Coroner’s report criticises University following death of Exeter student
THIS ARTICLE CONTAINS CONTENT RELATING TO SUICIDE WHICH SOME READERS MAY FIND DISTRESSING
An inquest into the death of Exeter student Harry Armstrong Evans, which concluded on 31 October, condemned the University for failing to respond to his “cry for help,” and for failing in its “safeguarding obligations.”
The coroner, Guy Davies, concluded the two-day inquest into Harry’s death by stating that there was “a risk of further deaths” at the University, and announced that he would issue a report to Vice Chancellor Lisa Roberts on how to prevent future deaths. Speaking to Exeposé after the results of the inquest, Rupert Armstrong Evans, Harry’s father, said “It’s a real step forward; the coroner not only identified failings, he put the important questions on record.” The inquest heard that there have been 11 suicides at the University of Exeter between 2016/17 and 2022/2023, eight of which have been officially confirmed by a coroner.
Harry Armstrong Evans, a physics and astrophysics student, took his own life in June 2021 after failing his third-year exams. The coroner, Guy Davies, stated that despite attempts by both Armstrong Evans and his parents to reach out to the University, “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.”
Davies went on, “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.” He stated that the University has a “safeguarding obligation” to its students which it ultimately failed in Harry’s case.
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
Guy Davies, Coroner
In May 2021, Harry Armstrong Evans emailed his personal tutor and welfare services detailing his concerns that isolation and other personal circumstances had negatively impacted his exam performance and mental health. He inquired about grades being capped at 40 per cent for resit exams, stating in his email to personal tutor Professor Matthew Browning: “I worked really hard for this degree and the thought of not achieving for reasons beyond my control is incredibly upsetting.” His tutor stated at the inquest that he had no “red flag” concerns subsequent to Harry’s email, to which he replied a week later. Davies outlined concerns that this email was a “cry for help.”
The inquest heard that Harry’s mother, Alice Armstrong Evans, had called the University wellbeing services twice, expressing concerns about her son’s welfare. However, on both occasions the logs were accidentally closed due to an IT error, culminating in no one from Wellbeing reaching out to Harry as a result of his mother’s concerns. The inquest also recommended changes to the Wellbeing team’s case management system following these two IT errors.
Outside the court, Harry’s family noted that there was a “silent student suicide pandemic” which gripped Britain, and said that Universities should be legally obliged to provide a “duty of care” to students. As a result, they are campaigning for the implementation of ‘Harry’s Law,’ which would mean that UK universities would be required to report their annual suicide statistics, and the academic departments in which these took place. They have set up a petition, which Alice Armstrong Evans told Exeposé, “will be online next week. We expect to be in communication with our local MP, Mr Scott Mann, who will promote the Harry’s Law in the Commons.” Harry’s Law would also give the Department for Education powers to investigate universities with an above-average suicide rate.
A particular area of concern raised by the inquest was training for academic staff. Professor Matthew Browning, Harry’s personal tutor, told the inquest he had received no in-person suicide prevention training which hindered his ability to spot “red flags.” Additionally, Davies stated that the University’ suicide prevention response included an “over-reliance” on email forms rather than face-to-face meetings, stating “Emails do not amount to personal engagement”, and recommending the University establish clear policies on matters such as whether pastoral tutors should give their mobile number to students, and clearer protocols on when staff could contact parents and family. Alice Armstrong Evans, Harry’s mother, told Exeposé: “I really hope that Exeter University will get its act together and I hope there will be a complete overhaul of the Wellbeing services and that academic tutors will immediately take action whenever any student suddenly fails any exams. That academic tutor must make time to spend a couple of hours with that student explaining his, her or their options in order to save his, her or their degree — and to explain how marks may be adjusted etc.”
Davies stated, “This court has heard evidence of the terrible consequences of academic pressures on students and the need for universities to provide a safety net… In Harry’s case the safety net did not operate.” Alice Armstrong Evans commented that if more provisions had been in place and Harry had been offered support, “My beautiful, kind clever much-loved son would still be alive with a future to look forward to.”
This court has heard evidence of the terrible consequences of academic pressures on students and the need for universities to provide a safety net… In Harry’s case the safety net did not operate
Guy Davies, Coroner
Harry’s parents also criticised Exeter University for the limited contact they had with Harry’s family following his death. Alice Armstrong Evans told Exeposé they received, “one phone call offering condolences and one defensive email. Needless to say no flowers or wreath for Harry’s grave. The first we heard from Harry’s tutor, Head of the Physics and Astrophysics Department and Head of Wellbeing was during the course of the Inquest… Really I don’t think that was good enough following the loss of our beautiful and clever son.”
The Students’ Guild Officer team provided Exeposé with the following statement: “Since hearing of the passing of Harry, our thoughts and condolences have been with Harry’s friends, family and all of those who knew him at University. We want to reassure you that at this time, and all others, as your Officers we are part of your community. We have felt the impact of this, and we are here to support you.
Mental health, wellbeing and support is one of our collective priorities for the year. We have already had a number of in-depth conversations with the University, where we have all agreed on the importance of taking the recommendations from the Coroner’s Report with utmost seriousness. We will, where necessary, continue to challenge the University when we feel that is needed, keeping your interests at our heart, and ensuring the University’s systems work for you. We encourage you to reach out for support if you are struggling with your mental health or know a friend who may need extra help — whether it’s being impacted by studies, finances or personal reasons.”
We will, where necessary, continue to challenge the University when we feel that is needed, keeping your interests at our heart, and ensuring the University’s systems work for you.
Students’ Guild Officer Team
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 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 UK 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.”
Article from print issue 737.
