Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0365, written 10 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jul 2024 |
|---|---|
| Reference | 2024-0365 |
| Deceased | Benjamin Faux |
| Coroner | Hannah Godfrey |
| Coroner area | Berkshire |
| Category | Suicide (from 2015) |
| Organisation named | Berkshire Healthcare NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Reading University 2 Universities UK 1 CORONER I am Hannah GODFREY, Area Coroner for the coroner area of Berkshire 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. A prevention of future deaths report raises issues and is a recommendation that action should be taken but does not recommend what that action should be. That is a matter for the recipient. It is important to note the case of R (Dr Siddiqui and Dr Paeprer-Rohricht) v Assistant Coroner for East London. This case clarifies that the issuing and receipt of a Regulation 28 report entails no more than the coroner bringing some information regarding a public safety concern to the attention of the recipient. The report is not punitive in nature and engages no civil or criminal right or obligation on the part of the recipient, other than the obligation to respond to the report in writing within 56 days. INVESTIGATION and INQUEST 3 On 3 October 2023 I opened an inquest into the death of Benjamin Faux on 5 August 2023, aged 21. The inquest concluded on 26 June 2024. The conclusion of the inquest was suicide, and the medical cause of death was 1a Hanging. The family requested that I refer to Benjamin as Ben, I will reflect that in this report. CIRCUMSTANCES OF THE DEATH 4 Ben graduated from Cambridge University in Summer 2022 and started a taught research Masters in the Chemistry School at Reading University in the autumn term of 2022. From October 2022 Ben had a diagnosis of mixed anxiety and depressive disorder on a background of chronic social anxiety since the Covid pandemic. Ben’s attendance fell drastically from Christmas 2022. From then on Ben missed lectures, hardly attended labs and missed deadlines repeatedly. In early 2023 he developed acute mental health issues probably triggered by the stress of managing academic work and deadlines and he reported suicidal thoughts to student welfare counsellors, his GP and NHS secondary mental health services. Ben had capacity and was adamant he did not want his parents to know about his mental health problems, or his difficulties with his studies. Ben’s academic tutor and department director of academic tutoring (DDAT) were Regulation 28 – After Inquest Document Template Updated 30/07/2021 unaware of Ben’s difficulties until he wrote to them in March 2023 explaining that he had severe mental health problems that were interfering with his work. They met with him twice and at the second and last meeting on 24 April 2023 proposed that he formally indefinitely suspend his studies and concentrate on his health. Ben was provided with paperwork to formally take this step. Ben’s academic tutor thought that Ben was going to do it. Ben in fact did not. On 17 May 2023 Ben told a member of staff at the Student Support Centre who contacted him that he no longer wanted to suspend and would contact his academic school to produce an academic plan of action. However he did not contact his school and they did not contact him. Academic staff became aware that Ben had not suspended his studies in late June 2023. No-one from the University took any other steps to contact or check on Ben, or to ask anyone else to contact or check on him. Ben did not re-engage with any academic work but continued living in his student accommodation where he took his own life on or around 5 August 2023. CORONER’S CONCERNS 5 During the course of the investigation my inquiries 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: (brief summary of matters of concern) The evidence heard at the inquest touching Ben’s death was specific to students on taught graduate research courses at the University of Reading, and my concerns set out below are specific to that group. I am copying this report to Universities UK as I consider there may be a wider application to comparable student groups in other universities nationally. (1) About 5 years ago, following concerns from academic staff that they were not equipped to support students with welfare issues, Reading University stripped out the pastoral care function from the academic supervisor role, leaving only ‘academic advisors/tutors’. There is alternative provision made for welfare but it is not part of the tutor role and students on taught research courses do not have named pastoral tutors; (2) The nature of taught research courses (largely independent work) makes it more challenging to monitor students’ engagement and identify issues at an early stage. Ben’s difficulties with his academic work started after Christmas 2022 but were not addressed by the department until he raised them himself in March 2023 by which point he was at a crisis point; (3) Ben was appropriately encouraged to use University procedures such as ‘exceptional circumstances’ applications through to a conclusion, however there was no process for ensuring that after being offered the option to suspend his studies Ben was supported through to a conclusion of that process one way or another, and that remains the case for students in that position now; (4) There is an established process for enforced suspension of studies and the University agreed that with hindsight Ben was clearly not fit to study and should have been identified as such and put on that pathway instead of leaving it to Ben to decide and take action to suspend his studies; (5) By March 2023 Ben’s department at Reading University knew that Ben was a student Regulation 28 – After Inquest Document Template Updated 30/07/2021 with severe mental health concerns linked to management of his academic work, who had not taken any exam and had not completed sufficient research to file a dissertation and by late June they also knew that he had not completed paperwork to suspend his studies and yet: a. The University staff who knew this did not appear to appreciate what it meant for Ben and his continuing risk of vulnerability; and b. There was no individual who was given or took responsibility for what should happen next with regard to resolving Ben’s academic situation; and c. Apart from brief further contact from the Student Support Centre re the suspension forms, no-one from the University contacted Ben between 24 April 2023 and when he took his life on or around 5 August 2023; (6) The primary responsibility to meet acute mental health needs when they arise lies with mental health care services. I acknowledge that Reading University have engaged with and are continuing to implement a lessons learned process since Ben’s death. However I consider that circumstances at Reading University continue to present a risk to vulnerable graduate students on taught research courses who struggle with their work and develop mental health issues. The risk is of being overlooked until a crisis is reached, or becoming isolated, or of being left in academic limbo, as Ben was, with tragic results. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 September 04, 2024. 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to Ben’s family and Berkshire Healthcare NHS Foundation Trust (the other interested persons in the inquest). 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, 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. Dated: 10/07/2024 9 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Hannah GODFREY Area Coroner for Berkshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 responses 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.
Pro-Vice Chancellor (Education and Student Experience) Vice-Chancellor’s Office Whiteknights House University of Reading, Whiteknights Reading RG6 6UR email Hannah Godfrey Area Coroner for Berkshire Berkshire Coroner Office, Town Hall, Blagrave Street, Reading RG1 1QH 4 September 2024 Dear Ms Godfrey, INQUEST INTO THE DEATH OF BENJAMIN FAUX I write on behalf of the University of Reading (“the University”) in response to the Prevention of Future Death Report (“PFD Report”) dated 10 July 2024. As a preliminary matter, the University would like to record its appreciation for the care and consideration with which the inquest into Ben’s death was conducted, and for the issues that have been identified in the subsequent PFD Report. Whilst the University has already taken steps to address a number of these concerns, we also recognise that there are points highlighted here which remain live issues, and where more work is required on our part. We are engaging constructively with the matters of concern raised in the PFD Report with the aim of reducing potential risks faced by future generations of vulnerable students. We note that the matters of concern raised in the PFD Report are specific to the group of students on “taught graduate research courses” at the University. We have interpreted this to mean our small portfolio of ‘Master’s by Research’ (“MbR”) programmes as Ben was on the chemistry MbR programme. As I briefly explained during my evidence at the inquest hearing, these are one-year Master’s degrees which are formally categorised as ‘research’ rather than ‘taught’ programmes. There are approximately 60 students at the University currently registered on MbR programmes. In terms of the practical delivery of these programmes, they have some features in common with postgraduate taught degrees, while in other respects they much more closely resemble research programmes. As such, we recognise that our student support processes (which are designed either for traditional ‘taught’ or ‘research’ programmes) have not been well-suited to this particular set of programmes. We have already undertaken a review of student support arrangements for MbR programmes, which we believe addresses some of the concerns raised in the PFD Report, alongside the actions set out in the table below. Concern Response Actions (Deadline) 1 The Academic Tutor role was revised a number of years ago, with a stronger provision of professional welfare support made available within the central student services teams. This change was an institutional decision made to reflect the view that it was more appropriate for academic staff to focus on providing academic and general pastoral support, with trained professionals providing more specialist welfare support where required. 1. Strengthen support system for MbR programmes to ensure that all MbR students have monthly meetings with two academic points of contact. Deadline: Complete Pro-Vice Chancellor (Education and Student Experience) Vice-Chancellor’s Office Whiteknights House University of Reading, Whiteknights Reading RG6 6UR email 2 3 This division of responsibility between the Schools and the Welfare Team ensures that students facing more complex wellbeing concerns are able to access specific professional support alongside more general pastoral and academic support from their Academic Tutor. In relation to MbR programmes specifically, we have identified the over-reliance on the Project Supervisor as a source of support. To address this concern, we have updated the support system for MbR programmes such that all MbR students will now have two academic points of contact with whom they will meet monthly throughout their programme, and who can monitor academic engagement. We believe that the recommendations we have put in place relating to student support in MbR programmes (as set out above) will significantly reduce the risk of delay in identifying a student ‘s lack of engagement. We recognise there is a need for further pro-active follow- up with students whose non-engagement has been identified. To address this, the University will introduce a new process for MbR programmes whereby the relevant School Director of Academic Tutoring (“SDAT”) emails relevant academic staff at regular intervals to request reports of any significant engagement concerns back to the SDAT (who would then follow up appropriately). This would be particularly pertinent for MbR programmes where there is limited scope for other forms of engagement monitoring. 1. Strengthen support system for MbR programmes to ensure that all MbR students have monthly meetings with two academic points of contact. Deadline: Complete 2. New notification system to be implemented whereby the SDAT emails reminders to relevant academic staff at regular intervals to monitor and report engagement of MbR students. Student Support Centres (“SSCs”) to provide templates to the SDATS for this purpose. Deadline: September 2024 (ahead of start of academic year) There will be a range of circumstances in which students, outside of our formal fitness to study process, may need to consider the possibility of suspending their studies. Our system for supporting students through to the conclusion of such discussions, is a weakness that the Coroner has correctly identified. 1. Updated process to be implemented for the 24/25 academic year Deadline: September 2024 (ahead of start of academic year) The University will take the necessary steps to ensure that: 2. New routine process to be i. ii. students who have had a discussion with their school about withdrawal or suspension and who are considered to be vulnerable are flagged to relevant teams in the SSCs and Student Wellbeing Services; staff in the SSCs actively support these students to suspend their studies, should that decision be taken by the student, for example by completing introduced whereby when a vulnerable student confirms to staff in the SSCs that they don’t wish to suspend, confirmation of this is sent back to the relevant member of academic staff. Deadline: September 2024 (ahead of start of academic year) Pro-Vice Chancellor (Education and Student Experience) Vice-Chancellor’s Office Whiteknights House University of Reading, Whiteknights Reading RG6 6UR email relevant paperwork on their behalf (with appropriate consent); and iii. in the event that no action to suspend is taken by the student, the Fitness to Study Process is triggered, empowering the University to carry out the suspension on the student’s behalf in appropriate circumstances and in accordance with our procedures. 4 The measures, referred to above, in relation to enhanced Academic Tutor support for students on MbR programmes are designed to reduce the risk of delays in identifying students who are not fit to study. See response to Concerns 2 and 3. Our response here is covered by our response to Concerns 2 and 3: • Our response to Concern 2 addresses the issue of identifying non-engagement. • Our response to Concern 3 addresses how we will ensure that identified engagement issues are followed up until resolved. 5a In response to this Concern, the University has circulated new guidance to key staff. This has included: Deadline: Complete i. ii. iii. Instructing welfare officers to be more prescriptive on next steps when raising welfare concerns about a student with their school; Reminding welfare officers not to assume that welfare references (such as the implications of the CRISIS team being involved with a student), and their implications will be understood by academics and other staff who are not trained welfare professionals; Instructing the Student Wellbeing Team to promptly share concerns about high-risk students with the school’s SDAT, in alignment with relevant professional codes of conduct (e.g. British Association for Counselling and Psychotherapy code of conduct for Counsellors). 5b and 5c The University has clarified that the student support in place for MbR students should be aligned as far as possible with those on taught programmes. Therefore, it is the relevant SDAT who is responsible for ensuring that student support processes are seen through to completion for these students. 1. New notification system to be implemented whereby the SDAT emails reminders to relevant academic staff at regular intervals to monitor and report engagement of MbR students. SCCs to provide Pro-Vice Chancellor (Education and Student Experience) Vice-Chancellor’s Office Whiteknights House University of Reading, Whiteknights Reading RG6 6UR email template to SDATS for this purpose. Deadline: September 2024 (ahead of start of academic year) 2. New guidance to be circulated to SDATs and Heads of Schools in all schools with MbR students to reinforce the SDAT’s responsibilities in relation to student support processes. Deadline: September 2024 (ahead of start of academic year) 6 This concern is addressed in the above responses. I would be grateful if you could confirm whether a copy of this letter will be served on Ben’s family and the Berkshire NHS Foundation Trust as the other Interested Parties at the inquest and/or Universities UK as the other recipient of the PFD Report. I also understand that you will be providing a copy of this response to the Chief Coroner. The University respectfully submits that in relation to the exercise of the Chief Coroner’s discretion to issue a copy of this report to other persons, we do not consider there are any other persons who would find it useful to receive a copy of this response. Yours sincerely, Pro-Vice Chancellor (Education and Student Experience)
14 January 2025 Hannah Godfrey Area Coroner for Berkshire Berkshire Coroner Office Town Hall Blagrave Street Reading RG1 1QH Sent by email Universities UK PFD response Dear Ms Godfrey, We write further to your Regulation 28 Report dated 9 July 2024. I can confirm receipt of your email requesting a response from Universities UK (UUK) on 7 January 2025. With deep sadness we wanted to acknowledge the tragic circumstances surrounding Ben’s passing and extend heartfelt condolences to his family and friends. We recognise the critical importance of addressing mental health challenges within the sector. UUK has long been committed to supporting member universities in fostering environments that prioritise student well-being. We have read the PFD closely and will take the relevant lessons forward into our ongoing work in this space. We will do this both in our ongoing member engagement, and in our involvement in the below initiatives: 1. National review of higher education student suicides: In 2023, the government commissioned a national review to share lessons across the sector around serious mental illness and preventing suicide. The review will also track progress against the usage of UUK’s Postvention guidance. The Head of Student Experience and Skills Policy Universities UK Woburn House 20 Tavistock Square London WC1H 9HQ Telephone +44 (0)20 7419 4111 Email Twitter @universitiesuk Website www.universitiesuk.ac.uk Company limited by guarantee and registered In England and Wales Number 2517018 Registered charity number England and Wales: 1001127 Scotland: SC052497 review is expected to report later in 2025, and we will work with the review team on any recommendations. 2. Higher education mental health implementation taskforce: UUK has worked closely with the taskforce since its inception. The taskforce oversees work across the mental health space including: identifying students at risk, compassionate communication, service design, the national review of HE suicides and improving HE and NHS partnerships. 3. University Mental Health Charter: UUK has been working closely with Student Minds to support engagement with the charter. Currently, 113 universities are covered by the charter with evaluation reports showing that the charter is having a positive impact. 4. Suicide-safer universities: Working with PAPYRUS, UUK has produced guidance to implement strategies to prevent student suicides through early intervention, staff training, and fostering a supportive institutional culture. UUK represents 141 autonomous universities across the United Kingdom. However, it is important to note that our organisation does not represent all higher education providers nor possess the regulatory authority to mandate specific actions by our member institutions. Each university operates independently, with its own governance and procedures. We have seen the University of Reading’s response dated 4 September 2024 addressing the concerns specific to their institution. A copy of this response has also been shared with University of Reading officials. We are not in a position to serve copies of this response on any other Interested Parties but trusts your office will do so as appropriate. We note too that a copy of this response will be sent to the Chief Coroner and that consideration will be given as to its publication. We have no representations to make with respect to its publication. UUK remains committed to working with universities and stakeholders to strengthen mental health provision and to mitigate risks faced by students experiencing 2 difficulties. We appreciate you sharing the report with us, and we will continue to share best practices across our membership. Yours sincerely, Head of Student Experience and Skills Policy 3
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