Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0230, written 11 Nov 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Nov 2020 |
|---|---|
| Reference | 2020-0230 |
| Deceased | Xuanze Piao |
| Coroner | Tom Leeper |
| Coroner area | Coventry |
| Category | Suicide (from 2015) · Railway related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
Xuanze Piao (died 3 December 2018)
THIS REPORT IS BEING SENT TO:
•
, Vice-Chancellor of Coventry University.
Vice Chancellor’s Office
Coventry University
Priory Street
Coventry CV1 5FB
1
CORONER
I am Assistant Coroner Leeper
Assistant Coroner for the Coroner area of Coventry
Coventry Coroner’s Office
The Register Office
Manor House Drive
Coventry
CV1 2ND
2
CORONER’S LEGAL POWERS
I 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 11/12/18 an investigation was commenced into the death of Xuanze Piao. The
investigation concluded at the end of the inquest on 06/11/20. The determination
of the inquest as to the medical cause of death was a massive head injury and
multiple trauma owing to impact with a train, and as to conclusion, suicide.
1
4
CIRCUMSTANCES OF THE DEATH
In Autumn 2018, Xuanze was a student attending Coventry University enrolled on
a degree course in Architecture. He was aged 17, having been born on 10/12/2000
in the Heping district of Shenyang, China. He was living in student accommodation.
At Coventry University he was categorised as a Tier 4 overseas student. Due to his
age and nationality he was required to have a guardian within the UK. A condition
of his UK student visa was that he attended his university course. Xuanze’s
attendance on his university course was limited. Because of the amount of the
course he missed he was sent a number of emails requesting his attendance at
meetings with staff to discuss his absence. He did not respond to these invitations
which resulted in an email being sent to him on 29/11/2018, indicating that he
was at risk of being removed from the course and that he should attend a meeting
to discuss this on 03/12/2018; removal from the course would in turn have
affected his permission to remain in the UK on his student visa. There was no face
to face meeting with Xuanze in advance of the email being sent to him on
29/11/2018, and neither Xuanze’s family nor his guardian were informed that
Xuanze was not attending his university course, nor were they informed of the
meeting he had been requested to attend to discuss his removal from the course.
On 03/12/18 shortly before 5 a.m. Xuanze left his student accommodation and
went to Coventry Railway station. He walked to the end of platform one and
proceeded along the side of the tracks. Approximately 500 meters outside of
Coventry Railway station heading south, Xuanze was struck by a passenger train
which caused him to sustain catastrophic injuries. He is likely to have died instantly
as a result of the collision and his life was formally declared extinct at 07:35 hours.
The inquest conclusion is suicide.
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 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) The University did not have a face to face meeting with Xuanze, a student
under the age of 18, prior to sending him the email dated 29/11/2018 indicating
that he was at risk of being removed from the course and that he should attend a
meeting to discuss this on 03/12/2018;
(.2) In the absence of a face to face meeting with Xuanze, the University did not
contact either Xuanze’s Guardian or Parents prior to sending Xuanze the email
dated 29/11/2018 indicating that Xuanze was at risk of being removed from the
course and that he should attend a meeting to discuss this on 03/12/2018;
2
Evidence was given at the inquest that in the case of an overseas student under
18, notwithstanding both prolonged absence from academic commitments and a
persistent omission to respond to email requests that the absentee student should
make contact with the university, there was no procedure or policy in place either
for a face to face meeting with the student or, in the absence of such a face to face
meeting, for contacting that student’s Guardian or Parents, prior to the email
being sent indicating that the U.18 student was at risk of being removed from the
course and that he should attend a meeting to discuss this.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your
organisation has 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 06/01/2021. I, 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to
•
•
•
•
Xuanze’s Parents
The Child Death Overview Panel
The Local Safeguarding Children Board
The Chief Coroner at the Chief Coroner’s Office.
, via their Solicitor
I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I believe may
find it useful or of interest.
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.
3
You may make representations to me, the coroner, at the time of your response,
about the release or the publication of your response.
9
DATE: 11/11/2020…. Signature
SIGNED BY ASSISTANT CORONER LEEPER
4
1 response 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.
Coventry University’s Response to the Report to Prevent Future Deaths Dated 11 November 2020 Xuanze Piao (died 3 December 2018) Coroner’s Concerns: (1) The University did not have a face to face meeting with Xuanze, a student under the age of 18, prior to sending him the email dated 29/11/2018 indicating that he was at risk of being removed from the course and that he should attend a meeting to discuss this on 03/12/2018. (2) In the absence of a face to face meeting with Xuanze, the University did not contact either Xuanze’s Guardian or Parents prior to sending Xuanze the email dated 29/11/2018 indicating that Xuanze was at risk of being removed from the course and that he should attend a meeting to discuss this on 03/12/2018. Response: Coventry University has a number of attendance/engagement and welfare policies and procedures in place which apply to international students who are under the age of 18. The policies and procedures result in contact being made with the students in a number of different ways and on many different occasions. The policies and procedures also ensure that students are provided with information about welfare services and given many opportunities to inform the University of any issues or concerns. If any concerns are identified either from the student or other sources at any time (including health professionals, family, friends, students and/or staff) then steps will be taken to address these concerns – this can include meetings with welfare advisors, home visits and/or appointments with mental health advisors or immediate contact with the police/health services and/or parents/guardians. In relation to Xuanze Piao, prior to his arrival at University, he was contacted by the Student Engagement Centre which has been created to provide pro-active advice and support to students. He was initially contacted by telephone on 30 August 2018 and then on 18 September 2018. When he did not answer, he was sent an email providing contact numbers so he could call with any questions that he had. As part of the enrolment process, on 25 September 2018, Xuanze had a “Welfare Check”. This was a face to face meeting with an international student advisor. During this meeting the international student advisor checked that Xuanze was settling in well, had everything he needed and had no issues or concerns. Students who are under the age of 18 are required to have a guardian in the UK. As part of the meeting, Xuanze’s guardian was contacted by the international student advisor. Xuanze was provided with information about the support services available at the University and was encouraged to contact international student advisors if he had any concerns. He also confirmed that he knew how to contact the emergency services. Xuanze attended some lectures and workshops in October 2018. During those sessions, he received face to face teaching and was encouraged to speak to course staff if he had any issues or concerns. On 31 October 2018, Xuanze’s course director sent him an email noting that there had been a number of absences recorded for him, asking if the faculty could assist with any problems, giving him the details of the next teaching sessions and encouraging him to attend. Students who are under the age of 18 are required to have contact with an international student advisor once a month until they become 18. The contact usually takes the form of a telephone call in the first instance and the advisors will seek to identify any welfare concerns during the call. Xuanze was called by an international student advisor on 1 November 2018 and he confirmed that there were no problems or concerns. Around that time, the University’s StREAM leaner analytics system sent an alert to the Student Engagement Centre highlighting Xuanze’s low engagement with the University’s online learning systems. When such an alert is triggered, the Student Engagement Centre seeks to contact students to check that they are well, to ask if they need any advice or support and to encourage them to engage more with their studies. The Student Engagement Centre therefore contacted Xuanze by telephone on 2 November 2018. Xuanze explained that he had had some “family issues” which had impacted on his engagement with the course but said that those issues had been solved. He insisted that there were no ongoing issues or concerns and was reminded of the services and support available. As Xuanze was an international student, the University was his Tier 4 sponsor. If a student missed 10 consecutive contact points, the University was expected to withdraw sponsorship and report the student to the Home Office unless the student had permission to miss a contact or for other exceptional purposes. The University therefore sent emails to Tier 4 students whose attendance had fallen below a specified level. The emails reminded students of the obligation to attend and engage, informing them of the consequences of non-engagement and providing details of the support available and how it could be accessed. Emails were sent to Xuanze on 8, 15 and 22 November 2018. As he did not respond, on 29 November 2018, he was invited to a face to face meeting to ascertain if there were any reasons for non-attendance before a decision would be made about withdrawing him from the course. The above short chronology demonstrates that there was contact with Xuanze in a number of different ways and on many different occasions during his time at the University including face to face teaching, face to face meetings, telephone calls and emails. He was given substantial information about welfare and support services that were available at the University and was encouraged to make contact if there were any issues. He was specifically asked about his welfare on 25 September 2018 in a face to face meeting and then on 1 November 2018 and 2 November 2018 by telephone. Each and every time he said that there were no welfare or health concerns. Xuanze did not respond to emails relating to his low engagement with his course but, before making any decision about withdrawing him, the University invited him to a face to face meeting to discuss the situation. The University’s attendance/engagement and welfare policies and procedures therefore already provide for face to face meetings and welfare checks and those policies and procedures were followed in this case. However, the University is committed to continuous evolution and welcomes any proposals, comments or suggestions about the development of its policies and procedures. The University is undertaking a full review of its policy and procedures relating to students who are under the age of 18. This is expected to be complete by 31 January 2021. The University will provide a copy of the new policy to the Coroner when it has been finalised. In relation to the concerns raised by the Coroner, the University refers to the chronology set out above. The University also confirms that it has already put in place an additional process for responding when international students who are under 18 fail to engage with their course where this results in them failing to meet the conditions of their visa and thereby puts them at risk of being withdrawn from their course. Those students are identified on engagement reports and the International Student Compliance Team consider what action is required in each case. In particular, where any such student is at risk of being withdrawn from their course, a face to face meeting (which may have to be undertaken virtually during the pandemic) will be organised between that student and a welfare advisor specifically to assess whether there are any welfare issues or concerns and, if so, to decide what action should be taken. This assessment will include consideration about whether the student’s parent or guardian should be contacted. No steps to withdraw the student from the course will be taken by the University until the welfare meeting has taken place. 6 January 2021
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