Cornish student took his own life, coroner concludes

A Cornish student took his own life after his mental health declined during lockdown and he became worried about his family's financial future and failing some of his university exams, a coroner has concluded.

Harry Armstrong Evans, 21, a third-year Physics and Astrophysics student at the University of Exeter, died in June 2021 at his home in Launceston.

Assistant Cornwall coroner Guy Davies said the university had a "safeguarding obligation" to its students and was "best placed for first response to a mental health crisis".

But recording his findings, the coroner said that obligation was different when compared with that of a patient and their doctor.

"This court has heard evidence of the terrible consequences of academic pressures on students and the need for universities to provide a safety net for their students," Mr Davies said.

"That should include welfare services and the capacity to proactively respond to concerns.

"In Harry's case the safety net did not operate to safeguard Harry. Concerns were raised on a number of occasions by both Harry and his parents.

"My central finding will be that the welfare service did not proactively respond to those concerns and did not provide the necessary support for Harry.

"Specifically, there was no engagement with Harry's family. Indeed, his parents only found out about the extent of his exam failure after his death.

"I further find that Harry's death was due to an acute mental health crisis which was preceded by a catalogue of missed opportunities along with system failures which together led to an absence of proactive results which meant Harry could not receive support.

"I further find that there are matters revealed by the investigation we heard in evidence at this inquest which give rise to a concern that there is a risk of further deaths, and I will be issuing a report to prevent future deaths in connection with those concerns."

Mr Davies has asked for the University to do the following five things in his report to the Vice Chancellor

• Review the emergency contacts system
• Review provision of training for suicide prevention for staff
• Review the university's suicide prevention response
• Review over-reliance on email responses with students struggling with well-being (and giving them an online form to fill out)
• Whether pastoral staff should share numbers with students where there are concerns involved

It was previously heard that a call of concern from Harry's mum, Alice, was never replied to due to failings in a computer record system.

Mark Sawyer, head of wellbeing and welfare services at the University of Exeter, told the inquest the referrals were passed to a welfare practitioner to respond.

But due to issues with the case management system, the logs were closed when they replied to the admin team asking for further information.

Mrs Armstrong Evans made a second call to the service later that month and was passed to a welfare practitioner to respond out-of-hours.

The inquest heard Mrs Armstrong Evans had only left her daytime contact details and when the practitioner replied to the admin staff asking for an alternative phone number, the log was closed.

What is Harry's Law?

Harry's parents - Alice and Rupert Armstrong Evans - have been calling on the government to adopt a new piece of legislation, which would mean all universities have to publish their student suicide rates and which faculty they were studying at.

'Harry's Law' would:

• Make it mandatory for coroners' courts to inform higher education institutions when the suicide of an enrolled student is registered
• Require universities to keep a record of student suicides and for them to publish annually, on their website, those figures and which faculty the student(s) belonged to
• Insist that the Department for Education be given powers to be able to investigate, intervene and place universities into ‘special measures’ where a specific institution’s suicide rate exceeds that of the national average as outlined by the Office of National Statistics in the year prior
• Legislate that universities do provide a ‘duty of care’ to all undergraduate students
• Make it mandatory for all pastoral and academic tutors at higher education institutions to carry out and record their attendance at mental health awareness training
• Open communication should be the default position between students, parents and tutors to ensure concerns can be shared if a student's mental health or wellbeing is of concern to any part. Only where the student actively 'opts-out' should existing privacy laws supersede this

Harry's father Rupert said: "It's obviously an absolutely appalling thing that you think couldn't possibly happen to your own children. Our reason for going public on this is to try and stop it from ever happening again.

"And it's completely unnecessary. If it's out in the open and people come together to come up with the best solution, I'm quite sure it can be overcome.

"If you go to a local council recycling centre, they post up on a board outside how many days it's been since they've had an accident and surely our children deserve better than that".

Rupert and Alice say they had been in touch with the university following their son's efforts to reach out to his tutor – after what they believe was an "anomalously low grade that had scuppered his chances of further post-graduate study".

In a statement this afternoon, Mike Shore-Nye - Registrar at the University of Exeter - said, “We are deeply saddened by Harry’s death and the family's loss. Everyone who knew Harry is devastated by his suicide at home during the Covid19 pandemic.

"We continually review and improve the wellbeing support we provide based on evidence and learnings, including from tragic cases such as Harry’s. We will consider the Coroner’s detailed conclusions in this case and make sure we learn the lessons to enhance our support and operations further, specifically in the areas recommended by the Coroner.

“We are acutely aware of the current mental health challenges for young people and the difficulties accessing external services and have invested significantly in student welfare and wellbeing support in recent years.

"We have set up a bespoke partnership with local NHS and support services for students with complex mental health needs, depression and anxiety. We provide student support services seven days a week both on campus and in the community, including throughout the Covid19 pandemic.

"Student health and wellbeing is always the University of Exeter’s top priority. We also welcome and support the recent Universities UK guidance on suicide prevention and their recommendation on a trusted student contact when there are serious mental health concerns.

"A number of the UUK recommendations have already been implemented at the University of Exeter, and we will implement all the recommendations.

“On education, during the pandemic all students were supported with a no disadvantage guarantee to ensure their assessment marks didn’t suffer as a result of the difficult circumstances surrounding the pandemic. "

And we continue to take a compassionate and supportive approach to all students who are struggling with personal circumstances and the societal pressures we face today.”

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