Source · Prevention of Future Deaths

Benjamin Murray

Ref: 2019-0155 Date: 16 May 2019 Coroner: Maria Voisin Area: Avon Responses identified: 3 / 2 View PDF

Low rates of mental health disclosure in university applications and the absence of formal investigation reports following student deaths indicate systemic gaps in student support.

Date 16 May 2019

56-day deadline 22 Sep 2019 est.

Responses identified 3 of 2

Suicide (from 2015)

Coroner's concerns

AI summary

Low rates of mental health disclosure in university applications and the absence of formal investigation reports following student deaths indicate systemic gaps in student support.

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For Bristol University, The Department of Education and The Minister for Suicide Prevention Bristol University have clearly made many fundamental changes to their practices to support students wellbeing and it may be that their current practices can be shared throughout the Higher Education sector to assist with suicide prevention: For UCAS, The Department of Education and The Minister for Suicide Prevention The concern mental health disclosure either on the UCAS application form or indeed to a prospective University: am told that currently such disclosure is at 37%. There needs to be a move towards de-stigmatising mental health and ensuring that students are made aware that by disclosing mental health problems on their UCAS form or to their prospective University that it will not affect getting a place at University. For Bristol University, The Department of Education and The Minister for Suicide Prevention The transition from home to University can be a challenging time for some students and Universities clearly have the primary role of education however this inquest has demonstrated they also carry out an important pastoral role It is not the role of the Coroner to investigate Ben'$ journey through University in light of the circumstances of his tragic death and the limited scope: That said as a Coroner has a duty to consider prevention of future deaths it was appropriate in this case that aspects of Ben's progress were investigated by me: In addition currently the University sector does not carry out an investigation report (such as a root cause analysis or sudden untoward investigation) after a death of a student: Such a written report usually affords an opportunity to review what happened; what was done well/the good practice points; areas of concern, if there are any, and importantly what lessons can be learned often with a formal written action plan: Such a document is also very helpful to the Coroner when considering and discharging this duty. Such a formal process and document most importantly assistsin preventing future deaths Telephone 01275 461920 Email AvonCoronersTeam@bristol gcsx gOv.uk Website Www.avon-coroner com The Coroner's Court; Old Weston Road, Flax Bourton, BS48 1UL over

Responses

3 respondents

University of Bristol University

11 Jul 2019 PDF

Action Taken

The University has shared its mental health and wellbeing strategies with sector colleagues and provided support to other institutions where student deaths have occurred. From September 2019 the SPRG will oversee the undertaking of a serious incident review for every suicide or serious attempted suicide. (AI summary)

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Dear Madam Re: University of Bristol response_to Requlation 28 Report Thank you for your report dated 2 May 2019. In respect of the concerns outlined in your report:
1. Sharing Changes to University Practices with the Sector: As you will be aware from evidence provided by the University for recent inquests, the University has carried out significant changes to its Support Services over the last two years. This has involved significant investment and continuing review of processes and structures for supporting students. The University has collaborated with other Universities, Mr James Murray and the charity Papyrus through the forum of Universities UK to produce guide entitled "Suicide Safer Universities The guide describes the University's ongoing collaboration with Public Health England and Bristol City Council (as the lead organisations for suicide prevention in the general population) to develop a suicide prevention policy which has now been published. The University has shared its mental health and wellbeing strategies with sector colleagues, and provided support to other institutions where student deaths have occurred, As the issue of student mental health is a serious ongoing issue, the University will continue to share information on best practices with other universities , Public Health England, student representatives and local authorities
2. Pre-registration Mental Health Disclosure The University notes the Learned Coroner's concern at potential for applicants to feel any declaration of mental health difficulties may adversely affect their application to Universities_ In addition to disclosures made by applicants on their UCAS forms; the University communicates with prospective students prior to enrolment and encourages them to the

contact Disability Services about any mental health or other disabilities to ensure they can access appropriate support, The University is supporting UCAS in its endeavours to find alternative ways of encouraging declarations and reducing the barriers to declarations about extenuating or mitigating circumstances as well as any mental health concerns, or other disabilities_ The University also provides regular prompts to applicants and students during their time at the University about the benefits of disclosing any mental health difficulties and reassures them that this will have no impact on their application or studies but will be used to support them: Our Accommodation Office sends pre-arrival online induction to students_ This covers important accommodation information (fire safety, recycling etc) , and also introduces students to the Residential Life team and the support services available_ In this induction we also ask students to answer one question about how are feeling about coming to university; excited, nervous but looking forward to it, or really apprehensivelworried_ We use this information to ensure that the Residential Life Team have additional information about students who may require additional support;
3. Formal University Process for Reviewing Student Deaths The University currently convenes standing committee (the Suicide Prevention and Response Group (SPRG)) quarterly to maintain oversight of policies and practice relating to student suicides. When there has been student death the group puts in place an Incident Response Team which meets regularly following the event to co-ordinate internal and external communications, plan for provision of support for those students and members of staff who have been affected , liaise with relevant family members, and act as mechanism for collating relevant information. Together with colleagues from the University of the West of England and Public Health England, the SPRG has undertaken an audit of student deaths by suicide to identify possible factors that can inform prevention strategies As part of its role from September 2019 the SPRG will oversee the undertaking of a serious incident review for every suicide or serious attempted suicide involving high mortality method or admission to intensive care. This will be based on practice in the NHS and other HEIs. An incident review report will include relevant information about the student, their interactions with the University and noting what went well in providing support and where there is possibility for improvement: Should a death occur; information gathered about the student will also be added to our suicide audit tool which aims to identify any trends over time that may inform future suicide prevention_ It will also form the basis of information provided to assist with Coroner's Inquests.

UCAS

12 Jul 2019 PDF

Action Planned

UCAS is redesigning the question about disabilities, special needs, or mental health issues on the application form, with a roundtable discussion planned for July and implementation in 2020 for the 2021 entry. The UCAS Hub is also being explored to alleviate anxiety and signpost support services. (AI summary)

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Dear Ms Voisin Im writing in response to your letter of 2 May 2019, concerning the inquest into the tragic death of Benjamin Murray on 5 May 2018_ In responding, wanted to set out the actions that UCAS already takes to help young people make well-informed choices about their futures, as well as the future steps that we are in response to the issues you and others have raised, to encourage students to share information about their mental health and wellbeing with universities_ UCAS is an independent charity, which delivers public benefit by helping everyone with the potential to benefit from higher education to make well-informed decisions about their futures and gain access to universities and educational establishments, regardless of their background: This includes providing information and advice about a range of post-18 choices which include apprenticeships, volunteering, and taking a gap year, as well as applying for university year; we help around 700,000 students apply for full-time undergraduate courses at nearly 400 UK universities and We work with a wide range of organisations such as Student Minds, Unlock; the National Association of Disability Practitioners (NADP), and Stand Alone, to offer tailored information and advice to students who are to have specific information needs about applying and progressing successfully to higher education: For example, we provide a student-facing information and advice page focusing specifically on the health and wellbeing support available at university or college, and another that deals with a variety of issues related to transition: Furthermore; to support cohorts of students for whom we are aware that mental health is a particular concern, we signpost them to relevant information, as seen on the UCAS estranged students hub When students apply to universities and colleges, they complete an online application. This includes mandatory information needed by higher education providers to decide whether or not to offer the student a place (and on what basis), and also voluntary information which can be used to support contextual admissions, provide specific student support, and is used for equalities monitoring: UCAS IS THE TRADING NAME OF THE UNIVERSITIES AND COLLEGES ADMISSIONS SERVICE REGISTERED IN ENGLAND AND WALES: 2839815 (LIMITED BY GUARANTEE) REGISTERED CHARITY IN ENGLAND AND WALES: 1024741 AND SCOTLAND: SC038598 REGISTERED OFFICE AS ABOVE taking Every colleges: likely

Applicants are encouraged to declare if have a disability, special need, or mental health concern, so that universities' student support teams are aware and offer additional help_ However; we understand from our work that it can be difficult for young people to self-declare this type of personal, sensitive information. To address this, we have worked with organisations such as Student Minds and the University Mental Health Advisers Network (UMHAN) to develop additional content that reinforces the importance of declaring a mental health concern, explains the benefits of doing So, and clarifies how this information is used by UCAS and the university or college_ We will continue to work with such organisations to ensure that our content is up-to- date, and reaches our applicants in a timely and appropriate manner: Later in the application process, when UCAS emails the applicant to confirm their place at university, we include information about mental health and wellbeing to support their transition to the next stage: To further support young people who declare a mental health condition on the application, we encourage teachers and advisers (with the consent of the student) to use the reference section of the application to advise universities and colleges of any issues, such as physical or mental health To ensure that advisers themselves are aware of why it is important for their students to declare a mental health condition, we signpost Student Minds' Know Before You Go and Transitions resources on our adviser-facing_pages: In addition, we regularly address student wellbeing and mental health at our teacher and adviser, and provider events, working with stakeholders such as AMOSSHE and Student Minds to ensure all involved in the application process are aware of good practice and the most up-to-date information available. Our data shows that there has been a significant uplift in the number of applicants self-declaring a mental health concern in their UCAS application in recent years. Since 2014,this number has increased from 7,433 to 17,520 (2.5% of total applicants), which may be a response to the greater encouragement given from a wide range of organisations and individuals to open up the conversation about mental health. However; we understand from our engagement with students and stakeholders, that some students still withhold this information, possibly due to the fear of stigmatisation, as well as an uncertainty about how the information will be used; applicants may not appreciate how this information could help universities and colleges to support them: Consequently, we are undertaking a number of additional activities to respond to these concerns_ As part of a wider programme of business change, we are redeveloping our online application for undergraduate students This affords us the opportunity to work with organisations such as Student Minds and the UMHAN to redesign we ask for information about disabilities, special needs, or mental health issues and the help text that supports this. To understand the most appropriate and effective way in which to redesign this question, we're holding a roundtable discussion on 30 with representatives from sector bodies and expert organisations, the result of which will be in place in 2020,for the 2021 entry Alongside the new application service, we have developed the UCAS Hub -a new online information and advice tool to support students through every step of their decision-making journey, which surfaces the right information at the right based on their expressed preferences and interests. The first version of this will go this autumn: We are exploring how the UCAS Hub could help strengthen the messaging about all aspects of applying and going to university to alleviate anxiety during the application process, as well as regularly signposting the support services and experts who can offer help once they have made the transition. they how July cycle. time, live

Additionally, UCAS is a core member of the Department for Education's new taskforce, the Education Transitions Network: We hope that this network will help to create a collaborative and consistent approach to addressing the challenges of student mental health in higher education. hope this clarified how we have been working to support young students as they consider their post-18 options, and explained how we are seeking to improve the connection between applicants and higher education providers in the future: Also, I hope this overview ofthe work UCAS is undertaking to support those with mental health concerns illustrates our ongoing commitment to this important agenda. We will continue to engage with stakeholders as we seek to improve the experience of students transitioning into higher education and would be happy to work further with you directly on this matter.

Department for Education Central Government

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Action Planned

The department will work with Universities UK to remind HE providers of the recommendation to carry out serious incident reviews. Public Health England is happy to work alongside partners to support the development of a serious incident framework. (AI summary)

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@ Department for Education M E Voisin HM Senior Coroner Area of Avon By ema i I : AvonCoronersTeam@ bristo Lqcsx.qov. uk ,s Department for Business, Energy & lndustrial Strategy Chris Skidmore MP Minister of State for Universities, Science, Research and lnnovation. 1 Victoria Street London SWlH OET +44 (O) 20 7215 5000 www. ed ucation. qov. uk/hel o/contactus enouiries@beis.qov.uk

Your ref: 10743 (t KL- July 2019 Thank you for providing the Regulation 28 report, dated 2 May 2019, in relation to Mr Benjamin James Charles Murray. This response is a joint one from the Department for Education and Department of Health and Social Care. We understand that your report was also sent to the University of Bristol, Universities UK, UCAS, Public Health England and Student Minds. We would like to say first how much the circumstances of Ben Murray's death have become a focus for government officials and colleagues across the higher education sector working on mental health policy, and that this focus has been greatly aided by the courage, drive, and ideas of the Murray family. Those individuals who have been involved with the family in this work are grateful for the contribution of Ben's father, James Murray, to support improvements to mental health guidance and provision for students both in Bristol and further afield. At the outset, we would like to assure you that mental health, and suicide prevention, are key priorities for this Government. In January, we published the first Cross-Government Suicide Prevention Workplan which sets out an ambitious programme of work to reduce suicides, including actions being taken to improve the mental health of university students:

Under the Equality Act 2010 higher education providers have legal responsibilities to support students with mental health conditions. Through the Department for Education's latest guidance to the Office for Students (OfS) on Student Experience, the Department for Education asked the OfS to continue its work supporting student experience, with a focus on wellbeing and mental health. Whilst it is for higher education (HE) providers to determine what welfare and counselling services they need to provide to their students, the government is proactive in promoting best practice by the Higher Education sector. The Department for Education is working closely with

Universities UK on embedding the Step Change programme within the sector. Step Change calls on higher education leaders to adopt mental health as a strategic priority throughout the whole institution, and embed good mental health practices beyond student services teams. The OfS has recently announced the award of almost €6 million of funding for ten large-scale projects encouraging higher education providers to find new ways of combating student mental health issues. The projects involve over 60 different universities, colleges and other organisations including NHS services, the police and charities, together contributing an additional €8.5 million in matched-funding taking the investment up to f 14.Smillion. The projects will address one or more of the following areas: o Transitions - for all types of students, whether from school or college to higher education, or from there into postgraduate study or employment. o Early intervention - by providing new forms of mental health awareness training to staff and students; or using data to improve or enhance interventions. . lmproving support - for example by developing links between university or college-level support services and those of local primary care and mental health services. The University of Bristol is a partner on one of the successful funded projects - the UWE National Leaming Collaborative bid. The OfS will communicate the outcomes widely so that students everywhere can benefit from the work undertaken by the programme. Building on this, in June 2019, the Prime Minister announced an additional f 1 million for the OfS funding for digital and innovative proposals that drive improvements in mental health support and early intervention for higher education students. The programme will fund proposals that promote partnership working between the health and higher education sectors. Further, the University Mental Health Charter announced in June 2018 is backed by the Government and led by the sector, focusing on driving up standards in promoting student and staff mental health and wellbeing. Prospective students and their families will be able to identify providers who have succeeded in achieving the standards of the charter. The government expects providers to engage with the charter. We will take the opportunity to address the concerns raised in your report in turn Concern 1: You ask that consideration be given to sharing the University of Bristol's good practice on suicide prevention throughout the sector. Both the Department for Education and Department of Health and Social Care worked with Universities UK, the OfS and other stakeholders within the higher education sector, to develop guidance on measures to help prevent suicide. The guidance was published in September 2018, ahead of the 2018119 academic year, with every Universities UK member receiving a printed version. The'suicide- Safer Universities'guidance can be found here: https://www.universitiesuk.ac.uk/policv-and- We expect all universities to engage actively with the guidance to improve mental health support and reduce suicide risks amongst their student population. The guidance was informed by the University of Bristol's good practice guide, the 'Suicide Prevention Framework'as well as other HE providers approaches to student mental health. The University of Bristol's Vice-Chancellor, Professor Hugh Brady, chaired the Universities UK- Papyrus Suicide Safer Universities Guidance Working Group. The guidance was launched by Bristol at a Universities UK Members Conference in 2018 at which James Murray, Ben's father, spoke. Papyrus also worked with James Murray to promote take up of the guidance.

We understand that Universities UK plan to re-launch the guidance in July this year, which will include an updated section on 'Postvention', contributed by the Samaritans, and a technology supplement co-authored by James Murray and digital support company, Jisc. Student accommodation providers also have a role to play in supporting student mental health, particularly to ensure that frontline staff who are in contact with students are appropriately trained to support students. British Property Federation guidance being published on Monday (1517119) makes a number of recommendations to ensure that student accommodation providers fulfil their duty of care towards students. This includes guidance on the legal requirements of accommodation providers, mental health policies and procedures, and training for staff. This training should include guidance on recognising the signs of mental distress and responding to a crisis involving student mental health, and how to refer cases to networks of appropriately trained professionals, including NHS mental health services. Concern 2: You raise the important issue of mental health disclosure to HE providers, students and advisers, either via the UCAS application process or direct to the provider. UCAS provides a range of information and advice to all audiences in relation to mental health and the support HE providers can offer. HE providers are responsible for their own admissions processes, however the government also has a role to play in promoting an environment in which students feel able to disclose a mental health condition without concern that this may be detrimental to their chances of either securing an offer, or thriving at that place of study. Disclosure at the point of application is designed to ensure that students are supported from the very start of their journey in higher education; to ensure that they receive the support from the provider right through from the application and interview process through to their time studying. UCAS have recorded a year-on-year increase in mental health disclosures in the admissions process; this is self-declared and optional and students may also declare outside the admissions process. UCAS is currently reviewing their'disability and special needs' question in UCAS Apply. This will involve a cross-sector project with the Higher Education Statistics Agency (HESA) and others, as well as experts in this area. The current question forms part of the HESA Student Record, therefore any change must be joined up. It is anticipated that any change would be implemented for the 2021 entry cycle at the very earliest. UCAS have been working with the student mental health charity, Student Minds, to develop and improve their existing guidance. We understand that they will respond to you separately providing full details of this. Students can experience pressures in moving from school/college to University. The Education Transitions Network was launched in March by the Department for Education to examine ways to help students deal with the pressures and challenges that may arise when starting university. More information is available on GOV.UK: ://www overnm rnment- creates-new-stud e nt-menta l-hea lth-tas kfo rce. The taskforce group will develop measures to make a smooth transition into higher education and help students maintain good mental health. The network will explore ways in which to increase disclosure at the point of application to encourage prospective students to declare mental health problems without fear that this will affect their admission offer prospects. This builds on the work already underway across the sector to improve support for student mental health. The network is currently developing its strategic approach to tackling risks to wellbeing which will be centred on embedding quality-assured, good practice initiatives across the sector

lmproving information sharing so that institutions can get better at involving families and friends in supporting students in difficulty is part of the package of measures announced at the Higher Education Mental Health Summit held in June 2018. Universities UK is leading the work - which is being chaired by Brunel Vice Chancellor and incoming Universities UK President
- to develop advice on how higher education providers can get better at involving support networks at an early stage when students are struggling. This work is approaching its final stages and will include a consensus statement and guidance being published before the start of next academic year. Concern 3: You note that currently the University sector does not carry out an investigation report following the death of a student. We recognise the value of a written report in order to identify lessons learned and develop an action plan to preventing future deaths, as well as the value to the Coroner. Universities UK's'Suicide-safer Universities' guidance on postvention, developed in conjunction with our Departments and the Office for Students, recommends carrying out a serious incident review to facilitate research, data collection and monitoring to get to the bottom of what has happened, and the lessons learned. This also includes sharing experiences of best practice and knowledge with others. As refened to above, the guidance was published in September 2018, ahead of the 2018119 academic year, with every UUK member receiving a printed version. The Universities Minister will work with Universities UK in the forthcoming academic year to remind Higher Education providers of this recommendation in the 2018 Universities UK guidance. Public Health England is happy to work alongside partners to support the development of a serious incident framework to help ensure incidents are identified correctly, investigated thoroughly and learned from to reduce the reoccurrence of incidents. ln 2017. DHSC established a national Learning from Deaths policy framework, providing guidance to NHS providers on how to investigate and learn from deaths, and also, engage meaningfully and sensitively with bereaved families. There may be much that the university sector, working with Public Health England, can take from this policy area to inform the development of any future framework. Thank you for writing on this important matter. Chris Skidmore Minister of State for Universities and Science t Jackie Doyle-Price Parliamentary Under-Secretary of State for Mental Health, lnequalities and Suicide Prevention

Report sections

Investigation and inquest

On 30/05/2018 commenced an investigation into the death of Benjamin James Charles MURRAY. The investigation concluded at the end of the inquest: The conclusion of the inquest was: suicide

Circumstances of the death

On 5th May 2018 Ben had lunch with his father left him shortly before Zpm. His father's statement stated that: "he seemed somewhat down and was concerned because he was sensitive but the thought that he would take his own life never crossed my mind" At 3pm Ben was found beneath the Clifton suspension bridge on the canopy area, the police officer reviewed the CCTV footage from the bridge, he described what he saw that Ben walked unaccompanied onto the bridge; he walked to the buttress wall; climbed up onto it and without hesitation propelled himself forward. It was clear from the investigation that there were a number of matters going on in Ben'$ personal life including: that Bristol was not Ben's choice of university to study at; that he never seemed to fully engage with University studies; that his place at University had been withdrawn; that there was a significant debt owed to the University for tuition and accommodation; that Ben had disclosed that he Telephone 01275 461920 Email AvonCoronersTeam@bristol gcsxgov.uk Website www.avon-coroner.com The Coroner'$ Court, Old Weston Road, Flax Bourton, BS48 1UL May and and first was suffering illness and anxiety and it appears that he may have been confused about his status with the University:

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_

Copies sent to

coroner com The Coroner's Court; Old Weston Road, Flax Bourton, BS48 1UL may may me

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Report details

Reference: 2019-0155
Date of report: 16 May 2019
Coroner: Maria Voisin
Coroner area: Avon

Responses identified

Responses identified 3 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Sep 2019 (estimated).

Sent to

Bristol University

Department for Education

Source links

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Data: judiciary.uk under OGL.