Prevention of Future Deaths reports · 2022

Finnian Kitson

Regulation 28 report to prevent future deaths, reference 2022-0023, written 27 Jan 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report27 Jan 2022
Reference2022-0023
DeceasedFinnian Kitson
CoronerZak Golombeck
Coroner areaManchester City
CategoryMental Health related deaths · Other related deaths · Suicide (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. 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: 

• Universities  and Colleges  Admissions  Service (UCAS)

Copied  for interest  to: 
• Chief Coroner
•
• The University of Manchester

 (Finn’s  parents)

1  CORONER 

I am Mr Zak Golombeck, Area Coroner  for Manchester  (City) Area 

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 

INQUEST 

I concluded  the inquest  into  the death  of Finnian  Gabriel Denney Kitson  on 24th 
January 2022 and recorded  that he died from: 

1a   Hanging 

I returned  a short-form conclusion  of Suicide. 

4  CIRCUMSTANCES OF THE DEATH 

The Deceased,  who had been diagnosed  with anxiety and prescribed  medication 
accordingly, took his own life in his student  accommodation on 8th October 2020.  At 
the time of his  death he had recently commenced his studies  at The University of 
Manchester.   

As part of his  application  process for his tertiary level education,  the Deceased 
applied  through  the Universities  and Colleges  Admissions  Service (UCAS) online 
system. As part of the UCAS application  form, an applicant  is asked  to confirm 
whether  they have any ‘disability’  or ‘special  needs’.  The Deceased,  using  the drop-
down list,  confirmed he had no disability.   

The Deceased  did in fact have a diagnosed  mental health  illness.  The guidance 
notes  for completion of the UCAS form make reference to ‘mental  health’;  however, 
such notes  are not commonly accessed  by applicants,  and reference to ‘mental 

1 

 health’  as a disability  can be confusing and discouraging  for applicants. 

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: 

The option  for applicants  to disclose  a mental health  illness  should  be considered 
separate  to them confirming whether  they have any ‘disability’  or ‘special  needs’.  It is 
likely that the majority of applicants  will consider  evidence of a disability  or special 
needs  to refer to physical  illness,  not mental health  illness.  Moreover, those  who 
suffer from mental health  illness  (irrespective  of its  severity) will often not consider 
themselves  to have a ‘disability’.   

Omitting to refer specifically (and  explicitly) to mental health  on the form could,  in my 
judgement,  discourage  applicants  from disclosing  information about  their mental 
health  diagnosis,  and thus provide  them with support  at the point  they commence 
their studies.   

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.   

7  YOUR RESPONSE 

You are under a duty to respond  to this  report within 56 days of the date of this 
report,  namely 24th March 2022.  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 the Chief Coroner and  to Interested  Persons.  I 
have also sent  it to organisations  who may find it useful or of interest. 

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:                                            NAME OF CORONER: 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 27th January 2022   

Signed: 

Zak Golombeck   
HM Area Coroner  for  

Manchester  City Area 

3

Responses

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.

Response from Ucas (PDF)
8 March 2022 

Zak Golombek 
Manchester City Coroners Office and Court 
Exchange Floor 
The Royal Exchange Building 
Cross Street 
Manchester 
M2 7EF 

Dear Zak Golombek, 

Thank you for sending a copy of the Regulation 28 report of 27 January 2022, concerning the inquest 
into the tragic death of Finnian Kitson on 8 October 2020. 

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. 

The experience of students with individual needs applying to higher education via UCAS 

Within the UCAS application, students are invited to share information about any support needs 
they may require, such as a disability, learning difference or mental health condition. This 
information is provided voluntarily by the student, and is not verified by UCAS. Students are 
supported by a range of information, advice and guidance to allow them to understand the use of 
this information, why it is relevant to their application, and build confidence in sharing. 

Once the application has been submitted, an important process begins within the university or 
college to arrange support. It’s important to note that this process varies significantly between 
institutions and it may differ for students who have applied for Disabled Student Allowances (DSAs), 
but is broadly as follows: 

1.  The application is sent by secure transfer to the university or college admissions 
department. All health data is handled confidentially under UK-GDPR legislation. 

2.  Admissions staff assess the application based only on the applicant’s academic aptitude and 

3. 

potential to succeed on the course. Information about an applicant’s health is kept 
confidential and only shared with those who are responsible for organising support. 
If the applicant is made an offer or invited to interview or audition, the information is 
transferred securely to the student support team where reasonable adjustments are 
organised as necessary. 

4.  Once an offer is accepted, the student services team may contact the applicant with more 

information about the available support or to discuss their needs. This may include 

 
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 completing a questionnaire, a visit to the university or college, or help with applying for 
DSAs. 

5.  Before the student’s arrival, the student services team may draft a support agreement 

outlining any reasonable adjustments and discuss this with the student – taking account of 
DSA recommendations where applicable. 

6.  Prior to starting the course, the student services team will discuss the distribution of any 

support document with the student. This will be securely shared on a strict ‘need to know’ 
basis, and may include academic staff, the personal tutor, the accommodation team, library 
staff, and exams officers as appropriate. 

Improving the experience of students with mental health conditions applying to higher education 

We can see from our records that Finnian originally applied through UCAS in November 2018 to start 
his course in September 2019, and later deferred his application to start his course at the University 
of Manchester in 2020. Since Finnian’s original application, UCAS has introduced a number of 
changes to the question that asks applicants about disability, mental and physical health and 
learning differences, as outlined below. 

In July 2019, UCAS held a cross-sector roundtable discussion to review this question, with a 
particular focus on the needs of students sharing a mental health condition. The group, which 
comprised representatives from sector bodies (such as Universities UK and Advance HE) and expert 
organisations (such as NADP, UMHAN and Student Minds), concluded that the format of the 
question remained fit for purpose, but a significant update to the wording of the question, help text 
and categories was needed – including a greater emphasis on mental health. Work to review the 
language was subsequently completed by autumn 2019 and the full revisions – outlined below – will 
be introduced in May 2022 for the 2023 entry cycle. The full text can be found in Annex A. 

In the period between the agreed changes and implementation, we made a number of interim 
adjustments: in November 2019, we updated the help text to reflect the broader range of conditions 
and impairments captured and, in May 2021, we made further improvements to the on-screen 
question text, as follows: 

Select the option which you feel best describes any physical and/or mental health condition, 
long-term illness, or learning difference you may live with. If you don’t have a disability, 
select to confirm you don’t have a disability. We've got more help here. Read more about 
applying to university with a physical and/or mental health condition, long-term illness, or 
learning difference. Click here to know more. You can also read our FAQS. 

Further changes to this question are planned for a future cycle, including the ability for an applicant 
to select multiple categories (instead of selecting the ‘two or more’ option), and to share an 
impairment or condition later in the cycle. 

As part of our ongoing commitment to ensuring students receive the best experience possible, we 
regularly review our products and services to ensure that they are fit for purpose. Student mental 
health is at the forefront of these commitments, and a matter UCAS takes very seriously. Cognisant 
of the changes to the landscape since we held our original roundtable in 2019, we have committed 
to convening another event in summer 2022 whereby we will revisit our discussion about the UCAS 
application and check our original decision remains the best approach. We are also currently 
undertaking a review of the reference section, which allows teachers and advisers – with the 
permission of the applicant – to flag any mitigating circumstances, such as a mental health condition. 

 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 UCAS research into the experience of students with mental health conditions applying to higher 
education 

In June 2021, we published our student mental health report, Starting the conversation. Here 
we found that, while mental health declarations had risen 450% over the last 10 years, nearly 
half of all applicants with an existing mental health condition chose not to share this with 
their university due to misconceptions about how the data was used. To address these 
misconceptions and lingering stigma around mental health, we recommend several next 
steps – for UCAS, the wider education sector and government, including a joined-up 
campaign to promote the benefits of disclosure and clarify how the data is used to connect 
students to the right support for their needs. 

This research also found there were significant differences in the disclosure rate depending 
on an applicant’s gender, ethnicity, LGBT+ group and care experience. Accordingly, the report 
highlights the importance for universities and colleges to consider the intersectionality of 
mental health with other characteristics, and for the sector to re-evaluate how they target 
communications about mental health to groups where disclosure rates are low. 

Other ways UCAS supports student mental health 

Other work UCAS has recently undertaken to support student mental health includes: 

-

-

-

-

-

Sector collaboration – we work closely with Student Minds (UCAS is a member of the 
Student Space Independent Governance Group), UMHAN, NADP and Advance HE 
(including the Disabled Students’ Commission) among others to ensure a joined up 
approach that informs our work. 
Information and advice – for students to help them understand more about how to 
get support and the benefits of sharing a mental health condition in the application. 
Social media to engage students in a timely and immediate way, and signpost 
support. Over the COVID-19 period, we delivered a series of Facebook live sessions to 
keep students fully updated about the changing situation – these sessions included 
mental health support from contributors including Dr 
, 
and Student Minds. 
New teacher and adviser resources to help them support students with mental 
health conditions in their application and transition. This includes a new toolkit and 
an online training module due for release later this month. 
UCAS events – we are currently in the process of developing wellbeing zones in our 
physical events to support students with more information about mental health and 
wellbeing in higher education. We have also partnered with Dr 
, the 
Youth Mental Health Ambassador to support year 12 students making decisions 
about their post-secondary choices as part of our UCAS Discovery events. 

, Dr 

I 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. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 Yours sincerely 

Chief Executive 
UCAS 

  
 
 
  
 
 
 Annex A: New question wording to be introduced for the 2023 cycle 

Every year, over 60,000 students with a physical and/or mental health condition, long-term 
illness, or learning difference apply through UCAS to study at a university or college in the UK, 
and access a range of support available to help with their studies, day-to-day activities, 
travel, or lifestyle. 

Would you consider yourself as living with any of the following: 

•  A learning difference (e.g. dyslexia, dyspraxia, or AD(H)D) 
•  A visual impairment uncorrected by glasses (e.g. blindness or partial sight) 
•  A hearing impairment (e.g. D/deafness or partial hearing) 
•  A physical impairment or challenges with mobility (e.g. climbing stairs or uneven 

surfaces), or dexterity (e.g. using a keyboard or laboratory equipment) 
•  A mental health condition, challenge or disorder (e.g. anxiety or depression) 
•  A social, behavioural or communication impairment (e.g. an autistic spectrum condition 

or Tourette’s Syndrome) 

•  A long-term illness or health condition which may involve pain or cause fatigue, loss of 
concentration or breathing difficulties – including any effects from taking associated 
medication. 

•  A condition or impairment not listed above (please give details in the box below) 
•  Two or more impairments or conditions (please give details in the box below) 
•  None 

Telling a course provider about a health condition or impairment early means they can work 
to make the arrangements or adjustments ready for your arrival. However, if you decide not 
to give this information now, you may do so after you have sent your application, by 
contacting them directly. 

Select the option(s) which you feel best describes any physical and/or mental health 
condition, long-term illness, or learning difference you may live with. If you have no 
impairment or condition, select None. 

IMPORTANT: The information you provide here will not negatively impact the academic 
judgement of your application, or the decision about whether to offer you a place. Under the 
Equality Act 2010, it is unlawful for any information you provide about an impairment or 
condition to be used in making an academic decision about your application. This information 
will only be shared with those involved in supporting you, or making the arrangements for 
your support – contact the course provider’s disability team to find out more about the 
support they can offer. The information you provide here may also be used (anonymously) for 
monitoring purposes to inform and improve support for future students. 

Please be aware that some courses – particularly professional courses – may have additional 
requirements relating to ‘fitness to practise’ – find out more about fitness to practise. 

For more information about answering this question read our FAQs.

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