Daniel Bowen

UNIVERSITY 
OF  SUSSEX 

Veronica Hamilton-Deeley 
The Coroner's Office 
Woodvale 
Lewes  Road 
Brighton 
BN23QB 

17 April 2019 

Dear  Ms.  Hamilton-Deeley 

I write on  behalf of the University of Sussex  in  response to your Regulation 28  Report to 
prevent further deaths dated  pt February 2019. This followed the conclusion  of the Inquest 
into the circumstances of the death of Daniel Alexander Jeremiah Bowen on  21 st September 
2018. 

The  Report to prevent future deaths and  the concerns raised  in  it have  been read  and 
considered  by the University of Sussex's Chair of University Council, 
the Vice-Chancellor, 
University. I wish to assure you the University takes its responsibilities and the well-being of 
students and staff extremely seriously, and we  have a comprehensive suite of initiatives 
underway to address the concerns that you  have identified. 

, together with other key  parties across the 

 and 

Your Report raised several concerns, each of which will be  specifically addressed. 

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)  Academic Advisor- Better use should be made of the person in  this post for each 

school.  There  was a wasted opportunity for the academic advisor to be involved in 
face to face meetings with Daniel and help him when he was struggling to get his 
work in  on time and to deal with his academic pressures.  In  the circumstances, I 
heard that if work was late a penalty would be imposed.  This seems ridiculous; 
why hit a man when he is alreadydown? 

STUDENT  EXPERIENCE 
Director's Office IUniversity of Sussex I Sussex House  I Brighton  B N 1  9 RH  I United Kingdom 

www.sussex.ac.uk 

 
 
 (2)  With  regard to communication - this appeared to be deeply flawed amongst the 

huge number of University departments and units.  The  health clinic incorporating 
amongst other things a pharmacy and the counselling service,  was excellent 
offering free access to students.  The system failed - Daniel was not in  the link 
between his GP/counsellor and the student support unit.  If this link had been 
complete I do  not believe Daniel  would have died when he did. 

Within the Record of Inquest your finding's state: 

Had his medical condition been flagged up to the Student Support Unit in March or 
April 2018 IFINO from the evidence and on the balance of probabilities that he 
would have had access to invaluable input and support targeted for his specific 
needs.  Had Daniel been given this support it is likely that the outcome for him 
would have been different.  This was a failed opportunity to help him. 

University Response: 
The  University takes the well-being of its campus community very seriously and  offers a 
range of services to support students throughout their studies. The following outlines the 
University's structure, student support provision and  new initiatives. 

The University Structure 
The Vice-Chancellor (
Executive, is  responsible to the University Council (the governing body),  for management of 
the University. He is supported by an  executive group, which includes the Provost, three Pro-
Vice-Chancellors, the Chief Operating Officer, the Director of Finance and  the Director of 
Human Resources. The  Heads of the Schools of Studies at the University of Sussex  report to 
the Provost. 

 is the senior academic officer and, as  Chief 

The  University has twelve academic schools, each  with a Head of School,  and  academic 
officerships including a Director of Student Experience (DoSE). Academic staff within each 
School also act as  academic advisers to a cohort of students, and  the School  DoSE  provides 
oversight for the academic advising system. 

The  University managed services include counselling and  therapeutic services,  disability and 
mental support, practical advisory support and academic support, the latter being primarily 
delivered within our academic Schools as  outlined above. In  addition, the University has a 
long standing contractual relationship with a General Practitioners Surgery,  embedded in-situ 
on the campus and  located within the same vicinity as the University Counselling Service and 
independent Pharmacy. 

Together, the School  based  academic advisory system  and  the centrally managed 
professional pastoral services are designed to offer holistic support to our students 
throughout their academic journey at University. 

In  circumstances when a student is  struggling academically or facing challenges that affect 
their academic performance or attendance, the student is offered support both informally, 

and  more formally where necessary, and  is supported via  the School Student Progress 
Committee (SSPC). 

Strategic Review 
In  November 2018 the University Council  agreed and  published the Education and Students 
strategy:  'Learn to Transform'. This provides the strategic direction for teaching,  learning and 
the student experience up to 2025, and  in  line with the Strategic Framework of the  University 

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 ("Sussex 2025 11 

). 

The  Learn  to Transform Strategy includes a series of pertinent actions as  outlined below with 
timelines: 

Creation  of a Well-being and  Mental Health Strategy 

September 2019 

Activity/Action 

Timeline for completion 

Introduction of an  on line student support tool to offer all 
students 24/7-year-round access and  oversight of 
vulnerable or at-risk students 

Fundamental review of assessment and feedback 
mechanism to ensure  inclusive practice, effective learning 
experiences and  achievement of fair outcomes 

Utilise learning analytic and  business intelligence software 
to provide real time data, informing practices and  allowing 
for targeted interventions. 

September 2020 
(expedited to Jan  2020} 

June  2021 

September 2021 

Reconfiguration of pastoral support 
The  University is  reconfiguring its student support provision from separate teams into 
thematic areas. The  objectives of this reconfiguration are: 

• 

• 

To  enhance each  student's experience through the provision of effective and  efficient 
cohesive support services and  activities across the whole University. 

To  deliver a fit for purpose structure within a framework that is  flexible and can 
adapt to change and evolve in  a planned and strategic manner. 

•  To  encourage harmonisation and more streamlined processes to take effect across 

the University. 

•  To  make better use  of resources  by reducing duplication, clarifying roles and 

responsibilities and consolidating good  practice. 

The  reconfigured structures and services will begin to take effect during the 2019-20 
academic year and  should enable student access to appropriate support and  engagement 
activities, when and  how they require it, and  without the need to know the University's 
support structures in  advance. 

Student Centre 
A purpose built Student Centre has been  commissioned and  the building is scheduled to open 
in January 2021.  The  Centre will be the primary location for students accessing services face 
to face,  and will be the main access  point for information, advice  and  guidance.  It will enable 
students to access friendly, consistent and  professional student focused services across 
campus and digitally. 

Communication and  Data Sharing 
Following Daniel's death, the University has  reviewed and  improved its data sharing and 
appropriate access  to case  notes and  systems to improve the flow of information across the 
professional service areas.  Professional service staff have improved access to necessary 
information, links and active referral  between constituent areas such  as:  the Student Support 
Unit (that works with disabled students and  those with specific learning differences and 
mental health conditions), Student Life and the Counselling Service, to facilitate more 
cohesive support to students and  remove barriers to service access. 

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 The  University is  also continuing to work with the GP's  Practice towards improving data 
sharing about patient/student service users, to ensure pertinent information and  knowledge 
is  available to expert practitioners, working together to support students and  mitigate the 
risk of serious self-harm as far as  it is  possible to do so. 

Online Student Support Tool 
Communication and  data sharing will be further improved by the introduction of an  on line 
communication platform, offering students access to student support on  a 24/7 basis. This 
should remove the need to hold duplicate student information at a local level  and  provide 
professional service staff with a clear line of sight to better support service users. The 
procurement, development and  implementation of this system  has  been  expedited from 
September 2020 to January 2020 following the outcome of the Inquest. 

Academic Advising System 
The  University accepts that improvements to the academic advising system are required; 
consequently, the University is  reviewing  its delivery model for the academic advisory 
system.  An  alternate delivery pilot is  already taking place this academic year (September 
2018 to July 2019) in  one school to improve the current offer to students. An  evaluation of 
this pilot model will take  place  in  the Summer with further work, and  additional pilots taking 
place during the 2019-20 academic year. Following evaluation, roll-out of an  improved 
academic advising system  is  expected from 2020-21 academic year onwards. 

Regulatory & procedural monitoring and  review 
The  University regularly reviews  its academic regulations and procedures, including the 
Principles underpinning this governance. As  is general practice across the higher education 
sector, the  University sets deadlines for submission of coursework. When  a student is  late or 
misses a submission for a deadline a penalty can  be  applied. When there are  known  reasons 
for late submission, a student may submit a request for exceptional circumstances, with 
evidence (e.g.  medical), where appropriate. Students with reasonable adjustments in  place 
due to a disability or specific learning difference have an  additional seven  days to submit 
work without penalty. When  the University is  unaware of such  circumstances,  a penalty will 
be  applied. 

The examination and  assessment regulations are  reviewed on  an  annual basis,  and specific 
consideration will be given to the late submission and penalty clauses.  Any change to these 
regulations will take effect from  pt September 2019. 

Immediate Action Taken 

Examination/ Assessments Results 
Upon receipt of the Regulation 28 Report in  early February 2019,  a temporary system was 
immediately adopted to identify repeating/re-sitting students for whom the School  DoSE 
(lead academic adviser) considered to be vulnerable. This was  based  upon information held 
within each School through ongoing contact with their students. Each  student was  contacted 
by telephone irrespective of the outcome of their results and  offered academic advice.  In 
addition, the University wide services were available to offer appropriate support (e.g. 
disability support, counselling). 

From Summer 2019 a university-wide pilot system of support will be  in  place.  Release of 
assessment and  examination results  will  now be  at the start of the week rather than just 
before the weekend.  This will facilitate a 'We are Here' Campaign whereby key academic 
staff will be  available during the week following release  of results in  order to ensure that 

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 students can  access  appropriate academic advice easily and quickly. This will be  underpinned 
by University wide services offering a wider range of enhanced advice for those students who 
require  it. 

"Enlitened" Pilot 
In  recognition of the increasing usage of digital platforms, social  media and  smart phone 
applications (apps)  by current and  future student population; the University is taking part in  a 
prototype pilot of an  app on  smartphones/tablets. Designed  by an  external partner, this App 
is designed to encourage positive student engagement and  well-being and  is  designed to 
enhance a sense of belonging and connection from  a digital platform. The  App  has  been 
piloted with the School of Psychology since  March 2019 and, subject to a positive evaluation 
of this pilot, it will be  rolled out across the University from September 2019. 

Imminent Risk Protocol 
An  Imminent Risk  Protocol has  been  developed as  an  additional safeguarding measure to 
enable expert staff to initiate an  immediate case  meeting (within 2 working hours) if they 
consider or anticipate that a student will be  at serious risk of harm to themselves or others 
within a 24-48 hour period. The  protocol is time specific and  action based,  and  designed to 
ensure protective factors are  in  place as well as  mitigate risk as far as  it is  reasonably possible 
to do so.  This  Protocol will be  launched on  29th  April 2019. 

In Conclusion 
I trust that this response and  actions taken to date will  provide the reassurance and 
information that you seek. 

The  University remains deeply saddened  by Daniel's death and  it is  hoped that you,  the Chief 
Coroner, and  Daniel's family will recognise the University is doing everything it is  reasonably 
possible to do  in  order to +keep our student and  staff community safe from  harm. 

Yours  sincerely 

Director for the Student Experience 

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