Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0503, written 12 Dec 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Dec 2019 |
|---|---|
| Reference | 2019-0503 |
| Deceased | Raees Rauf |
| Coroner | Emma Serrano |
| Coroner area | Derby and Derbyshire |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: ,
1. Bristol University;
2. Chief Coroner;
3. Family of the deceased.
CORONER
lam Emma Serrano, Assistant Coroner, for the coroner area of the Derby and
Derbyshire,
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.
INVESTIGATION and INQUEST 7
On the 20 September 2018 an investigation was commenced into the death of Raees
Osman Rauf by Assistant Coroner Rachael Sayed. The investigation concluded at the
end of the inquest on 4 December 2019. The inquest was conducted by myself. . The
conclusion of the inquest was a short form conclusion of Suicide.
The cause of death was:
1a) Shotgun wound to the head.
CIRCUMSTANCES OF THE DEATH
i) ‘Raees Osman Rauf started attending the University of Bristol, School of
Mathematics, in September 2016. During his first year the course was
structured fo. include lectures, weekly tutorials (led by his Personal Tutor)
and weekly homework assignments. Lectures, Tutorials and homework
assignment were not mandatory.
ii). Raees Osman Rauf, attended -his. initial induction tutorial, and. was
‘. signposted to the relevant Welfare Agencies at this point.
ili) After a few weeks Raees Osman Rauf ‘stopped attending his tutorials and
completing homework assignments. On the 10 November 2016 he was
sent an email by his personal tutor offering him support, but did not respond
to this.
iv) In early November Raees Osman Rauf failed at least one of his exams,
; obtaining 70/120. credits. He re-sat these, passed and continued to the
second year of his degree course in September 2017.
v)_. The structure of the second year is made up of lectures only, with no weekly
tutorial sessions. -Homework is set each.week but is not mandatory. The
- University accepted that this left the University no way of monitoring if a
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student was struggling until they started to fail exams. Personal Tutors are
required to offer four, one to one, meetings per year to their students.
Raees Osman Raufs did not undertake these offers.
vi) In January, May and June of 2018, Raees Osman Rauf failed to attend for
the majority of his exams. The exams he did attend, he failed. On the 11
January 2018 an-email: was sent to him ‘regarding his failure and he
responded saying that he was fine.
Around May/June (the university could not be sure) he received a phone call
from somebody within the University Administration Department who asked
how he was. He said he was fine. On the 26 June 2018 he was sent an
email asking that he withdrew from the university.
vii
viii) On the 12 September.2018 he took his own life with a shot gun to the head. °
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. —
-} During the Inquest:
1.
The University accepted during the course of the inquest that, due. to the non-
mandatory nature of tutorials and homework, within the School of Mathematics,
it was difficult to assess whether a student was struggling until examination
failures unless they specifically brought issues to the attention of the university
themselves;
During the first year of the mathematics degree, students were not required to
attend lectures or weekly tutorials, and weekly homework ‘set .was not
mandatory. As a result of this there were no sanctions, or requirements to meet
with form tutors.or other tutors within the School of Mathematics at any point
within the year;
There is no requirement to meet with a tutor at the school of mathematics after
failure of an examination;
During the second year there was significantly less opportunity to have contact
with the students. -This was due to the fact that there were no weekly tutorials
with personal tutors. There were lectures each week, for all ‘School of
Mathematics students however, attendance was not monitored and was not
mandatory. . Therefore, sometimes you only notice after exams if a student is
really struggling;
The university accepted that after this they then reach a dead end, where they
believe a student is unwell but they have no other means of addressing it.
Students can be required to withdraw from the university with no face to face
contact with any member of the University staff.
The University detailed how they had changed their policies to address issues
highlighted, but accepted that without adequate monitoring. measures,
mandatory attendance to tutorial and mandatory homework assignments, and in
the absence of sanctions for non-attendance of tutorials or failing to hand in
homework assignments, the policies may not bite. It was accepted that, were
the same situation to present itself again with another student, it may be that
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nothing different happened to try and assist or help.
7. Students in the School of Mathematics could potentially go without any face to
face contact with any member of staff at the University for almost a year.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you have the
power to take such action. You may wish to consider:
1) Policies and procedures surrounding first year attendance, homework assessment,
sanctions and escalation measures regarding students;
2) Policies and procedures surrounding the second year course structure, attendance.
Homework assessments, and escalation measures surrounding students;
3) University policies and procedures regarding contact, potentially face to face, with
students who are struggling;
4) Policies and procedures regarding contact, and potential contact of a next of kin,
and how they relate to introverted students who do not highlight any concerns to the
university; and
5) Policies and procedures regarding escalation of contact measures where a student
repeatedly fails to engage.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by-26-August2049. Q2b)S5 |Qo
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;
1. Family of the deceased;
| 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 2019
Se Srssr28ero
Miss Emma Serrano
Assistant Coroner
Derby and Derbyshire Coroners Area
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