the view that it was more appropriate for academic staff to focus on providing academic and general pastoral support, with trained professionals providing more specialist welfare support where required. | 1. Strengthen support system for MbR programmes to ensure that all MbR students have monthly meetings with two academic points of contact.”

Source location

Response from Reading University
Page 1 · response
Published 29 July 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

Produce guidance with PAPYRUS for suicide-safer universities covering early intervention, staff training and supportive institutional culture.

Verbatim wording from the response

“4. Suicide-safer universities: Working with PAPYRUS, UUK has produced guidance to implement strategies to prevent student suicides through early intervention, staff training, and fostering a supportive institutional culture.”

Source location

Response from Universities UK
Page 2 · response
Published 29 July 2024

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

Professional welfare support from central teams, alongside academic pastoral support, is considered more appropriate than restoring specialist welfare duties to Academic Tutors.

Verbatim wording from the response

“1 | The Academic Tutor role was revised a number of years ago, with a stronger provision of professional welfare support made available within the central student services teams.”

Source location

Response from Reading University
Page 1 · response
Published 29 July 2024

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 relevant School Director of Academic Tutoring is responsible for ensuring student support processes are followed through to completion for MbR students.

Verbatim wording from the response

“5b and 5c | The University has clarified that the student support in place for MbR students should be aligned as far as possible with those on taught programmes. Therefore, it is the relevant SDAT who is responsible for ensuring that student support processes are seen through to completion for these students. | 1. New notification system to be implemented whereby the SDAT emails reminders to relevant academic staff at regular intervals to monitor and report engagement of MbR students. SSCs to provide”

Source location

Response from Reading University
Page 3 · response
Published 29 July 2024

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 organisation lacks regulatory authority to mandate specific mental-health actions by member universities.

Verbatim wording from the response

“UUK represents 141 autonomous universities across the United Kingdom. However, it is important to note that our organisation does not represent all higher education providers nor possess the regulatory authority to mandate specific actions by our member institutions. Each university operates independently, with its own governance and procedures.”

Source location

Response from Universities UK
Page 2 · response
Published 29 July 2024

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

Individual universities are responsible for their own governance, procedures and decisions on specific mental-health actions.

Verbatim wording from the response

“UUK represents 141 autonomous universities across the United Kingdom. However, it is important to note that our organisation does not represent all higher education providers nor possess the regulatory authority to mandate specific actions by our member institutions. Each university operates independently, with its own governance and procedures.”

Source location

Response from Universities UK
Page 2 · response
Published 29 July 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

    Review student support arrangements for Master’s by Research programmes.

    Stated by University of ReadingStated completedThe respondent said that this action was complete when they made their response on 29 July 2024.
  2. 2

    Continue sharing mental-health best practices across member universities.

    Stated by Universities UKStated in progressThe respondent said that this action was in progress when they made their response on 29 July 2024.
  3. 3

    Support university engagement with the University Mental Health Charter in collaboration with Student Minds.

    Stated by Universities UKStated in progressThe respondent said that this action was in progress when they made their response on 29 July 2024.
  4. 4

    Work closely with the higher education mental health implementation taskforce on sector mental health initiatives.

    Stated by Universities UKStated completedThe respondent said that this action was complete when they made their response on 29 July 2024.
  5. 5

    Work with the national review team on its recommendations when the review reports.

    Stated by Universities UKStated plannedThe respondent said that this action was planned when they made their response on 29 July 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

Review student support arrangements for Master’s by Research programmes.

Verbatim wording from the response

“There are approximately 60 students at the University currently registered on MbR programmes. In terms of the practical delivery of these programmes, they have some features in common with postgraduate taught degrees, while in other respects they much more closely resemble research programmes. As such, we recognise that our student support processes (which are designed either for traditional ‘taught’ or ‘research’ programmes) have not been well-suited to this particular set of programmes. We have already undertaken a review of student support arrangements for MbR programmes, which we believe addresses some of the concerns raised in the PFD Report, alongside the actions set out in the table below.”

Source location

Response from Reading University
Page 1 · response
Published 29 July 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 sharing mental-health best practices across member universities.

Verbatim wording from the response

“difficulties. We appreciate you sharing the report with us, and we will continue to share best practices across our membership.”

Source location

Response from Universities UK
Page 3 · response
Published 29 July 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

Support university engagement with the University Mental Health Charter in collaboration with Student Minds.

Verbatim wording from the response

“3. University Mental Health Charter: UUK has been working closely with Student Minds to support engagement with the charter. Currently, 113 universities are covered by the charter with evaluation reports showing that the charter is having a positive impact.”

Source location

Response from Universities UK
Page 2 · response
Published 29 July 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

Work closely with the higher education mental health implementation taskforce on sector mental health initiatives.

Verbatim wording from the response

“2. Higher education mental health implementation taskforce: UUK has worked closely with the taskforce since its inception. The taskforce oversees work across the mental health space including: identifying students at risk, compassionate communication, service design, the national review of HE suicides and improving HE and NHS partnerships.”

Source location

Response from Universities UK
Page 2 · response
Published 29 July 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

Work with the national review team on its recommendations when the review reports.

Verbatim wording from the response

“1. National review of higher education student suicides: In 2023, the government commissioned a national review to share lessons across the sector around serious mental illness and preventing suicide. The review will also track progress against the usage of UUK’s Postvention guidance. The”

Source location

Response from Universities UK
Page 1 · response
Published 29 July 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

Official responses located
2/2

Data last updated 7 September 2026