Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0381, written 10 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Nov 2021 |
|---|---|
| Reference | 2021-0381 |
| Deceased | Daniel Hall |
| Coroner | Dr Sarah-Jane Richards |
| Coroner area | South Wales Central |
| Category | Mental Health related deaths · Suicide (from 2015) · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
South Wales Group; and
, Director of Student Services, University of South Wales
Vice-Chancellor and Chief Executive of the University of
1 CORONER
I am Dr. Sarah-Jane Richards, HM Assistant Coroner, for the Coroner area o f S outh
Wales Central.
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 16 December 2019, I commenced an investigation into the death of Daniel HA LL.
The investigation concluded at Inquest on 2 November 2021.
The medical cause of death provided by pathologist, Dr.
Glamorgan Hospital was:
, Royal
and
The Coroner’s short-form conclusion was that of “suicide”.
The f amily’s concern at inquest related to the University’s long wait ing list f or Ment al
Health Adviser support; a failure to expedite Daniel for mental health s upport k nowing
that he had expressed suicidal ideation and suffered ASD; and the lack of safeguard ing
by the University.
4 CIRCUMSTANCES OF THE DEATH
These were recorded as :-
Daniel Hall 20 years was a 2nd year student at the University of South Wales studying a
BSc in Computer Gamer Development. He suffered from Autis tic S pect rum D is order
(previously k/a Asperger’s Syndrome) and had successf ully c ompleted his 1st year
studies. Fellow student,
was his good friend and wit h whom he s hared
accommodation. Together they had travelled throughout Europe. He was aware of
Daniel’s depression and kept a watchful eye over him. Upon commencing his 2 nd y ear,
Daniel had made enquiries about benefiting from the Disabled Student Allowance (DSA)
and his application was being progressed by the University.
On 29 September 2019 and 23 October 2019 Daniel had f ace t o f ace meetings wit h
1
Nurse Adviser,
he expressed suicidal thoughts.
as a part of his DSA Needs Assessment. On both occasions
signposted Daniel to the ‘Request for Support’ form and t he S amaritans .
Following completion of these forms Daniel received confirmation on 17 and 22 October
2019 that his name had been placed on a waiting list to see a Mental Healt h Adv iser.
Due to ill-health and absences of the University’s three Mental Healt h A dvisers, t here
were ~200 students awaiting mental health support. Daniel was 16th on the waiting list to
be seen.
Daniel was prescribed antidepressant medication by his GP on 30 Oc t ober 2019 but
f ailed to attend his follow-up appointment on 27 November 2019.
, no ting
this f ailed appointment arranged for Daniel to be seen by the GP on 29 November 2019
and again on 11 December 2019. His antidepressant was providing little ‘mood
elevating’ cover.
On 15 November 2019 a ref erral was made for Specialist Mentor support and
was allocated to support Daniel on 21 November 2019 and she introduced hers elf
to him at a meeting on 3 December 2019. There is no attendance note of this meeting or
arrangements made for further contact.
On 18th November 2019, Daniel purchased a
spite of continued support from his sister and friends, Daniel
. In
9 December 2019 at his student accommodation. D uring
the 7-week period between expressing suicidal thoughts to Nurse Adviser,
and completing his suicide plan, Daniel had contact with a number of University
administrative, teaching, nursing and medical staf f yet he lacked receipt of any
meaningful mental health support or any ‘one to one’ safeguarding.
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 f uture 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 –
Lengthy delays for students at the University of South Wales to ac cess ment al healt h
support services even when suicidal ideation has been express ed o n more t han one
occasion and when risk factors (ASD) are known.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and your
organisation have the power to take such action.
• Provide a rapid response counselling/support service when being made aware
of an expression of suicide by a vulnerable student.
• Antidepressant prescription should not be seen as t he res olution t o suicidal
ideation. Pharmaceutical efficacy may take s ome t ime t o dev elop and drug
titration may be required. Throughout this time an individual may still be
vulnerable to suicidal planning and plan execution.
•
Inf ormation was provided by
, Director of Student Services, at
Inquest who explained the University had, in response to Daniel’s death,
recruited more Mental Health Advisers and had successfully red uced waiting
times f or support. Nevertheless, I remained concerned that support needed t o
be more proactively delivered whilst f orms requesting support were being
processed, especially as during this time Daniel was not attending his c ourse
and his well-being was neither being systematically monitored nor check ed i. e.
2
someone undertaking a home visit to ensure he was safe.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of t his rep ort,
namely by 10 January 2022, allowing for statutory holidays. I may ex t end t his p eriod
upon request.
Your response must contain details of action taken or proposed to be taken, sett ing o ut
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 Chief Coroner His Honour Judge Thomas Teague
QC;
Minister f or Mental Health and Wellbeing.
(mother of the deceased); and
Deputy
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 red act ed or s ummary
f orm. He may send a copy of this report to any p erson who he b elieves may f ind it
usef ul. 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 Dated - 10 November 2021
SIGNED:
Dr. Sarah - Jane Richards, HM Assistant Coroner for South Wales Central
3
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.
University of South Wales
Prifysgol De Cymru
Dr. Sarah-Jane Richards
HM Assistant Coroner
The Coroner's Office
The Old Courthouse
Courthouse Street
Pontypridd
CF37 1JW
Date: 7th January 2022
Dear Madam
Response of the University of South Wales to Regulation 28 Report to Prevent
Future Deaths
We write with reference to your Regulation 28 Report to Prevent Future Deaths ("the
Regulation 28 Report") of 12 November 2021 following the inquest into the death of Mr
Daniel Hall on 9 December 2019.
On behalf of the University of South Wales ("the University"), I want to express our
deepest condolences to Daniel's family.
At the outset of this Response, may we assure HM Coroner and the family that the
matters set out herein have been carefully and thoroughly considered at every level
within the University including our Executive which, we trust, reflects the serious
commitment of the University to place student wellbeing at the heart of everything we
do.
Further, as part of our ongoing commitment to continuous enhancement of our provision,
we will be commissioning a specialist independent external review of policies,
procedures and interventions around wellbeing, health and safeguarding to ensure that
our service continues to provide the very best support for our stakeholders. The Terms
of Reference for the review will include benchmarking how we operate against best
practice across the Higher Education sector and will inform future enhancements to the
established service the University provides.
We set out below the University's Response to the recommended actions of HM
Coroner as set out in the Regulation 28 Report.
Swyddfa'r ls-Ganghellor
Pontypridd, Cym ru, CF37 SUP
Office of the Vice-Chancellor
Pontypridd, Cymru, CF37 SUP
G decymru.ac.uk
W southwa les.ac.uk
Mae Prifysgol De Cymru yn elusen gofrestredig. Rhif yr elusen 1140312. IThe University of South Wales is a registered charity. Registration No. 1140312.
University of South Wales
Prifysgol De Cymru
ACTION 1: Provide a rapid response counselling/support service when being made
aware of an expression of suicide by a vulnerable student.
The University continually develops our service provisions. We have enhanced the two
routes to students receiving support from the Wellbeing and Disability Service, student
self-referral and staff referral.
Student self-referral
Since the 2019 Autumn term, the University has introduced new specialist Wellbeing
practitioner roles to our existing Wellbeing services and increased the overall number of
staff in the team by 37%, which has significantly reduced waiting time for students.
Wellbeing Advice and Specialist Provision appointments are monitored weekly by the
Service Manager, who may increase or alter provision to meet student need.
USW processes, which enable rapid response specialist Wellbeing services, have been
enhanced since March 2020. Direct and early conversation with a Wellbeing practitioner
is facilitated by Student Wellbeing appointments which are booked online. During the
Wellbeing Advice Appointment, the trained Wellbeing practitioners, together with the
student, assess need and risk there and then, agreeing and initiating a plan of action.
Any expression of suicide will be referred rapidly, if the assessment of individual need
and risk by the Wellbeing practitioner identifies a need for access to specialist support.
Referrals may be made internally and/or to a GP or other Secondary Care mental health
services.
The existing availability of internal specialist support including Counsellors, Mental
Health Advisers and Nurse Advisers has been adapted to ensure we have daily
availability reserved for urgent referrals following Wellbeing Advice Appointments.
, established this pilot for enhanced collaboration between
We are piloting a service for students in mental health crisis for direct referral to local
Primary and Secondary mental health services. In Autumn 2021, the South East Wales
Mental Health Partnership 1
university support services and local mental health services in cases where students are
presenting as particularly high risk or significantly unwell. The pilot will introduce a new
'University Liaison Service' ("ULS") hosted by Primary Care in the NHS, but based within
the participating universities, to support the student needs between the universities, GPs
and NHS Mental Health Services. The University is applying lessons learnt through this
pilot to its operating principles with other Local Health Board partners.
1 The Partnership consists of Cardiff University, Cardiff Metropolitan University, the University of South
Wa les , Royal Welsh College of Music and Drama and Cardiff and Vale University Health Board.
Swyddfa'r ls-Ganghellor
Pontypridd, Cym ru, CF37 SUP
Office of the Vice-Chancellor
Pontypridd, Cymru, CF37 SUP
G decymru.ac.uk
W southwa les.ac.uk
Mae Prifysgol De Cymru yn elusen gofrestredig. Rhif yr elusen 1140312. IThe University of South Wales is a registered charity. Registration No. 1140312.
University of South Wales
Prifysgol De Cymru
Staff referring students for support
Where University staff have a concern about a student, they can phone the Advice
Zone2 or email details of a student to the Wellbeing Service dedicated mailbox where
trained Mental Health First Aiders will be able to assist. Specialist Wellbeing
Practitioners provide daily duty cover and on receiving a concern, they will provide a
same day response to the member of staff and make contact with the student.
Chaplaincy3 services are also available and can be contacted , working closely with the
student services team and external partners, supporting vulnerable students and staff,
including referrals to specialist Wellbeing services where appropriate.
Information on how to refer students to Wellbeing support is made available to all staff
across the University via the staff portal. This information covers what to do in
circumstances of an emergency mental health situation - referral to emergency
services, and if there is a cause for concern. In addition, specific resources and training
are provided to University staff undertaking particular roles, for example, Personal
Academic Coaches who provide students with support through a series of rich
conversations regarding their overall academic and professional progress on their
course.
Course teams monitor student engagement with academic learning and if there are
concerns surrounding a students' engagement and/or vulnerability, they will refer to the
Wellbeing Service, as above .
During the 2020-21 academic year, the University introduced a pilot system to monitor
student engagement with digital learning resources . This provides clear information to
course teams enabling early identification of students who are not interacting to the
required level and may be vulnerable. To date, this has been rolled out to 100 courses
across the University.
ACTION 2: Antidepressant prescription should not be seen as the resolution to suicidal
ideation. Pharmaceutical efficacy may take some time to develop and drug titration may
be required. Throughout this time an individual may still be vulnerable to suicidal
planning and plan execution.
Prescriptions and pharmaceutical remedies are not provided within University services.
However, we recognise the benefits of tailoring our services to complement external
2 Advice Zone is a contact service for all student enquiries , providing confidential advice on anything that
affects a student's ability to study. It works with USW's range of other services to ensure students receive
the overall support they need .
3 The Chaplaincy is an open and inclusive service for the whole university community. It offers confidential
and non-judgmental support to staff and students .
Swyddfa'r ls-Ganghellor
Pontypridd, Cym ru, CF37 SUP
Office of the Vice-Chancellor
Pontypridd, Cymru, CF37 SUP
G decymru.ac.uk
W southwa les.ac.uk
Mae Prifysgol De Cymru yn elusen gofrestredig. Rhif yr elusen 1140312. IThe University of South Wales is a registered charity. Registration No. 1140312.
University of South Wales
Prifysgol De Cymru
services. We have therefore focused on improving our current engagement with
external services, allowing our Wellbeing services to act on up-to-date circumstances.
The University has extensive liaison with three Health Boards within whose areas our
campuses are located. As outlined above, the University is engaged in a project with
the NHS to provide additional resource to complement existing provision.
Other examples of collaboration with external services includes the University's long
running partnership with a GP practice to deliver services to students on campus at
Treforest. In 2022, we will be reviewing the communication links and expectations of
this relationship, drawing on the learning and standardised measures of mental health
severity from the Health Board collaboration. The aim will be to include a requirement
for primary care services to inform (with individual consent) University support services
of interventions in order that University supplementary support can be synchronized.
Director of Student Services, at
ACTION 3: Information was provided by -
Inquest who explained the University had, in response to Daniel's death, recruited more
Mental Health Advisers and had successfully reduced waiting times for support.
Nevertheless, I remained concerned that support needed to be more proactively
delivered whilst forms requesting support were being processed, especially as during
this time Daniel was not attending his course and his well-being was neither being
systematically monitored nor checked i.e. someone undertaking a home visit to ensure
he was safe.
HM Coroner will be aware through our previous statements that Daniel was regularly
engaging with the Course Leader and Chaplaincy services while he was not attending
his course. Through a series of meetings and correspondence during October and
November 2019 we had agreed a plan with him for adjusting the course to enable
continuation of his studies.
In addition to the enhancements identified under Action 1, the University has committed
to adopting a 'whole University' approach to wellbeing using the Universities UK
Stepchange framework to integrate services across the University. This framework
incorporates all aspects of wellbeing, including mental, physical, social, and financial
well being .
To manage the enhancement of our Wellbeing services, the University has created a
Wellbeing, Health and Safeguarding project under the governance of our Equality and
Diversity Steering Group with Executive level sponsorship and oversight. The
Wellbeing, Health and Safeguarding projects strands incorporate:
1. To enhance our current Wellbeing services and ensure greater connectivity
between them we are completing a review of policies, practices and interventions,
Swyddfa'r ls-Ganghellor
Pontypridd, Cym ru, CF37 SUP
Office of the Vice-Chancellor
Pontypridd, Cymru, CF37 SUP
G decymru.ac.uk
W southwa les.ac.uk
Mae Prifysgol De Cymru yn elusen gofrestredig. Rhif yr elusen 1140312. IThe University of South Wales is a registered charity. Registration No. 1140312.
University of South Wales
Prifysgol De Cymru
synchronizing wellbeing and safeguarding within a 'whole university' approach,
considering the need for proactive support for students and mechanisms for
systematically monitoring student and staff wellbeing.
2.
In August 2021 we committed to adopt the University suicide safer and self-harm
strategy in accordance with guidance from Universities UK. A task group has
been set up under this project to oversee the implementation and ensure
compliance.
3. Since October 2021, to build on our existing Wellbeing provision, we have been
working to help students and staff better understand the range of support services
and resources the University has available using a range of communication
channels. We will continue the development and co-creation (with students and
professionals) of those wellbeing, health and safeguarding resources.
4. From September 2021 we improved and extended our existing programme of
training and development for students and staff, including safeguarding, ASIST,
mental health first aid and other bespoke sessions through physical delivery
sessions and digital platforms.
The University recognises it is not a first response organisation nor is it a primary care
agency and should not be expected to provide emergency or clinical services nor
domiciliary visits. Those services are provided by GP, NHS and other public services.
Our services, as outlined above, have been devised to ensure the University can take
action when we are made aware of suicidal and other high-risk intentions. This includes
referring the matter to external clinical and specialist services best qualified to support
the student.
We trust that this Response provides assurance that action has already, and new
actions continue to be, taken with oversight from the University Executive to address the
matters raised by HM Coroner. We are committed to continuously improve our services.
Yours sincerely
Vice-Chancellor
Swyddfa'r ls-Ganghellor
Pontypridd, Cym ru, CF37 SUP
Office of the Vice-Chancellor
Pontypridd, Cymru, CF37 SUP
G decymru.ac.uk
W southwa les.ac.uk
Mae Prifysgol De Cymru yn elusen gofrestredig. Rhif yr elusen 1140312. IThe University of South Wales is a registered charity. Registration No. 1140312.
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