Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0045, written 20 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jan 2025 |
|---|---|
| Reference | 2025-0045 |
| Deceased | REDACTED |
| Coroner | Ian Potter |
| Coroner area | Inner North London |
| 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.
Report to Prevent Future Deaths [ , referred to as] ‘Student A’ (Date of death: 28 July 2024) Regulation 28 Report to Prevent Future Deaths THIS REPORT IS BEING SENT TO: 1. Chief Executive Officer The Unite Group plc Temple Back Bristol BS1 6FL 1 CORONER I am Ian Potter, assistant coroner for Inner North London. 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 6 August 2024, I commenced an investigation into the death of Student A, aged 21 years at the time of his death. An inquest was opened on 7 August 2024. The investigation concluded at the end of an inquest heard by me on 14 January 2025. The conclusion of the inquest was ‘suicide’. The medical cause of death was: 1a asphyxiation 4 CIRCUMSTANCES OF DEATH Student A lived in student accommodation at Somerset Court, Aldenham Street, London. He was last known to be alive on 27 July 2024, having spoken to his mother on the telephone and being seen returning to his address by staff at Somerset Court. The following morning, staff at the accommodation were requested to conduct a welfare check on Student A. At about 10:50 on 28 July 2024, staff noted Student A to be unresponsive (not responding to his name being shouted) in his room, but only saw his legs on the bed from the doorway to the room. Emergency services were called following a subsequent welfare check, at approximately 12:00, in which staff found Student A on his bed with . Paramedics verified the fact of Student A’s death shortly thereafter. He died of asphyxiation having intended to end his own life. 5 CORONER’S CONCERNS During the course of my investigation and the inquest, the evidence 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: I received statements (taken by police officers) from three members of staff at Somerset Court, which is operated by Unite Students. 1. On 28 July 2024, the request for a welfare check was received by staff at Somerset Court, from the Emergency Control Centre (the ECC) for Unite Students, at approximately 07:00. The basis of the request was that Student A’s mother had been unable to contact her son. The member of staff advised the ECC that they would try to ‘call the student and if he did not answer I would then go to his room.’ At approximately 10:15, the staff member called Student A’s mobile telephone three times, ‘but it did not ring it only beeped.’ At approximately 10:50, the staff member went upstairs to Student A’s room and received a call from the ECC but ‘ignored the call’ to go to Student A’s room. While at the material time there was no way of knowing whether this was an emergency or not, the concern here is that it nevertheless took hours for the request for a welfare check to be actioned in any way. Further, on getting no response from attempts at contact by telephone, there was further delay in physically attending Student A’s room. 2. When attending Student A’s room at about 10:50 on 28 July 2024, the member of staff knocked repeatedly on the door and asked for Student A to come to the door. The staff member then used their staff pass to open the door, on account of getting no response. In their statement, the staff member sets out that they remained in the doorway and could see Student A’s legs (from the knees down) on the bed within the room. The statement continues, ‘I called out to the student and stated that it was reception and asked if they were okay. At this time I was scared so I closed the door and went to the stairwell.’ The staff member spoke to the ECC and explained the circumstances to them and the ECC advised the staff member to call an ambulance ‘and to also get someone from one of the other buildings that is run by the university.’ Following the call with the ECC, the staff member sent a text message to their ‘general manager’ explaining the situation and requesting that a receptionist from another building be sent to assist. The staff member’s statement then says, ‘At approximately 1134 I called my manager and whilst on the phone returned to the room and knocked on the door repeatedly. I shouted out and knocked loudly. The student did not answer the door.’ The staff member then returned to reception and telephoned for a colleague in another building to come and assist. Assistance from a colleague arrived at approximately 12 noon. Both members of staff then made their way to Student A’s room where, upon entering they found Student A unresponsive on his bed in the manner already described at section 4 of this report. As a result, the staff left the room, returned to reception and ‘called our managers and emergency services and we waited for their arrival.’ The concerns here are numerous: It was obvious to staff that Student A was, at the very least, unresponsive / difficult to rouse at about 10:50, which on any view would be regarded as a serious / emergency situation. However, it appears that no positive or definitive action was taken to assist for over an hour. The ECC advised the staff member to call an ambulance at about 10:50, yet this was not done until approximately 12 noon. The staff member who first checked on Student A at 10:50, went no further than threshold (seeing no more than his legs) and therefore did little, if anything, to satisfy themselves about the true welfare status of Student A. The staff members who attended Student A’s room at approximately 12 noon, did not attempt to render basic assistance or first aid to Student A. In the particular circumstances of Student A’s case, he was highly likely to have been deceased for hours prior to his death being verified by paramedics at 12:27. However, that fact was not known to staff at the material time and, therefore, they would have been expected to act in accordance with any protocols or policy in place at that time. Given these matters, I am concerned that there may be a lack of appropriate training in place for staff or, if there is such training in place, that it may not be effective. Nothing in the evidence available to me has suggested that the future risks posed by my concerns have been addressed. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you 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 17 March 2025. 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 the following Interested Persons: The parents of Student A The University at which Student A was studying 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 summary form. She may send a copy of this report to any person who she 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 Ian Potter HM Assistant Coroner, Inner North London 20 January 2025
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.
HM Assistant Coroner Ian Potter Inner North London Coroner's Court By email: 10 March 2025 Dear Sir South Quay House Temple Back Bristol, BS1 6FL T: +44 (0)117 302 7000 unite-group.co.uk unitestudents.com Regulation 28 Report response from Unite Students Thank you for your Regulation 28 report (the Report) dated 20 January 2025 relating to the tragic death of Student A on 28 July 2024. I wish to extend our sincerest and deepest sympathies to the family and friends of Student A. Student welfare and safety is paramount for Unite Students and the case of Student A has had a profound impact on our teams. It is my understanding that Unite Students was not formally invited to provide evidence to the inquest. I wanted to therefore inform you that should the need ever arise, we are always willing to lend our support to a Coroner's inquiry, whether that be through the provision of information and records or releasing employees from their duties to give witness evidence. Having reviewed your Report, I would like to take the opportunity to provide some additional evidence which may help clarify some aspects of the Report and provide a fuller context for our response to the concerns you have raised. Timeline of events First, we noted your concern that it “took hours for the request for a welfare check to be actioned in any way”. From our review of the information available, and in particular the witness statements you kindly disclosed, post inquest, we believe this concern is based on an understandable misinterpretation of the witness evidence given by one member of staff ( ). The Report states “[O]n 28 July 2024, the request for a welfare check was received by staff at Somerset Court, from the Emergency Control Centre (the ECC) for Unite Students, at approximately 07:00”. In fact, 07:00 was the time when the time of the first call to the ECC. 's shift started, and it was not Our call records show the first call was made to the ECC at 09:33. During this call with the ECC, it was communicated that Student A had been spoken to the previous evening and there were no specific concerns about their physical or mental welfare. The caller requested contact be made with Student A and for someone to check whether they were present in the building. It is our view that there was nothing of particular concern at this stage given the information available. At around 09:40, the ECC phoned the staff member on site requesting that they try and get in touch with Student A. Immediate attempts were made by the staff member to contact Student A, with calls made three times between 09:40 and 10:40. In light of the information available at that time, we believe this to be a reasonable response. As recorded in the Report, at approximately 10:50, the staff member went upstairs to Student A’s room. Again, in light of the information available, we believe this escalation and the associated timescales were reasonable. The staff member opened the front door to the room and did not enter but observed Student A to be present and in bed. A further call was received by the ECC at 10:58 who relayed this to the staff member just after 11:00. This call to the ECC escalated the seriousness and highlighted the situation as a potential emergency. As per our safety protocol, the staff member on site requested a second staff member attend to allow for a two-person room entry. The second staff member, who had travelled from another property, arrived at the site and, at 12:00, a two-person room entry to Student A’s flat was carried out. At 12:02 an ambulance was called. Our response We recognise that a second staff member could have attended sooner to facilitate a room entry after the call escalation at 11:00. The steps that we are taking to address this are twofold: 1. We have changed the geography of our Duty Manager rota to reduce the number of properties each manager is responsible for; this will enable improved responsiveness in the event that room entry is required 2. We will review our training, policies and procedures to ensure that staff members feel comfortable calling emergency services and do so promptly and simultaneously with any request for a chaperone or other assistance in entering a student's room where there is a safety concern or an emergency situation The staff member's decision to not enter the room immediately and instead seek further assistance was ultimately a matter for that member of staff (who genuinely did not believe there was an emergency, but that Student A was likely to be sleeping). However, we believe additional guidance can be provided so that in any circumstances where the wellbeing of a student cannot be positively confirmed by a member of staff then matters are escalated to the emergency services immediately if staff members are unable to enter a room. More generally, we are reviewing all our procedures for dealing with calls made to the ECC to effectively triage calls received, and to ensure that appropriate questions are asked to understand the basis and potential seriousness of enquiries. Unite Students as a landlord Unite Students is very proud of its interventions around student welfare and our continuing aspiration to achieve better outcomes for our tenants. We go further than we must as a landlord and lead the sector in what we are able to offer tenants. We choose to do this as it is the right thing to do and, by extension, this choice helps us to align with some of the additional obligations faced by our university partners. As part of this commitment, we have a Support to Stay framework (details of which are available at Support to Stay: Improving our student support framework) which helps our teams deliver for our tenants. This is an important part of our offering and, in doing so, we undertake nearly 1,500 checks every year on students in our accommodation. To prepare our teams for this, they all receive training specific to the roles which they perform but, unfortunately, sometimes find themselves confronted by some of the most difficult situations imaginable. We have in recent years made the decision to have 24/7 staffing at all our sites and offer student welfare programmes; however, our teams are not emergency service professionals or staff providing supported living. We will, of course, work through the learnings from this tragic incident and will implement additional measures as necessary. Please do not hesitate to contact me should I be able to assist further. Yours sincerely Chief Executive – The Unite Group PLC and Unite Students
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