Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0624, written 8 Nov 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Nov 2024 |
|---|---|
| Reference | 2024-0624 |
| Deceased | Alexander Rogers |
| Coroner | Nicholas Graham |
| Coroner area | Oxfordshire |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Department for Education 1 CORONER I am Nicholas Graham, HM Area Coroner for the coroner area of Oxfordshire. 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 the 30 January 2024 an Inquest was opened into the death of Alexander Rogers, a student at Copus Christi College, Oxford. On 6 November 2024 I concluded an Inquest into his death after a 2-day hearing. 4 CIRCUMSTANCES OF THE DEATH Alexander took his own life when he jumped from a Oxford into the River Thames suffering a fatal head injury. In the preceding days, he had been ostracised, which included what was described as ‘name calling’, ‘targeted behaviour’ and exclusion and rejection following allegations made against him about his conduct. I reached a formal conclusion of Suicide. , 5 CORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concerns. In my opinion there is a risk that future deaths will occur unless action is taken. 1 In the circumstances it is my statutory duty to make this report to you. The MATTERS OF CONCERN are in relation to the following: Coroner's Concerns: In accordance with guidance to Universities, the College had commissioned an independent Serious Incident Review conducted by , a specialist in mental health, and that Review identified evidence of a concerning practice of social ostracism among students, often referred to as a ‘cancel culture’. Her evidence was that this behaviour, where individuals are isolated and excluded from social groups based on allegations or perceptions of wrongdoing, poses a significant risk to student mental health and well-being. Both , and the Director of Student Welfare at Oxford University, , were of the view that this practice was likely in evidence in other higher education institutions although there was some uncertainty as to his prevalence. has made a number of recommendations specific to the to the College and University which they are implementing with some diligence. It was acknowledged this was complex and highly-sensitive issue in student life. Accordingly, I have attached a redacted extract from the Review which sets out the evidence-base for this culture and its potential effects and risk, together with her proposals as to how it may be addressed through awareness raising and education. ’s I did not find on the balance of probabilities that this culture specifically caused or contributed to Alexander’s death, but it did give rise to a concern that circumstances creating a risk of future deaths could occur. The specific matters of concern are: • Prevalence of social ostracism: Evidence suggests that social ostracism is a recognized practice within student communities, with multiple cases observed and acknowledged by both students and staff. The evidence was that this may be an issue more broadly for Universities in the UK. • Social ostracism as 'self-policing': Students appear to employ social ostracism as a means of 'self-policing' their community, often in response to allegations of serious misconduct. This occurs in the absence of formal processes and without proper investigation or evidence. 2 • • Negative impact on mental health: Social ostracism can have severe and lasting negative impacts on mental health. It can lead to feelings of isolation, shame, guilt, and worthlessness, all of which are recognized risk factors for suicide. Lack of trust in formal processes: The prevalence of social ostracism may be linked to a lack of trust in formal channels for reporting serious concerns. Students may perceive these processes as ineffective, unfair, or biased, leading them to seek alternative means of addressing perceived wrongdoing. • Normalization of exclusionary behaviour: There is concern that social ostracism has become normalized within student communities, with individuals viewing it as an expected and accepted response to certain allegations or behaviours. This normalization hinders the development of healthy and supportive social environments. 6 ACTION SHOULD BE TAKEN In light of the above concerns, action should be taken to prevent future deaths related to the detrimental mental health effects of social ostracism in the higher education sector. It is believed that the Department of Education has 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. Your response must detail the 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 confirm that a copy of this report and your response will be sent all interested persons, including the family of Alexander Rogers, Corpus Christi College, Oxford, and the University of Oxford. The Chief Coroner will also receive a copy and may publish the report, in whole or in part, as well as any response received. 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 3 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 Signed Date Mr N Graham HM Area Coroner for Oxfordshire 8th November 2024 4
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.
Minister for Skills Department for Education Sanctuary Buildings 20 Great Smith Street London SW1P 3BT tel: 0370 000 2288 www.education.gov.uk/contactus/dfe Your Ref.: 06 January 2025 Regulation 28 Report/Prevention of Future Deaths - Response Inquest into the Death of Mr Alexander Rogers Dear Mr Graham, Thank you for sending the Regulation 28/Prevention of Future Deaths Report (the Report) to the Department for Education (DfE) following the Inquest into the tragic death by suicide of Alexander Rogers, and for bringing your concerns to our attention. Having sought your consent, we have shared the Report with the Office for Students (OfS), the independent regulator for higher education in England. The OfS are responsible for protecting the interests of students in the higher education sector and we have included actions OfS are taking as part of our response. We have also spoken to representatives of the University of Oxford and with Dr , who as you know, led the serious incident review, in forming our response. Mental health and suicide prevention I wish to first express my condolences to Alexander’s loved ones who have suffered unimaginable loss. I know the impact of this would have also been felt widely among the student community. This government is committed to tackling suicide as one of this country’s leading causes of death for younger people. We are recruiting 8,500 new mental health workers who will be specially trained to support people at risk from suicide. We also continue to implement the five-year multi-sector and cross-government suicide prevention strategy, which set out a comprehensive set of actions to reduce the rates of suicide in England. In higher education, we have taken the issues of mental health and suicide prevention extremely seriously. We are taking action in partnership with the OfS and the sector to ensure students are better supported. Our Higher Education Support Champion, Professor , is leading a Higher Education Mental Health Implementation Taskforce representing students, bereaved parents, the health and higher education sectors and mental health and suicide experts. It aims to bring about meaningful change in mental health practice and has recently published its second stage report.1 To ensure universities are taking a whole university approach to mental health, the OfS has provided £400,000 of funding to the student mental health charity, Student Minds. This has enabled significant expansion of the University Mental Health Charter Programme, with 113 universities now signed up and committed to embedding the Charter’s principles. This includes principles such as universities ‘actively encouraging healthy behaviours’ and ‘community-building’, which are relevant to the matters raised in your Report. Office for National Statistics data suggests that the higher education student suicide rate is significantly lower compared to those of similar ages in the general population, with 64 deaths by suicide occurring in England and Wales in academic year ending 2020. However, we are clear that we expect higher education providers to go further in their efforts and take all reasonable steps to support students and prevent suicides. That is why we have asked a team of suicide experts at the University of Manchester, overseen by Professor , to conduct a National Review of Higher Education Student Suicides (the National Review). We have seen exceptional engagement from the higher education sector, and the National Review will report in the Spring with valuable lessons learned and recommendations for better prevention of student suicides. We would expect this to comment on whether similar issues have arisen as those highlighted in your Report. To support engagement with the National Review and enable higher education providers to develop mental health and suicide prevention strategies, DfE has made available £15 million in funding this academic year 2024/25, allocated via the OfS, to English higher education providers. The OfS and Medr (formerly the Higher Education Funding Council Wales) have also 1 worked with Student Minds to provide direct support to students, investing more than £3.6 million to develop Student Space. Since 2020 it has since provided over 620,000 students with free online mental health resources and confidential support. Social ostracism and lack of trust in formal processes As well as those actions in train already on student mental health there are additional steps being taken to address the other particular matters of concern raised in your Report - social ostracism and lack of trust among students in formal processes: 1) Action by the OfS to bring more consistency and rigour to the handling of harassment and sexual misconduct allegations in higher education settings. The OfS has introduced new regulatory requirements for preventing and addressing harassment and sexual misconduct which will be a condition of being registered with the OfS. This new condition of registration (condition E6) will come into force from August 2025. DfE and the OfS are working with sector bodies to help providers implement the new measures. All universities and colleges registered with the OfS will be required to publish and maintain policies and procedures that set out how they will deal with incidents of harassment and sexual misconduct. They will need to provide students with training on policies and processes, and ensure they understand behaviour that may constitute harassment and sexual misconduct. The new condition will require universities and colleges registered with the OfS to set out the ways in which students, staff and others are able to report behaviour that may amount to harassment or sexual misconduct and how this information will be handled sensitively and used fairly. Higher education providers registered with the OfS will also need be clear about the appropriate support that will be provided to students in response to incidents. This includes students who are reporting experiencing incidents of harassment and sexual misconduct, and actual or alleged perpetrators. We believe changes brought about following the introduction of these new mandatory requirements for providers registered with the OfS will lead to significant improvements in the understanding of students and their confidence in the system; this will support greater engagement with reporting mechanisms and enable providers to better support both alleged victims and alleged perpetrators. 2) We will work with experts and leading university student welfare officials and students to convene a roundtable in early 2025 exploring the issues around social ostracism and lack of trust in formal processes in more depth. This will build on work being led by the University of Oxford to establish a working group on social ostracism and open discussions around how students can ‘disagree well’ and engage with ‘constructive dialogue’. The intention of the roundtable is to build shared knowledge on the issue, understand what gaps there may be currently in action in the higher education sector and appropriate responses. Insights and outputs which emerge following the roundtable will be publicised. We would like to thank you again for your Report and a redacted extract from Dr. Thompson’s review. We believe that working with OfS and the higher education sector to learn lessons and take strong action in response is the best way to stop further tragedies from occurring. We trust that this response will provide the reassurance and information that you seek. Yours sincerely, Minister for Skills
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