Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0371, written 28 Oct 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Oct 2019 |
|---|---|
| Reference | 2019-0371 |
| Deceased | Julius Little |
| Coroner | Graeme Irvine |
| Coroner area | Inner North London |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Julius Jake Little died 7th June 2019
THIS REPORT IS BEING SENT TO:
1.
Dean of Students
University of the Arts London
272 High Holborn
London WC1V 7EY
United Kingdom
2.
Chief Executive - Claire Marchant
UCAS
Rosehill
New Barn Lane
Cheltenham
Gloucestershire
GL52 3LZ
1
CORONER
I am: Mr Graeme Irvine
Assistant Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
1
3
INVESTIGATION and INQUEST
On 12th June 2019 I commenced an investigation into the
investigation
death of Julius Jake Little aged 20. The
concluded at the end of the inquest on 9th October 2019. I
made a determination at inquest of suicide, recording that;
"At 1.03 am on 7th June 2019 Julius Jake little was found
unresponsive in his room in student halls of residence. A self
applied ligature secured to a wardrobe clothes rail was tied
around his neck. Despite efforts to resuscitate him, life was
pronounced extinct at 02.03."
The medical cause of death was recorded as;
"1.a suspension by ligature"
4
CIRCUMSTANCES OF THE DEATH
Mr Little was a first year undergraduate at UAL living in halls of
residence. On 7th June 2019 he was found hanging from a belt
attached to a clothes rail in his wardrobe. Mr Little had a
history of depression and was receiving treatment in the form
of psychotherapy and medication overseen by a psychiatrist
5
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 will occur unless action is taken. In the
circumstances, it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows.
In the course of hearing an inquest at Poplar Coroner's Court
on 9/10/19 into the death of Julius Jake Little, evidence was
considered in relation to available support services offered to
undergraduates at UAL who have a history of mental health
problems.
The Dean of Students at UAL
, gave
2
evidence that applicants to UAL make an online application to
the admissions organisation UCAS. The application invites
them to disclose any history they have of mental health
problems, upon being accepted on a course of study this
information is provided to the admitting university.
indicated
the mental health disclosure
information is used to target students that may require support,
and at UAL emails are sent to undergraduates, inviting them to
register with the university's support services.
that
Regrettably, it would appear that of UAL's cohort of students
that disclosed mental health problems to UCAS, only 66% of
undergraduates responded to the email invitation offering
mental health support. The remaining 33%, a total of some 200
students, did not respond to the offer.
I asked
whether the identity of students who had
made a mental health disclosure in their UCAS application
was communicated to tutors and halls of residence staff at the
university. I was informed that this information was not so
disseminated as it would be breach of data protection
legislation, this appears to be a missed opportunity.
I cannot suggest a solution to this problem, however it does
appear to be a lost opportunity to secure this valuable
information but not to utilise it effectively.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths
and I believe that your organisation have the power to take
such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of
the date of this report, namely by 23rd December 2019. I, the
coroner, may extend the period.
Your response must contain details of action taken or
3
proposed to be taken, setting out the timetable for action.
Otherwise you must explain why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
The Office for Students, Nicholson House, Lime Kiln
Close, Stoke Gifford, BRISTOL BS34 8SR
University Mental Health Advisers Network (UMHAN). c/o
Impact Hub, Walker Building, 58 Oxford Street,
Birmingham, B5 5NR
I 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.
9
DATE 28th October 2019
SIGNED BY ASSISTANT CORONER GRAEME IRVINE
4
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.
Udl: ; 23 DEC 2019 Mr Graeme Irvine 20 December 2019 Assistant Coroner Inner North London St Pancras Coroner’s Court Camley Street London NiC 4PP __ Dear Mr Irvine, | write on behalf of University of the Arts London in response to the Prevention of Future Deaths report dated 28 October 2019, related to the death of Julius Jake Little. My response describes improvements made in the university’s processes for the 2019/20 academic year with the aim of preventing future deaths, | also explain our approach to sharing information. Improvements in our processes For the 2019/20 academic year we have made improvements to our processes for engaging disabled students, including those with long-term mental health conditions, with our support services. At the point that the information in respect of mental health conditions is shared with the university by UCAS, a pre- and post-enrolment email campaign is initiated, asking students to engage with support services. Our Disability Advisers make contact with students who have declared a disability and are requesting support. In addition, Disability Advisers are now actively following up on those students who have not engaged with support services. This has enabled us to significantly reduce the number of students who declared a long-term mental health condition prior to enrolment and are not engaging with support services from 33% in 2018 to 4% in 2019. Our Disability Advisers are continuing to follow-up with those students. Our approach to sharing information Members of staff within the Disability Service are aware of the condition or impairment of individual students, including in relation to when there are concerns in respect of mental health. We then develop an individual support agreement with the student which includes making reasonable adjustments including adapting the environment, in order to meet their needs. This information is shared more widely with the express permission of the student. Disability-related information is classified as ‘special category personal data’ under the GDPR. This means there are very limited circumstances in which we can share such data without the informed consent of the student in question. University of the Arts London 272 High Holbom +44(0)20 7514 8852 London WC1V 7EY m.crawley@arts.ac.uk United Kingdom www.arts.ac.uk The GDPR and the Data Protection Act 2018 permit such data to be shared only where there is a risk of harm to self or others. In such circumstances we share information about the student on a case by case basis if we believe it is necessary to protect the individual or others from harm. We regularly review our policies and procedures around data sharing in the context of mental health to ensure we are both compliant with the law and supporting the needs of students effectively. | believe this response provides the information requested. If you require further details please contact me. Yours sincerely orcs of Students
UCAS Ref: CM/SN UCAS Mr G Irvine Rosehill Assistant Coroner 5 r New Barn Lane Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Cheltenham GLS2 3LZ t +44 (0)1242 222 444 f +44 (0)1242 544 960 www.UCas.com 18 December 2019 Dear Graeme Irvine, Thank you for sending a copy of the Regulation 28 report of 28 October 2019, concerning the inquest into the tragic death of Julius Little on 7 June 2019. 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 can 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 underrepresented groups, as well as producing reports to inform public debate. As part of this commitment, we regularly review our products and services to ensure that they are fit for purpose. We have been reviewing the questions we currently ask applicants on the UCAS application, and considering how we can improve the flow of information between the student and the course provider. A key area we have been focusing on is the question that allows applicants to disclose a disability, learning difference, illness or mental health condition, acknowledging that there are changes we could make to facilitate disclosure and reassure students about how this information is used. However, the data collected by UCAS flows into the systems of nearly 400 universities and colleges across the UK, and into a range of other data collection exercises, such as the Higher Education Statistics Agency (HESA) Student Record, so significant planning and engagement across the whole higher education sector is necessary to implement any changes - it isn’t just a change to the UCAS application. In order to initiate work on the question, we held a roundtable discussion in July 2019 with representatives from higher education sector bodies, expert organisations and course providers to understand the most appropriate and effective ways in which this question could be improved. Subsequently, we have drafted changes to the language of the question and the accompanying help text in response to the points raised, and we have just finished collating feedback on the first draft. We anticipate the improved version will be in place for actions, which we will are now looking to take forward in the new year. Most significantly, JCQ (Joint Council for Qualifications) has agreed to move their A level results embargo to 8am to minimise the time gap between students receiving results and accessing support. Additionally, UCAS will be working collaboratively with JCQ, the Department for Education and other stakeholders to develop good practice for schools, colleges and HE providers to Promote consistency in how results are communicated to students, and the support offered. | hope this offers clarification on how UCAS has been working to collaboratively with experts and course providers to improve the applicant experience and support students with mental health concerns. We will update you on the details of the reviewed question and good practice once they are finalised, along with any future developments, in due course. Yours sincerely Clare Marchant Chief Executive
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