Lily Jahany

Dear Miss F Butler, As stated in the Regulation 28 Report for JAHANY L P (09122022) and following its publication, I am writing to you with details of current and proposed future actions which forms our wider suicide prevention strategy at Student Roost. Firstly, I wish to acknowledge that this was a tragic case, and the death of a resident leaves a devastating, lasting impact on our team members. Our thoughts will always be with Ms Jahany’s friends and family. We aim to work collaboratively within the higher education sector, alongside universities throughout the UK, and have seen a dramatic increase in mental health challenges within the student population since the Coronavirus pandemic four years ago. As a result of this, we have significantly invested in resident wellbeing support at Student Roost, creating and growing a team of dedicated resident wellbeing advisors and partnering with Mental Health First Aid England to train over 70 team members as Mental Health First Aiders. This provision is not standard within the Purpose-Built Student Accommodation (PBSA) sector, and we aim to be leaders in driving best practice within the industry. In 2022, we launched our #BehindEveryDoor campaign in partnership with award-winning national mental health charity, Chasing the Stigma. The campaign cements Chasing the Stigma’s award- winning digital app, Hub of Hope, as Student Roost’s official mental health signposting tool for all residents and team members living and working at one of over 50 Student Roost properties in the UK. The QR code, found on posters behind every bedroom door at every property, has seen over 4,500 scans from individuals seeking preventative, tailored support from charities and organisations in their area, and assists us in gaining insight and visibility into student demographics across our properties, allowing us to pinpoint what additional mental health support and guidance residents may require. Quite often, our team members are alerted by a flatmate, friend or relative of the resident in crisis when a serious incident has occurred and then attend to support and assist. They are often not the first to arrive at the scene when there is a resident at risk, or an unfortunate event of a resident death, which is a traumatic experience for all involved. Our teams are trained to enlist the support of the emergency services and university welfare teams where required. There is no expectation on our teams to put themselves in a situation where they don’t feel safe or comfortable. However, after receiving this report, we wholeheartedly believe that providing additional first aid training for our team members, especially to those who feel confident in administering first aid or wish to refresh their existing knowledge, is a step we can take to further ensure the safety and wellbeing of our residents. PBSA Portfolio Advisor Limited t/a Student Roost Registered in England, company number 08721957 Registered office: Charles House, 8th Floor 148 Great Charles Street, Birmingham B3 3HT

Charles House 8th Floor 148 Great Charles Street Birmingham B3 3HT

As soon as we received this report, our Senior Leadership Team conducted an analysis of our property teams. I’m pleased to share with you that this has resulted in our decision to train 223 operational team members in first aid, with training programmes commencing in August 2024. Following completion of this training, which is estimated to be at the end of this year (2024) all Student Roost properties (over 50 across 21 UK towns and cities) will have access to a trained first aider. We hope you find that our response clearly sets out what actions we are taking following the inquest and publication of your report. Hopefully this also provides you with reassurance that we will continue to implement necessary training, policies and procedures to ensure resident wellbeing and safety will always be our top priority at Student Roost. If you would like further information or have any questions, please do not hesitate to contact me directly. Kind regards,

Managing Director – Student Roost

PBSA Portfolio Advisor Limited t/a Student Roost Registered in England, company number 08721957 Registered office: Charles House, 8th Floor 148 Great Charles Street, Birmingham B3 3HT

Dear Miss Butler Lily Precious Jahany Inquest date: 17th 2024 On behalf of the Leicestershire Partnership NHS Trust ("the Trust' ) , am responding to your Report to Prevent Future Deaths (hereafter 'your Report") dated 17th May 2024 concerning the death of Miss Jahany. In advance of responding to the concerns raised in your Report;, would like to express my deepest condolences to Miss Jahany's family and loved ones_ The Trust wishes to assure the Jahany family and HM Coroner that the concerns raised about his care have been listened to reflected upon and action has been taken as a result In your Report, you raised two Matters of Concern: The first of these Matters of Concern is better addressed by Student Roost who no doubt will respond direct will therefore respond to the second matter of concern which is relevant to the Trust In your report; you have raised a Matters of Concern: have spent a lot of time in this inquest investigating the information which was known about Lily, about her mental health and who had access to what information in the context of assessing her risk In September of 2023, Miss Evans, Assistant Coroner sitting within the Rutland and North Leicestershire jurisdiction heard an inquest concerning a student at Loughborough University. Similar to Lily's case he was under the care of a private psychiatrist elsewhere in the country where he had lived prior to attending university. As a result of concerns in that case (his death occurring year before Lily') around lack of contact by the Crisis Team at the time of assessment or otherwise with the private psychiatrist; the Coroner wrote to the Leicestershire Partnership Trust to share her concerns: Trust Headquarters_ Pen Lloyd Building, County Hall, Leicester Road, Glenfield, Leicestershire. LE3 8RA Chair: Chief Executive Max

The Trust referenced the Crisis Team Standard Operating procedure in the inquest in September 2023, the Coroner was concerned about the level of awareness that staff members had of any expectation required of them set out within that procedure to seek information from other agencies now have sight of the Crisis Team Standard Operating Procedure_ It sets out the keyworker responsibilities The section is drafted presupposing that patients are receiving care and treatment from the Crisis Team and only at that point does the responsibility for seeking relevant information from other agencies kick in. Furthermore, the emphasis upon that requirement is limited to one line which reads 'responsibility for referrals and liaising with other agencies involved' That is anything but clear as to any expectation upon staff to ensure they have at their disposal all of the relevant risk information at the time of making that assessment; nor does it in my view set out any expectation upon staff to proactively make contact with treating clinicians in the private sector to information: It would not capture situations such as Lily' $, who was discharged from the Crisis Team after an hour assessment and therefore was not under their care and treatment; having found a failure to obtain all relevant information pertinent to risk in assessing that risk Access to necessary information: We understand and accept the importance of having access to all the necessary information including previous contact with NHS and private providers during a comprehensive assessment and for safety planning: We have undertaken a full review of the Crisis Resolution Home Treatment Team Standard Operating Procedure and the Mental Health Central Access Point Standard Operating Procedure (SOP): These SOP's have been updated to explicitly clarify the professional expectations regarding information gathering by liaising with key professionals which includes private providers and psychiatrists. The SOP's also include a process for what to do when we are unable to contact key professionals including private sector care providers. The Trust continues to be a stakeholder in the Leicester Leicestershire & Rutland (LLR) University workstream, led by the LLR Integrated Care Board. This ensures that collaborative working continues to streamline and optimise access to mental health support and advice for students and university staff across LLR_ Thank you for bringing this important patient safety issue to our attention, and trust that the action we have taken responds to the concern set out by HM Coroner in her Report; with focus on avoiding a recurrence of the circumstances around Miss Jahany's death.