Vice Chancellors
Action Planned
The University of Exeter has reviewed mental health awareness training, consolidating courses and clarifying attendance. They are also progressing replacement of the CMS, through the procurement of a new case management product, with implementation aimed for the 2023/24 academic year, and have introduced a welfare tracker to track case progress. (AI summary)
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Dear Sir, Harry Armstrong-Evans – Regulation 28: Report to Prevent Future Deaths
We refer to your letter and attached Regulation 28: Report to Prevent Future Deaths received on 4 November 2022 (“the Report”). The University fully respects the Inquest process and appreciates the considerable time and attention of the Senior Coroner and Interested Persons in considering the facts surrounding Harry’s death. The University also recognises that the death of Harry and the subsequent investigation will have been incredibly traumatic and difficult for Harry’s parents and we offer our deepest condolences again to the Armstrong-Evans family. The Report raised a number of specific areas of concern, which you identified during the Inquest into Harry’s death. You asked the University to consider these concerns and provide a response. Taking each matter of concern in turn, our response is as follows:
1. Training You invited the University to review the provision of training on information sharing, mental health awareness and suicide prevention for academic staff. University Response: The University currently offers a range of mental health awareness training courses for academic and Professional Services colleagues who are in student facing roles. Following receipt of the Report, the University has undertaken a detailed review of this provision. Part of this review has identified the need to consolidate the courses offered and to provide clarity on who should attend, to ensure that everyone in student facing roles has the awareness and information to support students who are struggling. This work is already underway. As an immediate response to the Report, the University has provided guidance to all staff which outlines where and how to seek support, both for themselves and when identifying support options available to students. Further to the review of staff training, the University wishes to embed good practice in suicide safety and adopt a whole university approach to suicide prevention. This will involve a phased roll-out of training for all staff that is (a) appropriate to their personal/emotional capacity (it may not be appropriate for some colleagues) and (b) relevant and proportionate to their institutional role. The training will be separated into four levels ensuring the level of training taken is based on training needs assessment, role and individual skills and expertise, as follows:
• Level 1: All staff will watch a short (20 minutes) introductory online video that helps in raising suicide awareness, identifying warning signs, and developing basic communication skills in this context. This is supported by a further video on Mental Health awareness raising/ developing skills to approach individuals with mental health concerns. This material is already available on the University website.
This will be included as part of the induction materials new staff receive and will be a mandatory module for all staff.
• Level 2: Staff with any kind of student-facing role (including staff in accommodation, the Sports Park etc.) will be required to participate in an in-house half-day ‘Introduction to Mental Health’ training session. This course has been run for a number of years and explores the impact of poor mental health on a student’s experience, how to approach a conversation around poor mental health and how to support a student who is in distress or suicidal, including clear onward referral routes. Training materials will also include a clear pathway of support for colleagues. All personal tutors, colleagues with student-facing roles in our information points and education support Hubs and Senior Leadership teams should undertake this training.
• Level 3: Mental Health First Aid (2 day training) – This course will be for selected staff in key student-facing roles whose roles have an element of wellbeing or welfare support (e.g. Directors of Education and Student Experience, Senior Personal Tutors, Residence Life (student support in accommodation), Hub Managers (student support in academic settings), Estate Patrol (the University’s security services) etc).
• Level Four: Suicide awareness and risk screening – this in-house training will be specifically for staff in key student-facing welfare roles, such as Estate Patrol and all Wellbeing and Welfare Services teams. The University will keep this suite of training opportunities under regular review and will ensure refresher training is provided to ensure updated sector best practice is adopted.
2. Responding proactively You invited the University to review its policy as regards the response to welfare concerns and whether the current approach is sufficiently flexible and proactive. Specifically, whether there is an over-reliance on email responses and students themselves completing online application forms to access support. University Response: A review has been undertaken of our response to students in distress and, in the short term, we are also carefully reviewing existing processes for the upcoming January assessment period. The current Wellbeing and Welfare service is carefully balanced to triage student issues and communications, identify support routes available to students and provide advice to students with mental health issues. Students with acute mental health crises that indicate harm or self-harm are also referred to statutory services for ongoing support. However, public services continue to be stretched and many students will not reach the threshold for ongoing support via the NHS. The University has a close working relationship with the Devon Partnership NHS Trust through the University Community Mental Health team (UCMHT) model and we are seeking to further optimise our approach with all external partners to provide the best possible support to our students. We have considered the package of communications sent out in preparation for, during and after examination periods to ensure these have a supportive tone and clear signposting to the support available. Student-facing Welfare Advisors will continue their work located within Hubs (local student academic support teams) in key academic buildings to be visible in their offer of support for students throughout this period. These teams are available to support students with queries regarding exam outcomes but also applying for mitigation for assessments and any other support needs a student may have. We will keep the demand for these services under review to ensure our support can be expanded and increased as necessary to respond to increasing demand. We have also set out below (see section 4 – ‘Pastoral Support’) details of our enhanced ‘out of hours’ operation and associated communications which demonstrate the proactive support that can be accessed by students who are suffering with a mental health crisis or other concerns at any time of day or night. This can be accessed by the student themselves, other flatmates or housemates, members of staff who have concerns or parents. The University has focussed on ensuring there are a range of
ways a student can communicate with the University and ask for support using their preferred approach, including in person, over the telephone or via email. The University is further informing its approach through wider sector insight, research and guidance including consideration of the UUK Report into Suicide Prevention1
3. Sharing information You invited the University to review the thresholds for sharing information and staff awareness of those thresholds, and the implementation and understanding across academic and welfare staff of the ‘Think Family’ approach (which encourages practitioners to consider the parent, the child and the family as a whole when assessing the needs of, and planning care packages with, those suffering from a mental health problem). University Response: The University has considered the Report alongside wider sector publications including the UUK Report into Suicide Prevention. The University has been operating using the guidelines of a ‘trusted contact’ framework since 2020, taking a risk-based approach to determine when this is invoked, and allowing us to contact students’ families or guardians or trusted contacts in times of crisis. A trusted contact framework considers whether in times of crisis or ill health the University could contact their nominated person to provide additional support to a student or to raise concerns for a student’s wellbeing. The latest sector guidance from UUK provides a recommendation to formalise this practice and recognise it within our policies, including the use of the terminology of ‘trusted contact’ rather than ‘parent/guardian’, and this is being taken forward over the current academic year. Detailed information on the service approach to working with third parties and parents is available on our 'Consent Form Procedure'. The following sections are of particular relevance: 'Exceptional Circumstances,' 'Principles of Practice' and 'Liaison with parents/emergency contact.' The University recognises that such clarity is essential to ensure best standards of safe practice in the management of students with complex needs. In addition, the University has reviewed its risk assessment procedure to ensure contact with family is routinely considered in safety planning. Alongside the work to update terminology to reference Trusted Contacts, further work is taking place to agree further data sharing policies with relevant key statutory organisations including the mental health care teams and the police. We are also updating our risk policy, ensuring consistent application and use of the ‘trusted contact’ across all student facing services and identifying high risk areas to ensure robust support is in place. The University is taking part in a number of sector discussions on further measures, including engaging with clinical practitioners and sector experts to inform further changes to policies and processes regarding Trusted Contacts. We will remain aligned with best practice in the sector, including guidance from Universities UK (UUK).
4. Pastoral Support You invited the University to review whether pastoral tutors should offer to exchange mobile numbers with their students, and to consider whether pastoral tutors should have a work mobile to facilitate a proactive approach in the event that there are concerns for the wellbeing of their tutees. University Response: Supported by the enhanced training provision described above, Personal Tutors will be able to reach out to students who they feel are struggling, and identify support available, including referral to expert Wellbeing support, with the ability to check and review how the support has been received. Furthermore, we have set up a practice review on academic support for students and we will consider and implement its findings carefully. 1 Suicide-safer universities (universitiesuk.ac.uk)
As was set out during the Inquest, concerns have been flagged by academic colleagues, professional services and sector representatives with regards to the proposed sharing of mobile numbers. The concerns include that this approach could have potential safeguarding implications, severe impacts on colleague wellbeing, and may mean students requiring urgent support do not use the appropriate Out Of Hours support service. With this in mind, the University is expanding its out of hours provision to ensure emergency support is available via phone for students in crisis twenty four hours a day across all our campuses. Advice is available to all staff out-of-hours (via our Estate Patrol team in the first instance) where there are serious student mental health concerns. The University has invested significantly in out of hours support to ensure there is a team of trained members of staff who can proactively support students in need. The Out of Hours provision is being further reviewed for additional investment, however, the University has already taken the opportunity to strengthen its Out Of Hours provision and to provide additional detail and information for all staff and students regarding the availability of this resource. This means wherever a personal tutor has concerns about a student they can immediately reach out to these teams to ask for support. Additional information and details of the available support is also included on the University’s website. Whilst the University will not be asking staff to exchange mobile numbers with their students, and nor will work mobiles be provided for this purpose, the University has increased its awareness raising for academic staff on the availability of access to people who can provide support to students outside of the working day and the associated contact details so they can arrange for proactive reach outs. We will play an active part in sector discussions on this issue and will keep our position under review to ensure we continue to be fully aligned with the sector.
5. Welfare services case management system You invited the University to review whether our current welfare case management system is fit for purpose, and whether it is sufficient to capture and ensure actions on welfare concerns raised by students or third parties. University Response: As was noted during the Inquest, following Harry’s death the University had already undertaken a robust review of its current Case Management System (“CMS”). Steps had already been taken to identify technical issues and options for mitigation. All relevant colleagues have been made aware of the potential weaknesses in the existing system and appropriate mitigations are in place to minimise, as far as is possible, repeat issues occurring before the new system is implemented as soon as possible in 2023 with a view to the system being operational within the Academic Year 2023/24. These mitigations include:
• Introduction of a welfare tracker to track case progress.
• Defining a clear procedure through which referrals with voicemail messages can be safely stored.
• Reminders to welfare staff (and broader staff team) to take caution in responding to enquiries, and clarity on which ‘menu option’ to use when seeking further information on an enquiry.
• Review and restatement of proper procedures in the online training guides, and provision of individual training support, where needed. In addition, the University is actively progressing a replacement of the CMS, through the procurement of a new case management product. We are pushing procurement timelines to ensure this system can be in place as quickly as possible, and to ensure the integration of this software into our support service is as simple as possible. This exercise is being undertaken in compliance with all relevant rules and regulations, whilst having regard to the necessary integration with existing systems and processes. We trust this provides a comprehensive response to the Report and addresses the matters of concern flagged therein. The University will continue to strive to support its students in the best way possible and will always have student health and wellbeing as its highest priority, and at the heart of its educational provision.
I would like to thank you for your careful consideration of the circumstances of, and issues arising from, Harry’s tragic death.
We refer to your letter and attached Regulation 28: Report to Prevent Future Deaths received on 4 November 2022 (“the Report”). The University fully respects the Inquest process and appreciates the considerable time and attention of the Senior Coroner and Interested Persons in considering the facts surrounding Harry’s death. The University also recognises that the death of Harry and the subsequent investigation will have been incredibly traumatic and difficult for Harry’s parents and we offer our deepest condolences again to the Armstrong-Evans family. The Report raised a number of specific areas of concern, which you identified during the Inquest into Harry’s death. You asked the University to consider these concerns and provide a response. Taking each matter of concern in turn, our response is as follows:
1. Training You invited the University to review the provision of training on information sharing, mental health awareness and suicide prevention for academic staff. University Response: The University currently offers a range of mental health awareness training courses for academic and Professional Services colleagues who are in student facing roles. Following receipt of the Report, the University has undertaken a detailed review of this provision. Part of this review has identified the need to consolidate the courses offered and to provide clarity on who should attend, to ensure that everyone in student facing roles has the awareness and information to support students who are struggling. This work is already underway. As an immediate response to the Report, the University has provided guidance to all staff which outlines where and how to seek support, both for themselves and when identifying support options available to students. Further to the review of staff training, the University wishes to embed good practice in suicide safety and adopt a whole university approach to suicide prevention. This will involve a phased roll-out of training for all staff that is (a) appropriate to their personal/emotional capacity (it may not be appropriate for some colleagues) and (b) relevant and proportionate to their institutional role. The training will be separated into four levels ensuring the level of training taken is based on training needs assessment, role and individual skills and expertise, as follows:
• Level 1: All staff will watch a short (20 minutes) introductory online video that helps in raising suicide awareness, identifying warning signs, and developing basic communication skills in this context. This is supported by a further video on Mental Health awareness raising/ developing skills to approach individuals with mental health concerns. This material is already available on the University website.
This will be included as part of the induction materials new staff receive and will be a mandatory module for all staff.
• Level 2: Staff with any kind of student-facing role (including staff in accommodation, the Sports Park etc.) will be required to participate in an in-house half-day ‘Introduction to Mental Health’ training session. This course has been run for a number of years and explores the impact of poor mental health on a student’s experience, how to approach a conversation around poor mental health and how to support a student who is in distress or suicidal, including clear onward referral routes. Training materials will also include a clear pathway of support for colleagues. All personal tutors, colleagues with student-facing roles in our information points and education support Hubs and Senior Leadership teams should undertake this training.
• Level 3: Mental Health First Aid (2 day training) – This course will be for selected staff in key student-facing roles whose roles have an element of wellbeing or welfare support (e.g. Directors of Education and Student Experience, Senior Personal Tutors, Residence Life (student support in accommodation), Hub Managers (student support in academic settings), Estate Patrol (the University’s security services) etc).
• Level Four: Suicide awareness and risk screening – this in-house training will be specifically for staff in key student-facing welfare roles, such as Estate Patrol and all Wellbeing and Welfare Services teams. The University will keep this suite of training opportunities under regular review and will ensure refresher training is provided to ensure updated sector best practice is adopted.
2. Responding proactively You invited the University to review its policy as regards the response to welfare concerns and whether the current approach is sufficiently flexible and proactive. Specifically, whether there is an over-reliance on email responses and students themselves completing online application forms to access support. University Response: A review has been undertaken of our response to students in distress and, in the short term, we are also carefully reviewing existing processes for the upcoming January assessment period. The current Wellbeing and Welfare service is carefully balanced to triage student issues and communications, identify support routes available to students and provide advice to students with mental health issues. Students with acute mental health crises that indicate harm or self-harm are also referred to statutory services for ongoing support. However, public services continue to be stretched and many students will not reach the threshold for ongoing support via the NHS. The University has a close working relationship with the Devon Partnership NHS Trust through the University Community Mental Health team (UCMHT) model and we are seeking to further optimise our approach with all external partners to provide the best possible support to our students. We have considered the package of communications sent out in preparation for, during and after examination periods to ensure these have a supportive tone and clear signposting to the support available. Student-facing Welfare Advisors will continue their work located within Hubs (local student academic support teams) in key academic buildings to be visible in their offer of support for students throughout this period. These teams are available to support students with queries regarding exam outcomes but also applying for mitigation for assessments and any other support needs a student may have. We will keep the demand for these services under review to ensure our support can be expanded and increased as necessary to respond to increasing demand. We have also set out below (see section 4 – ‘Pastoral Support’) details of our enhanced ‘out of hours’ operation and associated communications which demonstrate the proactive support that can be accessed by students who are suffering with a mental health crisis or other concerns at any time of day or night. This can be accessed by the student themselves, other flatmates or housemates, members of staff who have concerns or parents. The University has focussed on ensuring there are a range of
ways a student can communicate with the University and ask for support using their preferred approach, including in person, over the telephone or via email. The University is further informing its approach through wider sector insight, research and guidance including consideration of the UUK Report into Suicide Prevention1
3. Sharing information You invited the University to review the thresholds for sharing information and staff awareness of those thresholds, and the implementation and understanding across academic and welfare staff of the ‘Think Family’ approach (which encourages practitioners to consider the parent, the child and the family as a whole when assessing the needs of, and planning care packages with, those suffering from a mental health problem). University Response: The University has considered the Report alongside wider sector publications including the UUK Report into Suicide Prevention. The University has been operating using the guidelines of a ‘trusted contact’ framework since 2020, taking a risk-based approach to determine when this is invoked, and allowing us to contact students’ families or guardians or trusted contacts in times of crisis. A trusted contact framework considers whether in times of crisis or ill health the University could contact their nominated person to provide additional support to a student or to raise concerns for a student’s wellbeing. The latest sector guidance from UUK provides a recommendation to formalise this practice and recognise it within our policies, including the use of the terminology of ‘trusted contact’ rather than ‘parent/guardian’, and this is being taken forward over the current academic year. Detailed information on the service approach to working with third parties and parents is available on our 'Consent Form Procedure'. The following sections are of particular relevance: 'Exceptional Circumstances,' 'Principles of Practice' and 'Liaison with parents/emergency contact.' The University recognises that such clarity is essential to ensure best standards of safe practice in the management of students with complex needs. In addition, the University has reviewed its risk assessment procedure to ensure contact with family is routinely considered in safety planning. Alongside the work to update terminology to reference Trusted Contacts, further work is taking place to agree further data sharing policies with relevant key statutory organisations including the mental health care teams and the police. We are also updating our risk policy, ensuring consistent application and use of the ‘trusted contact’ across all student facing services and identifying high risk areas to ensure robust support is in place. The University is taking part in a number of sector discussions on further measures, including engaging with clinical practitioners and sector experts to inform further changes to policies and processes regarding Trusted Contacts. We will remain aligned with best practice in the sector, including guidance from Universities UK (UUK).
4. Pastoral Support You invited the University to review whether pastoral tutors should offer to exchange mobile numbers with their students, and to consider whether pastoral tutors should have a work mobile to facilitate a proactive approach in the event that there are concerns for the wellbeing of their tutees. University Response: Supported by the enhanced training provision described above, Personal Tutors will be able to reach out to students who they feel are struggling, and identify support available, including referral to expert Wellbeing support, with the ability to check and review how the support has been received. Furthermore, we have set up a practice review on academic support for students and we will consider and implement its findings carefully. 1 Suicide-safer universities (universitiesuk.ac.uk)
As was set out during the Inquest, concerns have been flagged by academic colleagues, professional services and sector representatives with regards to the proposed sharing of mobile numbers. The concerns include that this approach could have potential safeguarding implications, severe impacts on colleague wellbeing, and may mean students requiring urgent support do not use the appropriate Out Of Hours support service. With this in mind, the University is expanding its out of hours provision to ensure emergency support is available via phone for students in crisis twenty four hours a day across all our campuses. Advice is available to all staff out-of-hours (via our Estate Patrol team in the first instance) where there are serious student mental health concerns. The University has invested significantly in out of hours support to ensure there is a team of trained members of staff who can proactively support students in need. The Out of Hours provision is being further reviewed for additional investment, however, the University has already taken the opportunity to strengthen its Out Of Hours provision and to provide additional detail and information for all staff and students regarding the availability of this resource. This means wherever a personal tutor has concerns about a student they can immediately reach out to these teams to ask for support. Additional information and details of the available support is also included on the University’s website. Whilst the University will not be asking staff to exchange mobile numbers with their students, and nor will work mobiles be provided for this purpose, the University has increased its awareness raising for academic staff on the availability of access to people who can provide support to students outside of the working day and the associated contact details so they can arrange for proactive reach outs. We will play an active part in sector discussions on this issue and will keep our position under review to ensure we continue to be fully aligned with the sector.
5. Welfare services case management system You invited the University to review whether our current welfare case management system is fit for purpose, and whether it is sufficient to capture and ensure actions on welfare concerns raised by students or third parties. University Response: As was noted during the Inquest, following Harry’s death the University had already undertaken a robust review of its current Case Management System (“CMS”). Steps had already been taken to identify technical issues and options for mitigation. All relevant colleagues have been made aware of the potential weaknesses in the existing system and appropriate mitigations are in place to minimise, as far as is possible, repeat issues occurring before the new system is implemented as soon as possible in 2023 with a view to the system being operational within the Academic Year 2023/24. These mitigations include:
• Introduction of a welfare tracker to track case progress.
• Defining a clear procedure through which referrals with voicemail messages can be safely stored.
• Reminders to welfare staff (and broader staff team) to take caution in responding to enquiries, and clarity on which ‘menu option’ to use when seeking further information on an enquiry.
• Review and restatement of proper procedures in the online training guides, and provision of individual training support, where needed. In addition, the University is actively progressing a replacement of the CMS, through the procurement of a new case management product. We are pushing procurement timelines to ensure this system can be in place as quickly as possible, and to ensure the integration of this software into our support service is as simple as possible. This exercise is being undertaken in compliance with all relevant rules and regulations, whilst having regard to the necessary integration with existing systems and processes. We trust this provides a comprehensive response to the Report and addresses the matters of concern flagged therein. The University will continue to strive to support its students in the best way possible and will always have student health and wellbeing as its highest priority, and at the heart of its educational provision.
I would like to thank you for your careful consideration of the circumstances of, and issues arising from, Harry’s tragic death.