Prevention of Future Deaths reports · 2018

Edward Farmer

Regulation 28 report to prevent future deaths, reference 2018-0390, written 12 Dec 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report12 Dec 2018
Reference2018-0390
DeceasedEdward Farmer
CoronerKaren Dilks
Coroner areaNewcastle Upon Tyne
CategoryAlcohol, drug and medication related deaths
Sourcejudiciary.uk record · original PDF
Responses published6

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

Karen Dilks
Senior Coroner for the City of Newcastle upon Tyne

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

1. Right Honourable Damian Hinds, Secretary of State for Education.
Dept for Education, 20 Great Smith Street, Westminster, London,
SW1P 3BT

CORONER

| am Karen Dilks, Senior Coroner, for the Coroner area of the City of Newcastle
upon Tyne

CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act
2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations

2013.
http://www. legislation.gov.uk/i '2009/25/schedule/5/paragraph/7

http://www. legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On 15 December 2016 | commenced an investigation into the death of Edward
James Farmer, 20yrs.

The investigation concluded at the end of the inquest on 25 October 2018.

The conclusion of the inquest was:

Narrative: Died due to the toxic effects of the consumption of an excessive
amount of alcohol in a short period of time and in part because the inherent risks of

doing so were not known.

CIRCUMSTANCES OF THE DEATH

Edward James Farmer was a first-year student at Newcastle University.

He was a member of the Agricultural Society.

On 12 December 2016 an initiation event was organised by the Agricultural
Society. Both organisers and attendees were aware of the nature of the event and
that Initiations were prohibited by the University.

Initiation events had continued to take place for many years notwithstanding the
University’s prohibition.

On 12 December 2016 Mr Farmer attended the said Initiation Event together with
approximately 20 to 30 other first-year students.

All involved knew or believed the aim of the event to be that first-year students
would consume large quantities of alcohol and take part in such activities as eating
rotten substances and head shaving.

Mr Farmer and other first-year students were accompanied throughout the event
by second-year students who actively encouraged the drinking of large quantities
of alcohol.

Between approximately 8pm and 10pm on 12 December 2016 Mr Farmer
consumed between 6/8 treble vodka and orange drinks. In addition he consumed
undiluted spirits from various bottles, the volume of which is unknown.

Several students were drunk and vomiting.

Mr Farmer was extremely drunk. He was unable to walk unaided. He was carried
on to a Metro Train and taken to the home of a second-year student to be “looked

after’.
He was checked regularly and found to be snoring loudly. He did not vomit.
He was last checked between 2:30 and 3:30am on 13 December 2016.

At 4:43am on 14 December he was found unresponsive without signs of breathing
or pulse.

He was taken by car to the Royal Victoria Infirmary in Newcastle in the belief that
this would expedite his arrival at hospital. The premises where he was staying
being within a short distance from the said hospital.

Despite maximum medical intervention he died due to a hypoxic brain injury the
consequence of a prolonged cardio respiratory arrest.

There was overwhelming evidence that those involved in the organisation of and
who attended the Initiation Event on 12 December were unaware of the inherent

risks of excessive alcohol consumption and that snoring is an indicator of
respiratory depression.

There was further clear evidence that the issues in Mr Farmer’s case were
both national and local issues.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to
concern. In my opinion there is a risk that future deaths could occur unless action
is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

(1) That consideration be given to conducting a national campaign dealing with
the:
a. Inherent risks of alcohol consumption within a short period
b. How to identify persons at risk
c. The importance of timely medical intervention

The campaign should address the inherent risks of participating in initiation events.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you the
Right Honourable Damian Hinds, Secretary of State for Education have the power
to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 6 February 2019. |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken,
setting out the timetable for action. Otherwise you must explain why no action is
proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:

| have also sent it to:

e Chief Inspector Pickett of Northumbria Police Licencing Department

° BE e.castic City Council, Legal Services Dept

who may find it useful or of interest.
| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or
summary form. He may send a copy of this report to any person who he believes
may find it useful or of interest. You may make representations to me, the coroner,
at the time of your response, about the release or the publication of your response
by the Chief Coroner.

12 December 2018

Dus
Signed by Karen Dilks (Senior Coroner)

Responses

6 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Department for Education (PDF)
Department for

Depar tment Business, Energy
for Education & Industrial Strategy
. The Rt Hon Chris Ski
a aie aa Ve of State for Univereliee: Science,
enior Coroner Research and Innovation.
Newcastle upon Tyne Coroners 1 Victoria Street
Civic Centre Sant er
Barras Bridge
Newcastle upon Tyne was (0) ots oe aiTaasiion etus
education gov. uk/help/contactus
NE1 SQH enquiries@beis.gov.uk
Email: coroneradmin@newcastle.gov.uk acre
LA

2. November 2019

Qos ws Dells |

Thank you for the letters from your office of 12 December 2018 and 4 February 2019, and the
associated Regulation 28 report relating to Edward Farmer.

In your report, you asked that consideration be given to a national campaign addressing the
risks of alcohol consumption within a short period, how to identify persons at risk, the
importance of timely medical intervention and the inherent risks of initiation events.

Your letter of 4 February supported the proposed action detailed by the former Education
Secretary in his letter to you of 15 January, namely that government departments and bodies
from the education and health sectors would work together to design the measures most likely
to achieve the desired outcome of preventing future such tragedies as the death of Edward
Farmer.

The outcome of that action is the comprehensive guidance published on 23 September by
Universities UK and Newcastle University, /nitiations at UK Universities, to raise awareness of
the dangers of initiations and excessive alcohol consumption among students (see:
https://www.universitiesuk.ac.uk/news/Pages/New-advice-for-universities-and-students-on-

dangers-of-initiations.aspx )

The launch of this guidance was publicised by national media, including BBC Television News,
BBC Online and the Times, the i, the Guardian the Metro and the Independent newspapers.

The guidance includes:
e Higher education institutions’ duty of care and other statutory obligations to students

e Recommendations to the higher education sector in 10 areas including staff training,
disciplinary processes, reporting systems, focusing on prohibited behaviours, and

awareness raising. This includes how training activities should point out the signs of
dangerous consumption of alcohol.

e Advice that interventions should be developed and administered at key points in a
student’s time at university (e.g. UCAS application, open days, induction days, enrolment
and re-enrolment).

e Information on the National Union of Students’ ‘Alcohol Impact’ campaign, which is a
whole-institution programme to create the conditions for a social norm of responsible
alcohol consumption by students

e A suite of initiatives for tackling initiations in student sport, designed by British
Universities & Colleges Sport (BUCS) - the national governing body for higher education
sport in the UK

e Signposting to the UK Chief Medical Officers’ Low Risk Drinking Guidelines which
provide information about the health risks associated with different levels and patterns of
drinking to enable the general public, including students, to make informed choices about
their drinking.

The above has been achieved through a determined collective effort by stakeholders across the
higher education sector and government to take fully considered action to mitigate the risk of a
similar such tragedy happening again.

US RUA,

THE RT HON CHRIS SKIDMORE MP
Response from Department of Health and Social Care (PDF)
S ; From Steve Brine MP

Departm ent Parliamentary Under Secretary of State for Public Health and Primary Care
of Health & 39 Victoria Street
Social Care SWicet

Your Ref: KLD/LD/FARMER/1895 020 7210 4850

Our Ref: PFD-1161031

76 1

Ms Karen Dilks 5 IAN 2019

HM Senior Coroner, Newcastle upon Tyne

HM Coroner's Court

Civic Centre

Barras Bridge

Newcastle NE1 8QH 22 JAN 2019

ank you for your correspondence of 12 December to Matt Hancock about the death
of Edward James Farmer. I am replying as Minister with portfolio responsibility for
Alcohol.

Lhave noted carefully the matters of concer raised in your report. I understand that
you have also copied your report to Damian Hinds, the Secretary of State for
Education.

In your report you request that consideration be given to conducting a national
campaign of the risks of consuming alcohol within a short period; how to identify
persons at risk; and the importance of timely medical intervention. The death of
Edward Farmer is tragic and careful consideration is needed on how best to address
the issues raised in your report.

I suggest our approach should be the same as the one suggested by the Secretary of
State for Education, in that any action on this is deferred until the Department of
Health and Social Care has had the chance to work with colleagues across
Government and in other health sector bodies.

Can I take this opportunity to thank you for highlighting this important issue to me; I
will write back to you on how best we can prevent similar deaths in the future.

Us
Response from Department of Health and Social Care2 (PDF)
aR From Jo Churchill MP

Department eee ane Sable Heath and Primary Care

of Health &

Social Care ee
SW1H OEU

Your Ref: KLD/LD/FARMER/1895 (aioasen

Our Ref: PFD 1161031

Mrs Karen L Dilks

HM Senior Coroner, Newcastle upon Tyne

Civic Centre

Barras Bridge

Newcastle upon Tyne 05 Nov 2019

NE! 8QH

Dear ites

In your letter of 12 December 2018, you asked that consideration be given to a national
campaign addressing the risks of alcohol consumption within a short period, how to
identify persons at risk, the importance of timely medical intervention, and the inherent
risks of initiation events.

In the response to you dated 22 January 2019, the then Minister for Public Health,
Steve Brine MP, explained that the Department of Health and Social Care would work
with colleagues across Government and others to determine the action that could be
taken to respond to the risks highlighted in the Prevention of Future Deaths report.

On 26 June 2019, a national roundtable event was held at Newcastle University to
discuss the issues you raised. This meeting was attended by representatives from the
Department of Health and Social Care, the Department for Education, Public Health
England and other bodies representing higher education and sport.

As a result of this meeting, guidance was published on 23 September 2019 by
Universities UK and Newcastle University to raise awareness of the dangers of
initiations and excessive alcohol consumption among students. The guidance can be
accessed on the Universities UK website at:
www.universitiesuk.ac.uk/news/Pages/New-advice-for-universities-and-students-on-
dangers-of-initiations.aspx.

I am aware that Chris Skidmore, Minister of State at the Department for Education is
writing to you with further detail about the guidance.

With regard to wider public health messages, Public Health England is engaged in a
number of actions targeted at young people about the dangers of excessive alcohol
consumption through the ‘Rise Above’ and ‘Talk to Frank’ campaigns.

The Rise Above social marketing programme aims to equip 11 to 16-year olds with the
skills required to reject or manage risky behaviours, including drinking alcohol. It
reaches young people through social media and provides lesson plans accredited by the
Personal, Social, Health and Economic (PSHE) education Association for use in
secondary schools. Further information is available on the Rise Above website.

FRANK is a drugs information website which is widely used by young people and
provides guidance on the risks associated with alcohol consumption and how to manage
them. The website provides a help service by phone, text, live chat and email for
people who are concerned about their own, or others’, alcohol consumption. Further
information is available on the FRANK website.

Public Health England sits on an oversight group advising the National Union of
Students (NUS) on its alcohol impact project. The NUS alcohol impact project is a
voluntary scheme for higher education institutions. The project aims to provide a range
of activities and services to students to promote alternatives to alcohol and help foster a
healthy attitude and respect for alcohol. Summary reports, surveys and other associated
research from the project is available at alcoholimpact.nus.org.uk/research,

In addition, the ‘One You’ social marketing campaign engages people to make and
sustain changes to improve their physical and mental health. The campaign focuses on
promotion of eating well, quitting smoking, physical activity and reducing alcohol
consumption. One You provides information, advice and online tools, including the
‘How Are You’ health quiz, website, email programme, and a suite of mobile apps.
The overarching communication objective of One You is to reduce unhealthy
behaviours as well as prompt uptake of healthier behaviours.

I hope this response demonstrates the collective effort by stakeholders across the higher

education sector and across Government to raise awareness and prevent a similar
tragedy from happening again. Thank you again for bringing these concerns to my

attention. add 1s dP
a

JO CHURCHILL
Response from Nus (PDF)
Macadam House
275 Gray's Inn Road
London WC1X 8QB

national union of students (0845 5210 262
@ nusuk@nus.org.uk
www.nus.org.uk

07 FEB 2019

30 January 2019

Mrs Karen Dilks

HM Senior Coroner

Newcastle upon Tyne Coroners
Civic Centre

Barras Bridge

Newcastle upon Tyne

NE1 8QH

Dear Mrs Dilks
Re: Investigation into the death of Edward James Farmer
Thank you for your letter of 12 December 2018.

I would like to take this opportunity to express my condolences to the family and friends
of Edward following the tragic events on 12 and 13 December 2016. Any life cut short is
one too many, and I am sure the circumstances relating to Edward’s death make it even
more difficult to come to terms with.

As you may know, NUS is a confederation of students’ unions, comprising c98% of all
further and higher education students’ unions in the UK, totaling 538 students’ unions.
Through our representative structures we are the collective voice of seven million students.
We work to promote and defend the student interest across all aspects of society. The
behavior change campaigns we run are primarily delivered to individual students through
our work of developing their respective Students’ Unions.

Before I respond to your proposal for a new national campaign, I will outline our work to
date on the issue of promoting responsible consumption of alcohol by students.

1. Campaigns work

We have been publicly opposed to initiation ceremonies for many years and sought to
highlight the issue though the student voice of our full-time student officers. In addition,
we have produced training resources on the development of students’ union rules,
procedures and systems that address contentious issues, including initiations
(http://studentopportunities.nus.org.uk/2014/06/05/the-unions-rules-systems-
procedures/).

In 2013 we published guidance on bar crawls, both for students’ unions and the police (see
two attached documents: ‘Guidance notes for students' unions - commercial bar crawls’
and ‘Guidance Notes for Law Enforcement Officers - Bar Crawls‘), so that students’ unions
could intervene when commercial bar crawl companies were not meeting their legal duties.
The guidance underlines our opposition to that kind of activity.

Our work on tacking the lad culture, which substantively started in 2014, has extensively
cited the initiation ceremonies and irresponsible consumption of alcohol as key issues.
This includes our report ‘That’s What She Said’
(www.nus.org.uk/PageFiles/12238/Thats%20What%20She%20Said%20-
%20Full%20Report%20(1).pdf), which later featured prominently in discussions at our
Lad Culture summit. This work led to various resources and tools for students’ unions to

National Union Of Students (United Kingdom). Company No. 08015198.

help them develop policies and procedures to tackle issues pertaining from lad culture
(www.nusconnect.org.uk/liberation/women-students/tackling-lad-culture), and at a
national level was the impetus for further work by UUK (www.universitiesuk.ac.uk/policy-
and-analysis/reports/Documents/2016/changing-the-culture.pdf), BUCS
(www.bucs.org.uk/athlete.asp?section=18767&sectionTitle=%23TakeAStand) and
others. It is a matter of regret that much of the media coverage characterises our work
as being the fun police or snowflakes.

2. Best Bar None

Best Bar None is an accreditation scheme, supported by the Home Office, which promotes
responsible management and operation of alcohol licensed premises. The scheme includes
questions in the prevention of crime and disorder, public safety, prevention of public
nuisance, protection of children from harm, social responsibility and a large section on
training which ensures all venues are training their staff in key areas. Entrants are required
to show a raft of documentation and policies that cover things like safe alcohol retailing,
challenge 25, conflict management and dealing with customers who are vulnerable. The
entrants go through a four hours assessment which is both a review of documentation but
also a chance for the assessor to check staff members understanding, through speaking to
staff and asking them questions.

This work has been ongoing for a number of years. As early as 2004 we led on taking the
regional police-led pilot in Manchester to scale nationally through our members students’
unions. This academic year we have 55 students’ unions working towards their annual
accreditation. Last academic year a similar number took part, with 37 achieving gold level
accreditation, and all students’ unions that entered gaining accreditation.

We proactively support entrants on an ongoing basis through a Facebook workplace page
and run communities of practice sessions throughout the year. Participating students’
unions can assess the Drinkaware library of resources.

There are four criteria, all of which are mandatory for accreditation, that are particularly
relevant to your enquiry: F46 - Drinks Promotions / Mandatory Code; E47 - Drink
Promotions - Risk Assessment; E17 - Responsible Alcohol Retailing; E18 ~ Duty of Care
Policy / Safeguarding. More information on the criteria, and national scheme, can be found

here: http://bbnuk.com/.

3. Alcohol Impact

We established Alcohol Impact as a partnership with the Home Office four years ago,
through an £80k grant for one year, and now run it as a self-funded programme, funded
by universities, supported in a non-financial way by the Home Office. Alcohol Impact seeks
to reverse the social norm of irresponsible alcohol consumption by students, especially first
years. It is a supported accreditation programme which brings the students’ union and
university together as a partnership through shared actions to change norms and
behaviours.

Alcohol Impact does have a mandatory criterion on initiations: ‘INO39: The partnership has
taken action to moderate or prevent alcohol-related initiation ceremonies. All partnerships
also must carry out an annual innovative intervention, and these can, and sometimes do,
relate to preventing initiation ceremonies.

To date thirty-one universities have / are taking part in Alcohol Impact, delivering a broad
array of actions that collectively help to change student attitudes and behaviors on alcohol
consumption. We have substantive evidence that the programme has led to reductions in
alcohol-related incidents on campus, as detailed under the summary reports section of our
website (https://alcoholimpact.nus.org.uk/research). We are also in the process of
publishing a new detailed report showcasing outcomes and case studies from the last few
years of the Programme, which will be released in February 2019.

It should be noted that, Newcastle University Students’ Union disaffiliated from NUS and
is not currently a member. As with all our programmes, Alcohol Impact is only formally
open to students’ unions that are members of NUS. Newcastle University Students’ Union
would need to reaffiliate to NUS to formally take part. They can, however, freely access
the criteria, and our extensive resources, as they are all openly published on our

programme website: https://alcoholimpact.nus.org.uk/about.

As part of Alcohol Impact we run our annual Students and Alcohol Survey
(https://alcoholimpact.nus.org.uk/research), which provides a national snapshot of how
students think about, and consume, alcohol and provides us with baselines of attitudes
and behaviours that we are working to change, and evidence of change at participating
institutions.

We also run an annual Students and Alcohol Conference which, this year, is happening on
Wednesday 27 February in Manchester (www.cvent.com/events/students-and-alcohol-
2019/event-summary-acb21a2c18cc4503838c1baba3b6834e.aspx). It is a showcase
event for participants to present their innovative interventions and find ways to collaborate
on this agenda. You are very welcome to attend the event if you would like to find out
more about the programme. If you could put me in touch with Edwards family I will extend
an invitation to them as well.

4. Drink Rethink

Our new pilot, Drink Rethink, funded by the BUPA Foundation, is a preventative approach
which aims to reduce high-risk drinking behaviour among students by training student
ambassadors to use an evidence-based behaviour change tool (Identification and Brief
Advice ~ IBA) to deliver an alcohol intervention on campus. This academic year we recruited
and trained twenty-one student ambassadors to engage their fellow students and oversee
the completion of the Alcohol Use Disorders Identification Test (AUDIT), followed by the
provision of brief advice through leaflets appropriate to the level of risk identified by the
AUDIT. The ambassadors delivered a total of 250 hours of engagement across three weeks,
at sites across the University of the West of England and Keele University. A total of 576
students were engaged in completing the AUDIT and receiving brief advice through specific
leaflets appropriate to their risk level. 149 students who opted not to participate in the
AUDIT received general information leaflets, meaning a total of 725 students engaged at
some level. The end of funding report from our pilot can be viewed here.

In relation to your proposal for a campaign, our portfolio of activity has together generated
significant interest, support and momentum on the issue of responsible alcohol
consumption by students. In part, we believe this is because NUS is student-led, which
helps build partnerships on this work between student representatives and students.
Similarly, the structure of Alcohol Impact creates partnerships between students’ unions
and their institutions on responsible consumption. This partnership working is coupled with
an evidence-based and strategic approach to reversing the social norm of irresponsible
consumption, which is grounded in academic theory, which is well received by universities.

As such, rather than create a new national campaign, our preference would be to re-engage
sector stakeholders on our existing work in this area, predominantly through Alcohol
Impact, as a national campaign overarching our other initiatives, as it clearly has
momentum and wider support, is proving to be impactful, and is very much in the student
interest.

I am aware that the Department for Education have responded requesting time to prepare
a sector response. To progress this, we would welcome a high-level meeting, at the earliest
opportunity, with the Home Office, Department for Education, Public Health England,
Universities UK and the Office for Students to explore how we can work together on this
important issue and will look to convene such a meeting before the end of March 2019.

We will use the meeting to explore what others are doing, or planning to do, on responsible
alcohol consumption, and assess the appetite for us to work together on this, ideally by
collectively railying around Alcohol Impact so we can take it to scale, engaging other
universities, such as Newcastle, in this agenda. As part of any sector-wide partnership on
responsible consumption, we would welcome discussion and action relating to the specific
issues you raise around increasing the awareness of risk and provision of advice. I am
aware that the Department for Education have responded

Yours sincerel

PR

Acting Chief Executive
Response from Newcastle University (PDF)
Response of Newcastle University and Newcastle University Students’ Union to the 
Coroner’s report on the death of Edward James Farmer, December 2016 

1.  Context 

a)  This report is submitted in response to the Coroner’s report of 12 December 2018, sent to 
Professor Chris Day (Vice-Chancellor & President, Newcastle University) and Mr Simon 
Gerry (Chief Executive, Newcastle University Students’ Union) 

b)  The report was made under Paragraph 7, Schedule 5, of the Coroners and Justice Act 
2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

c)  The nature of the recommendations in the report, and the close collaboration between the 
University and the Students’ Union, make it appropriate to submit a single, joint response 
on behalf of both parties. In light of the specific nature of the formal relationship between 
the University and the Students’ Union, some of the actions described in this report are / 
will be collaborative, and others the specific responsibility of the relevant party. This is 
made clear in the information provided below and the Appendices to this report. 

d)  In very brief summary, in the context of this report: the University is responsible for 

University-wide induction of new students, general awareness-raising, communication and 
disciplinary action against individuals or groups who commit misconduct. Staff training 
also falls within the remit of the University.   

The Students’ Union is responsible for oversight of the affiliated student clubs and 
societies, including training, health and safety, key elements of awareness-raising, 
financial support and the application of appropriate sanctions when societies / clubs do not 
comply with the requirements. 

2.  The Coroner’s Report 

The Coroner’s investigation into the death of Edward James Farmer in December 2016 raised 
a number of Matters of Concern, together with some recommended actions which are 
addressed in the Action Report and Plan attached as Appendix 1 to this response.  

3.  Approach taken by the University and Students’ Union  

The University and Students’ Union acknowledge the validity of the Matters of Concern raised 
by the Coroner, and welcome the recommendations regarding possible actions. In the 
approaches described below, and in the attached Action Report and Plan, we have taken care 
to address the Coroner’s recommendations, alongside other relevant issues which have 
emerged during our discussions, to ensure that our response is as comprehensive and 
effective as possible. 

a)  Following the Inquest, in October 2018, the University took some immediate interim 

actions, which are recorded in Appendix 1. 

b)  A Student Initiations Group was established, jointly chaired by the Vice-Chancellor and 
the Academic Registrar, with membership including the Newcastle University Students' 
Union Chief Executive, relevant Faculty and Professional Service staff, Students’ Union 
staff and Sabbatical Officers, Presidents (or representatives) of key student societies / 
clubs, and alumni representation.  

c)  The work of this Group includes the establishment of some Definitions, Principles and 

Values, which are attached to this report as Appendix 2 

1 

 
 
 
 
 d)  The Group identified four Workstreams and established working groups to address the 

key issues and make specific recommendations relating to the following themes: 

Group 1: Defining ‘initiations’ and tackling traditions and cultures 

This group clarified and articulated the nature of activities that are considered 
unacceptable and considered the issue of cultures and expectations which are perceived 
to drive some events (eg the tradition of ‘initiations’ associated for many years with the 
Agriculture Society).  

Group 2: Raising awareness to reduce risks: education, campaigns, training 
(students and staff) 

This group considered how best to communicate with and educate staff and students about 
the risks associated with excessive alcohol consumption including the specific risks of 
death and serious illness resulting from unacceptable and dangerous behaviours.  

Group 3: Expectations, policies, discipline and sanctions 

This group clarified the University’s expectations and prohibitions in terms of unacceptable 
behaviours at student socials (including dangerous initiations), and how these expectations 
are communicated. It reviewed the University’s disciplinary procedure and protocols for 
dealing with such activities and clarified, for communication to students and staff, the 
sanctions applicable.  

Group 4: Working with the city, the local community, the police and other outside 
organisations 

This group worked with Newcastle City Council, Northumbria Police, the Licensing 
organisations and other external bodies to raise awareness of the issues associated with 
excessive alcohol consumption by students (and others). A particular focus has been to 
increase awareness and enforcement of regulations governing licensed premises selling to 
visibly drunk patrons and also the practice of ‘proxy’ sales where patrons can buy on behalf 
of others. 

4.  Emerging issues/ constraints in responding to the Coroner’s report 

In considering the matters of concern and recommended actions in the Coroner’s report of 
December 2018, the University and the Students’ Union have identified a number of 
important issues, some of which have an impact on the response to specific 
recommendations: 

a)  The unacceptable behaviours which fall under the auspices of this report go beyond 

‘initiations’ per se, and include any organised event, ceremony or ritual which could be 
reasonably perceived as involving coercion or manipulation that results in a risk or 
occurrence of physical or mental detriment to students or other parties. This could 
apply to any organised social activity, including ‘initiations’, taking place at any time 
(i.e. not just associated with the beginning of the year).  

b)  The University and Students’ Union seek to achieve the right balance in offering a 

positive, welcoming and enjoyable student experience whilst effectively communicating 
the key messages about behaviours and risks. 

c)  The recommendation that compulsory training be provided for all academic staff may 
need to be balanced against the practicalities and challenges of doing so. Many 
academic staff have no day-to-day interactions with students, and other (eg 
professional service) staff also have an important role in academic units and central 
Student Services. Our initial focus is therefore to focus on the training of key staff who 
are in a position to influence students and who have the opportunity to be vigilant. We 

2 

 
 
 
 will also explore other (eg digital) channels through which we may be able to raise the 
awareness and vigilance of all University staff, whilst recognising that compulsory 
participation may be impossible to achieve.  

d)  Following the conclusion of the work of the Student Initiations Group, the University’s 
Alcohol and Substance Misuse Working Group will oversee and monitor this area of 
work for longer-term sustainability and impact. This will ensure that the actions agreed 
now become embedded in the normal practices of the University and Students’ Union 
and that we can be pro-active in taking forward our plans for culture change with 
successive generations of students and Students’ Union sabbatical officers.  

We recognise that culture change takes time, and that the matters of concern raised in 
the Coroner’s report are not unique to Newcastle University, but reflect wider societal 
challenges. We hope that our work will also help to inform the wider debate across the 
university sector through the Vice-Chancellor’s work with Universities UK.  

e)  Newcastle University and the Students’ Union are fully committed to doing everything 
the law expects from us when aiming to take appropriate and proportionate steps to 
manage and control the risks to our students. However, we are mindful of the need to 
recognise and remind ourselves that our students are independent adults, upon whom 
we must rely to some extent by expecting them to take some personal responsibility for 
their own actions and behaviour. 

5.  Conclusions 

This report concludes the response of Newcastle University and the Students’ Union to 
the Coroner’s report of 12 December 2018. Appendix 1 summarises actions taken to 
date, planned actions and timescales for completion.  

Professor Chris Day, Vice-Chancellor and President, Newcastle University 

Mr Simon Gerry, Chief Executive, Newcastle University Students’ Union 

, Director of Student & Academic Services (Academic Registrar) 

28 March, 2019 

3
Response from Secretary of State (PDF)
±

;D

2018-OO49994POSoS

Rt Hon Damian Hinds MP
Secretary of State

Sanctuary Buildings Great Smith Street Westminster London SW1P 3BT
tel: 0370 000 2288 wwweducationgov.ukJhelp/contactus

Mrs Karen L Dilks
HM Senior Coroner
Newcastle upon Tyne Coroners
By email: coroneradmin@newcastle.ciov.uk

Your ret: KLD/LD/FARMER/1 895

15 JAN 2019

Thank you for your letter of 12 December, enclosing the Regulation 28 report
relating to Edward Farmer.

I understand from one of your officers that the report was also sent to the
Secretary of State for Health and Social Care, the Vice-Chancellor of
Newcastle University, the Chief Executive of Newcastle Students’ Union, the
National Union of Students, Northumbria Police and local licensing authorities.

You ask that consideration be given to a national campaign addressing the
risks of alcohol consumption within a short period, how to identity persons at
risk, the importance of timely medical intervention and the inherent risks of
initiation events.

Given the particularly tragic circumstances of Edward Farmer’s death, I am
keen to ensure full and thorough consideration is given to how best to raise
people’s awareness of these issues and encourage them to take sensible
decisions. This thinking will enable the right decision to be made on whether a
national campaign would be the most effective approach for the prevention of
future such tragedies.

I would therefore like to agree with you that a response with the details you
require on proposed action is deferred until my department has had the
opportunity to work with colleagues in the health and education sectors on
designing the measures most likely to achieve the desired outcome over a
sustained period. I look forward to presenting a fully considered approach to
preventing similar deaths.

 Thank you for writing on this important matter.

44

Damian Hinds
Secretary of State for Education

CC:

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