Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0250, written 25 Jul 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Jul 2019 |
|---|---|
| Reference | 2019-0250 |
| Deceased | Owen Williams |
| Coroner | Mary Burke |
| Coroner area | West Yorkshire (West) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Secretary of State for Education The Right Honourable Mr Gavin Williamson 2. The Chief Executive of UCAS 3. The Chief Executive of The Sixth Form Colleges Association 1 | CORONER lam Mary Burke, Assistant Coroner, for the Coroner area of West Yorkshire — Western Division. 2 | 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. 3 | INVESTIGATION and INQUEST On the 20 August 2018 an investigation was commenced into the death of Owen Arron Wynne Williams. The investigation concluded at the end of the inquest on the 2™ May 2019 The inquest determined that the medical cause of Owens death was due to hanging and a conclusion of suicide was made. 4 | CIRCUMSTANCES OF THE DEATH Owen Williams attended Greenhead Sixth Form College in Huddersfield West Yorkshire to undertake various A levels, sitting all relevant exams in May / June 2018. He was described as a high performing student by the principal of the college who gave evidence at the inquest. He was described by teaching staff and his tutor as a reliable, cheerful and fully engaged young man. Owen was expected to achieve the grades required to be accepted on the university course he had set his mind upon attending. None of his teachers or tutor had any cause for concern fer his health and wellbeing. Owen stayed with his sister and her family in Elland the night before his A level results were released. There was nothing in Owens presentation which gave his sister and her family cause for concern. At 6.00am on the 16” August 2018 Greenhead College released A level results electronically which was accessible to all students. The college was open from 8.00am to provide student support and result sheets were available from the college from 9.00am. At 6.30 am on the 16" August 2018 Owens brother in law got up for work and noted Owen was not in the house, his laptop was open, all of Owens personal possessions including his phone and wallet were still present. Over the ensuing hours his sister and brother in law immediately undertook checks and searches to try and locate Owen, all to no gain. They therefore contacted West Yorkshire Police, who immediately commenced a missing persons investigation. Later that day Owen was found unresponsive suspended by a rope tied to a tree in a secluded wooded area near to his sisters home. Owens death was confirmed by attendant paramedics a short time later. Subsequent enquiries revealed that Owen had accessed his results and had not achieved his expected grades required for the university course he wished to attend. Owen's father expressed deep concerns at the way in which Owen had access to his results and stated that if Owen had been required to personally attend the college, an approach adopted by other educational institutions, and expressed the view that Owen would have been able to immediately access support and guidance and that the tragic events which occurred would have been avoided . During the course of the inquest the evidence revealed matters giving rise for concern. In my opinion there is a risk that future deaths may occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows:- | heard evidence from the Principal of the college that Owen attended that there is wide variance both locally and nationally of the timing and way in which colleges release A level results, some release results electronically as early as 6.00 am and later the same morning provide a facility within the school and college to provide support to students, some colleges / schools require the students to physically attend to obtain their results, when at the same time support by staff members is immediately on hand. | understand UCAS is available from 8.00 am onwards, once again some hours after some students have obtained their results. In particular, from the evidence presented to me it appears:- 1. That there is no national agreement across all educational institutions to the timing and manner in which A level results are released. 2. That there can be a significant time lag between results being released by some schools and colleges and the timing of when there is the availability of staff to provide support to those students that may have received unexpected results. 3. That UCAS is presently available some hours after some educational institutions have released student results. 4. That there is no national requirement for educational establishments to communicate directly to parents in advance of results day and explain the system in place for the release of the A level results at the educational establishment that their child is attending and to alert them to the potential that unexpected results can occur and to be alert to the impact that this may have upon their child. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] 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 20" September 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 — (Owen’s Mother) and to (Owen's Father). lam 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. [DATE] - =| [SIGNED BY ASSISTANT CORONER]
2 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.
adie ERIN ae ' ware roomate 24 SEP 2019 a wes BD RP ie, poe a i &, Se ot MENT FoR EO te Rt Hon Gavin Williamson CBE MP Secretary of State Sanctuary Buildings Great Smith Street Westminster London SW1P 3BT tel: 0370 000 2288 ~www.education.gov.uk/help/contactus M.T. Burke Assistant Coroner, West Yorkshire — Western Division City Courts The Tyrls Bradford BD1 iLA C2 i Thank you for song me your Regulation 28 report into the death of Owen Arron Wynne Williams in August 2018. | was deeply saddened to read of Mr Williams’ death and would like to express my sincere condolences to his family. | have read and carefully considered the important matters of concern that you raise, and what my department, in conjunction with others, can do to help prevent any future tragic deaths in similar circumstances. L |-september 2019 Exams are an essential part of ensuring that young people have acquired the knowledge and skills they need and supporting their progression into further study and work, but | am clear that this should not come at the expense of their wellbeing. Schools and colleges are best placed to understand the needs of their students and | expect them to offer comprehensive support as exam results are issued. | am determined that we avoid any situations where students with unexpected results feel that they have nowhere to turn. In order to ensure that no pupil finds themselves in this situation, later this year, my department will be jointly hosting a roundtable with UCAS, who are responsible for the release of information about university places on the morning of A level results day. We will invite organisations from across the education sector to consider the student journey — from sitting exams to receiving results — to agree how, together, we can ensure that pupils are supported should they encounter difficulties. Attendees will include the JCQ (Joint Council of Qualifications) and the Sixth Form Colleges Association (SFCA). | understand that UCAS and the SFCA will be responding to you separately. The time at which GCSE, AS and A level results can be released by schools to pupils is a matter for the JCQ, a membership organisation representing independent awarding organisations including the four exam boards offering GCSE, AS and A level exams in England. The JCQ oversees exam processes and results announcements for these qualifications; for other qualifications, the release of results is a matter for the individual awarding organisation. My officials are in contact with JCQ about this matter and we understand that they are considering changes which will mean that young people are best supported during what can be a difficult period for some. Currently, JCQ lift the embargo on results at 6am, at which time they can be issued by exam centres (schools and colleges) to students. JCQ is reviewing the possibility of a later embargo to reduce the likelihood that students will receive results without support available. In addition, JCQ is planning improvements to its guidance, including considering whether to recommend that students pick up results from their schools or college directly. | recognise that young people and their parents need extra support at what can be a challenging time which is why the government funds the delivery of the Exam Results Helpline. The helpline is open for two weeks following the release of A level and GCSE results. It gives young people, parents and carers access to independent, professional careers advisers who can help them talk though all their options and make a decision about their future. This year the helpline worked with Mental Health UK to improve the service provided to young people around this stressful time. | can assure you that | am committed to improving student wellbeing and to fostering collaboration across the education sector to learn lessons from this tragic death, ensuring that students receiving exam results are given appropriate support by all parties concerned. | hope that you, and Mr Williams’ family, will be assured that | take the matter of student wellbeing incredibly seriously and expect to see clear action taken in order that students sitting their exams are given the support they need. Thank you for raising this important matter. eee anu Rt Hon Gavin Williamson CBE MP Secretary of State for Education
AT UCAS UCAS Ref: CM/SC Chief Executive 19 September 2019 Clone Merchant M T Burke 4 ) 4 Rosehill . y I New Barn Lane Assistant Coroner . West Yorkshire — Western a : § SEP 2018 so City Courts _ Bradford ‘ - t BD1 1LA Www.ucas.com Dear MT Burke Thank you for sending a copy of the Regulation 28 report of 26 July 2019, concerning the inquest into the tragic death of Owen Williams on 16 August 2018. in responding, | wanted to set out the actions that UCAS already takes to support students in the release of examination results and university decisions, as well as the future steps we are taking to address the issues you have highlighted. UCAS is an independent charity, running the UK’s national higher education admissions service. Every year, we help around 700,000 students apply for full-time undergraduate courses at nearly 400 UK universities and colleges. We are committed to ensuring that everyone who can benefit from higher education is able to do so — and to go on to succeed once they have started their course. We work in partnership with charities and other organisations to provide practical and inspiring information, advice and resources for under- represented groups, as well as producing reports to inform public debate. In particular, we seek to provide information on the options available to students throughout the process, including when a student has been unsuccessful in securing their preferred place. Each year, UCAS and UK universities and colleges are given early access to A level results under strict embargo arrangements with the Joint Council for Qualifications (JCQ). The embargo period covers the defined period of time where early access to embargoed examination results is given. This allows universities and colleges to prepare and make decisions by the official publication dates of exam results. During this time, neither UCAS nor universities are permitted to discuss results or the subsequent admission decisions (from which a result could be inferred) with students. This embargo is lifted by JCQ at 06:00 on the morning of A level results day, at which point students can receive their A fevel results. Many schools and colleges require students to collect their results in person, thus ensuring they are supported if they do not achieve the results they wanted; however, practice does vary across the sector. UCAS Track is the online system students use to monitor their university offers and decisions. During the embargo period, Track is temporarily suspended and re-opens at 08:00 on the morning of A level results day. Whilst students are unable to access their A level results this way, they can see if they have been accepted by their chosen university, or whether they have entered Clearing. UCAS IS THE TRADING NAME OF THE UNIVERSITIES AND COLLEGES. ADMISSIONS SERVICE. REGISTERED IN ENGLAND AND WALES: 2839815 (LIMITED BY GUARANTEE) REGISTERED CHARITY IN ENGLAND AND WALES: 1024741 AND SCOTLAND: SCO38598 REGISTERED OFFICE AS ABOVE Throughout the day, and in the lead up to results day, we send applicants email updates that include practical information and advice about what to expect, and what to do if their application has been unsuccessful. Our website, ucas.com, explains what happens on results day and gives advice on preparing for results day (www.ucas.com/ undergraduate/results- confirmation-and-clearing/ucas-undergraduate-results), what to do after you have received your exam results (www.ucas.com/undergraduate/results-confirmation-and- clearing/results/after-you-get-your-exam-results), and Clearing (www.ucas.com/undergraduate/results-confirmation-and-clearing/what-clearing). This year we signposted new resources from the Charlie Waller Memorial Trust for students who feel they need help looking after their wellbeing at this time. Most importantly, our Customer Experience Centre offers support via telephone and social media during the Confirmation and Clearing period, ensuring students have access to the right information and advice for their needs. Please note that other Level 3 qualification results are subject to different embargo periods. For example, the results of Pearson BTEC qualifications (RQF) are released the day before A level results, although some centres do not provide these until A level results day. This means that, for students who have early access to these results, there is a long period of uncertainty. On receipt of your letter, we contacted the Department for Education (DfE) and (JCQ) to discuss our own concerns about the time at which students can access their results without support from their school or college — and the inconsistency in approach. We believe improvements could be made to the process, and we are keen to work with DfE, JCQ, awarding organisations, schools, and colleges to improve the overall experience for students. In order to take this forward, we will jointly host a roundtable with DfE to explore how we can support students throughout the examination and results periods, particularly those who do not receive the grades they had hoped for. At this roundtable, we will explore with JCQ, and a range of school and HE representatives, how we can achieve this, and protect students’ wellbeing. In particular, we will explore: e The creation and promotion of good practice amongst schools and colleges to facilitate a more consistent experience across different centres. e Changing the time at which the embargo is lifted to ensure students are more able to readily access any support they may require from teachers, careers advisers, parents and carers. e How we can continue to support students who may not have secured a place at their chosen higher education provider, and to ensure they are made aware of all the different choices available to them throughout the application process. In addition, UCAS will seek to improve the information and advice provided to students at this time, to ensure consistency and reassurance about alternative options where appropriate. This roundtable will happen before the end of 2019 to ensure outcomes are implemented prior to the 2020 examination awarding period. | hope this offers clarification on how UCAS has been working to support students through the application process, and how we are seeking to improve the connection between applicants and higher education providers in the future. We will update you on the outcome of the roundtable, and any future developments in due course. Yours sincerely Clare Marchant Chief Executive
See every Prevention of Future Deaths report matching Mary Burke, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.