Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0353, written 4 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Nov 2022 |
|---|---|
| Reference | 2022-0353 |
| Deceased | Harry Evans |
| Coroner | Guy Davies |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Suicide (from 2015) |
| Organisation named | Devon Partnership NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Information Classification: PUBLIC REGULATION 28: REPORT TO PREVENT FUTURE DEATHS HARRY JOSEPH PENGELLY ARMSTRONG EVANS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Vice Chancellor, Exeter University 1 CORONER My name is Guy Davies, I am His Majesty’s Assistant Coroner for Cornwall & the Isles of Scilly. 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 24 June 2021 I commenced an investigation into the death of Harry Joseph Pengelly Armstrong Evans. The investigation concluded at the end of the inquest on 31 October 2022. The conclusion of the inquest was Suicide. The four questions - who, when, where and how – were answered as follows Harry Joseph Pengelly Armstrong Evans died on 24 June 2021 at Trecarrell Mill Trebullett Launceston Cornwall by hanging against a background of an acute mental health crisis 4 CIRCUMSTANCES OF THE DEATH Harry was 21 years old at the date of his death, he lived in Cornwall with his parents and younger sister. He was a student at Exeter University, studying Physics and Astrophysics. At the time of his death, he was in his third year of a 3 year degree course. Information Classification: PUBLIC Harry had no relevant medical history. He had not consulted his GP about mental health problems Harry took exams in January 2021; his exam results can be characterized as a disastrous failure. His results leading up to those exams indicated a high performing student. Harry subsequently chose to defer the re-takes of both his January and May 2021 exams to August 2021. A total of 6 exams. Our academic witnesses indicated this was a huge amount of work for a difficult subject. Harry resided at university continuously from 29 December 2020 to May 2021, during which time there was little or no contact with his parents and family. On two occasions during May 2021 Harry’s mother, contacted by phone and email the University welfare services, raising concerns about Harry. stated that Harry was not sharing information with the family. Due to a systems failure both of these safeguarding alerts were closed off without further action. In late May 2021 his parents visited Harry and were concerned at his physical and mental condition. They brought back Harry back to Cornwall. then emailed Harry’s tutor, raising further concerns about Harry, and indicating that he was not sharing information with the family. These indicated that no concerns were forwarded to Welfare Services who information could be shared with parents without the consent of the student. On 28 May Harry contacted his personal tutor and welfare services raising concerns about his mental health and expressly referring to the difficulties he had in communicating those concerns. He referred to the isolation that he had suffered during the pandemic and the mounting academic pressures he faced in undertaking the re-sits. These concerns were forwarded to Welfare Services who sent a number of emails to Harry inviting him to fill out an online form to access a telephone appointment. There was no attempt to contact Harry by phone or in person by anyone at Exeter University. There was no consideration given to sharing information with Harry’s parents without his consent. There was no attempt to speak to Harry to obtain that consent. Only after Harry’s death did his parents find out about the extent of Harry’s exam failures. Information Classification: PUBLIC 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. – 1) Training The evidence that indicated an absence of mandatory training for academic staff on suicide prevention and mental health awareness. The University is invited to review the provision of training for academic staff upon information sharing [see below], mental health awareness and suicide prevention. 2) Responding proactively The evidence indicated that nobody from the university attempted to speak to or visit Harry despite numerous concerns being raised regarding his wellbeing. There was a total absence of personal engagement. The court heard that research has consistently shown that most students and staff who experience poor mental health do not access formal support. The university response was entirely by email and can be characterized as reactive. The evidence indicated a marked reluctance to respond flexibly and proactively to concerns. The university is invited to review their policy as regards their response to welfare concerns and whether the current approach is sufficiently flexible and proactive. Specifically, whether there is an over-reliance on email responses and students themselves completing online application forms to access support. 3) Sharing information in The university policy allows sharing of circumstances involving a concern for wellbeing, and without consent in exceptional circumstances. involved a conversation with Harry and failing that a consideration whether exceptional circumstances applied for sharing information with his parents. This necessarily would have information with consent The evidence revealed a lack of staff awareness regarding university policy on information sharing. There was evidence of a misunderstanding of policy which specifically allowed the sharing of information in cases of concern, subject to discussion with Harry, and then in exceptional circumstances Information Classification: PUBLIC without his consent. Witnesses referred to a blanket ban on sharing or alternatively to sharing only if they perceived imminent risk to life. The evidence indicated that there was insufficient consideration given to notifying Harry’s parents of the extent of his exam failure, in order to fully mobilize Harry’s support network. There was no evidence of the ‘Think Family’ approach adopted by the university following previous suicides. The University is invited to review the thresholds for sharing information and staff awareness of those thresholds, and the implementation and understanding across academic and welfare staff of the Think Family approach. 4) Pastoral support The evidence indicated that if Harry’s pastoral tutor had known Harry’s mobile number, he may have called him. The court heard that there was no policy for pastoral tutors exchanging mobile numbers with students. The university is invited to review whether pastoral tutors should offer to exchange mobile numbers with their students, and to consider whether pastoral tutors should have a work mobile to facilitate a proactive approach in the event that there are concerns for wellbeing. 5) Welfare services case management system The court heard evidence that systems failures led to safeguarding alerts not being followed up and the case marked closed. The university is invited to review whether the welfare case management system is fit for purpose, whether it is sufficient to capture and ensure actions on welfare concerns raised by students or third parties. 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 by 30 December 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. Information Classification: PUBLIC 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; I have also sent it to who may find it useful or of interest. , His Majesty' Senior Coroner for Exeter, 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 04.11.2022 Guy Davies
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.
Coroner for Cornwall & the Isles of Scilly H.M. Coroner’s Office,
The New Lodge,
Newquay Rd,
Penmount,
Truro,
Cornwall, TR4 9AA
By Email
23rd December 2022
Dear Sir,
Vice Chancellor & Chief Executive
University of Exeter
Northcote House
The Queens’ Drive
Exeter, Devon, EX4 4QJ
Telephone: 01392 723000
Email: Vice-chancellor@exeter.ac.uk
Web: www.exeter.ac.
Harry Armstrong-Evans – Regulation 28: Report to Prevent Future Deaths
We refer to your letter and attached Regulation 28: Report to Prevent Future Deaths received on 4
November 2022 (“the Report”).
The University fully respects the Inquest process and appreciates the considerable time and attention
of the Senior Coroner and Interested Persons in considering the facts surrounding Harry’s death. The
University also recognises that the death of Harry and the subsequent investigation will have been
incredibly traumatic and difficult for Harry’s parents and we offer our deepest condolences again to the
Armstrong-Evans family.
The Report raised a number of specific areas of concern, which you identified during the Inquest into
Harry’s death. You asked the University to consider these concerns and provide a response.
Taking each matter of concern in turn, our response is as follows:
1.
Training
You invited the University to review the provision of training on information sharing, mental health
awareness and suicide prevention for academic staff.
University Response:
The University currently offers a range of mental health awareness training courses for academic and
Professional Services colleagues who are in student facing roles. Following receipt of the Report, the
University has undertaken a detailed review of this provision. Part of this review has identified the
need to consolidate the courses offered and to provide clarity on who should attend, to ensure that
everyone in student facing roles has the awareness and information to support students who are
struggling. This work is already underway.
As an immediate response to the Report, the University has provided guidance to all staff which outlines
where and how to seek support, both for themselves and when identifying support options available to
students.
Further to the review of staff training, the University wishes to embed good practice in suicide safety
and adopt a whole university approach to suicide prevention. This will involve a phased roll-out of
training for all staff that is (a) appropriate to their personal/emotional capacity (it may not be appropriate
for some colleagues) and (b) relevant and proportionate to their institutional role. The training will be
separated into four levels ensuring the level of training taken is based on training needs assessment,
role and individual skills and expertise, as follows:
•
Level 1: All staff will watch a short (20 minutes) introductory online video that helps in raising
suicide awareness, identifying warning signs, and developing basic communication skills in this context.
This is supported by a further video on Mental Health awareness raising/ developing skills to approach
individuals with mental health concerns. This material is already available on the University website.
This will be included as part of the induction materials new staff receive and will be a mandatory module
for all staff.
•
Level 2: Staff with any kind of student-facing role (including staff in accommodation, the Sports
Park etc.) will be required to participate in an in-house half-day ‘Introduction to Mental Health’ training
session. This course has been run for a number of years and explores the impact of poor mental
health on a student’s experience, how to approach a conversation around poor mental health and how
to support a student who is in distress or suicidal, including clear onward referral routes. Training
materials will also include a clear pathway of support for colleagues. All personal tutors, colleagues with
student-facing roles in our information points and education support Hubs and Senior Leadership teams
should undertake this training.
•
Level 3: Mental Health First Aid (2 day training) – This course will be for selected staff in key
student-facing roles whose roles have an element of wellbeing or welfare support (e.g. Directors of
Education and Student Experience, Senior Personal Tutors, Residence Life (student support in
accommodation), Hub Managers (student support in academic settings), Estate Patrol (the University’s
security services) etc).
•
Level Four: Suicide awareness and risk screening – this in-house training will be specifically for
staff in key student-facing welfare roles, such as Estate Patrol and all Wellbeing and Welfare Services
teams.
The University will keep this suite of training opportunities under regular review and will ensure refresher
training is provided to ensure updated sector best practice is adopted.
2.
Responding proactively
You invited the University to review its policy as regards the response to welfare concerns and whether
the current approach is sufficiently flexible and proactive. Specifically, whether there is an over-reliance
on email responses and students themselves completing online application forms to access support.
University Response:
A review has been undertaken of our response to students in distress and, in the short term, we are
also carefully reviewing existing processes for the upcoming January assessment period.
The current Wellbeing and Welfare service is carefully balanced to triage student issues and
communications, identify support routes available to students and provide advice to students with
mental health issues. Students with acute mental health crises that indicate harm or self-harm are also
referred to statutory services for ongoing support. However, public services continue to be stretched
and many students will not reach the threshold for ongoing support via the NHS. The University has a
close working relationship with the Devon Partnership NHS Trust through the University Community
Mental Health team (UCMHT) model and we are seeking to further optimise our approach with all
external partners to provide the best possible support to our students.
We have considered the package of communications sent out in preparation for, during and after
examination periods to ensure these have a supportive tone and clear signposting to the support
available. Student-facing Welfare Advisors will continue their work located within Hubs (local student
academic support teams) in key academic buildings to be visible in their offer of support for students
throughout this period. These teams are available to support students with queries regarding exam
outcomes but also applying for mitigation for assessments and any other support needs a student may
have. We will keep the demand for these services under review to ensure our support can be expanded
and increased as necessary to respond to increasing demand.
We have also set out below (see section 4 – ‘Pastoral Support’) details of our enhanced ‘out of hours’
operation and associated communications which demonstrate the proactive support that can be
accessed by students who are suffering with a mental health crisis or other concerns at any time of day
or night. This can be accessed by the student themselves, other flatmates or housemates, members
of staff who have concerns or parents. The University has focussed on ensuring there are a range of
ways a student can communicate with the University and ask for support using their preferred approach,
including in person, over the telephone or via email.
The University is further informing its approach through wider sector insight, research and guidance
including consideration of the UUK Report into Suicide Prevention1
3.
Sharing information
You invited the University to review the thresholds for sharing information and staff awareness of those
thresholds, and the implementation and understanding across academic and welfare staff of the ‘Think
Family’ approach (which encourages practitioners to consider the parent, the child and the family as a
whole when assessing the needs of, and planning care packages with, those suffering from a mental
health problem).
University Response:
The University has considered the Report alongside wider sector publications including the UUK Report
into Suicide Prevention. The University has been operating using the guidelines of a ‘trusted contact’
framework since 2020, taking a risk-based approach to determine when this is invoked, and allowing
us to contact students’ families or guardians or trusted contacts in times of crisis. A trusted contact
framework considers whether in times of crisis or ill health the University could contact their nominated
person to provide additional support to a student or to raise concerns for a student’s wellbeing.
The latest sector guidance from UUK provides a recommendation to formalise this practice and
recognise it within our policies, including the use of the terminology of ‘trusted contact’ rather than
‘parent/guardian’, and this is being taken forward over the current academic year. Detailed information
on the service approach to working with third parties and parents is available on our 'Consent Form
Procedure'. The following sections are of particular relevance: 'Exceptional Circumstances,' 'Principles
of Practice' and 'Liaison with parents/emergency contact.'
The University recognises that such clarity is essential to ensure best standards of safe practice in the
In addition, the University has reviewed its risk
management of students with complex needs.
assessment procedure to ensure contact with family is routinely considered in safety planning.
Alongside the work to update terminology to reference Trusted Contacts, further work is taking place to
agree further data sharing policies with relevant key statutory organisations including the mental health
care teams and the police. We are also updating our risk policy, ensuring consistent application and
use of the ‘trusted contact’ across all student facing services and identifying high risk areas to ensure
robust support is in place.
The University is taking part in a number of sector discussions on further measures, including engaging
with clinical practitioners and sector experts to inform further changes to policies and processes
regarding Trusted Contacts. We will remain aligned with best practice in the sector, including guidance
from Universities UK (UUK).
4.
Pastoral Support
You invited the University to review whether pastoral tutors should offer to exchange mobile numbers
with their students, and to consider whether pastoral tutors should have a work mobile to facilitate a
proactive approach in the event that there are concerns for the wellbeing of their tutees.
University Response: Supported by the enhanced training provision described above, Personal
Tutors will be able to reach out to students who they feel are struggling, and identify support available,
including referral to expert Wellbeing support, with the ability to check and review how the support has
been received. Furthermore, we have set up a practice review on academic support for students and
we will consider and implement its findings carefully.
1 Suicide-safer universities (universitiesuk.ac.uk)
As was set out during the Inquest, concerns have been flagged by academic colleagues, professional
services and sector representatives with regards to the proposed sharing of mobile numbers. The
concerns include that this approach could have potential safeguarding implications, severe impacts on
colleague wellbeing, and may mean students requiring urgent support do not use the appropriate Out
Of Hours support service. With this in mind, the University is expanding its out of hours provision to
ensure emergency support is available via phone for students in crisis twenty four hours a day across
all our campuses. Advice is available to all staff out-of-hours (via our Estate Patrol team in the first
instance) where there are serious student mental health concerns.
The University has invested significantly in out of hours support to ensure there is a team of trained
members of staff who can proactively support students in need. The Out of Hours provision is being
further reviewed for additional investment, however, the University has already taken the opportunity to
strengthen its Out Of Hours provision and to provide additional detail and information for all staff and
students regarding the availability of this resource. This means wherever a personal tutor has concerns
about a student they can immediately reach out to these teams to ask for support. Additional
information and details of the available support is also included on the University’s website.
Whilst the University will not be asking staff to exchange mobile numbers with their students, and nor
will work mobiles be provided for this purpose, the University has increased its awareness raising for
academic staff on the availability of access to people who can provide support to students outside of
the working day and the associated contact details so they can arrange for proactive reach outs. We
will play an active part in sector discussions on this issue and will keep our position under review to
ensure we continue to be fully aligned with the sector.
5. Welfare services case management system
You invited the University to review whether our current welfare case management system is fit for
purpose, and whether it is sufficient to capture and ensure actions on welfare concerns raised by
students or third parties.
University Response:
As was noted during the Inquest, following Harry’s death the University had already undertaken a robust
review of its current Case Management System (“CMS”). Steps had already been taken to identify
technical issues and options for mitigation. All relevant colleagues have been made aware of the
potential weaknesses in the existing system and appropriate mitigations are in place to minimise, as
far as is possible, repeat issues occurring before the new system is implemented as soon as possible
in 2023 with a view to the system being operational within the Academic Year 2023/24. These
mitigations include:
•
•
Introduction of a welfare tracker to track case progress.
Defining a clear procedure through which referrals with voicemail messages can be safely stored.
Reminders to welfare staff (and broader staff team) to take caution in responding to enquiries,
•
and clarity on which ‘menu option’ to use when seeking further information on an enquiry.
Review and restatement of proper procedures in the online training guides, and provision of
•
individual training support, where needed.
In addition, the University is actively progressing a replacement of the CMS, through the procurement
of a new case management product. We are pushing procurement timelines to ensure this system can
be in place as quickly as possible, and to ensure the integration of this software into our support service
is as simple as possible. This exercise is being undertaken in compliance with all relevant rules and
regulations, whilst having regard to the necessary integration with existing systems and processes.
We trust this provides a comprehensive response to the Report and addresses the matters of concern
flagged therein. The University will continue to strive to support its students in the best way possible
and will always have student health and wellbeing as its highest priority, and at the heart of its
educational provision.
I would like to thank you for your careful consideration of the circumstances of, and issues arising from,
Harry’s tragic death.
Yours sincerely
Vice-Chancellor and Chief Executive
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