Harry Evans
4 Nov 2022 · Coroner Guy Davies · Cornwall and the Isles of Scilly
The coroner's concerns
1. absence of mandatory training for academic staff on suicide prevention and mental health awareness
“evidence that indicated an absence of mandatory training for academic staff on suicide prevention and mental health awareness”
2. lack of personal engagement with student wellbeing concerns
“evidence indicated that nobody from the university attempted to speak to or visit [the deceased] despite numerous concerns being raised regarding his wellbeing”
3. insufficient staff awareness of information sharing policy
“evidence revealed a lack of staff awareness regarding university policy on information sharing”
4. lack of mobile number exchange between pastoral tutors and students
“evidence indicated that if [the deceased]'s pastoral tutor had known [the deceased]'s mobile number, he may have called him”
5. failure to follow up safeguarding alerts in welfare case management
“systems failures led to safeguarding alerts not being followed up and the case marked closed”
6. insufficient notification of parents about critical academic failure
“evidence indicated that there was insufficient consideration given to notifying [the deceased]'s parents of the extent of his exam failure”