A 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 from asphyxiation at his home in Launceston, Cornwall.
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 said Mr Armstrong Evans had died from asphyxia and recorded a conclusion of suicide.
He said he would be writing a preventing future deaths report to the university’s vice-chancellor, which would highlight his concerns about training for suicide prevention, whether the wellbeing service’s case management system was “fit for purpose”, and the considering of providing the mobile numbers of personal tutors to students.
Cornwall Coroner’s Court had heard two days of evidence from witnesses, including Mr Armstrong Evans’s family and the university, and the coroner had adjourned to consider his conclusion.
Mr Armstrong Evans had been struggling with his mental health and was concerned about passing his degree following disappointing module results in the January – as his results were “falling off a cliff edge”.
Weeks before he died, he emailed his personal tutor and the wellbeing service expressing concerns about his isolation during lockdown, his declining mental health and worries about his exams.
Academic staff and the wellbeing service said there was nothing in what he had told them that was a “red flag” and that he was in an immediate crisis.
“There were no obvious red flags to any of us at that time in May,” Mark Sawyer, head of the university’s wellbeing and welfare service said.
Mr Armstrong Evans’s personal tutor, Professor Matthew Browning, said the first time he was aware of his personal difficulties was in May when he received emails from him and his mother.
“It latterly became apparent from Harry’s email to me in May 2021 that he was going through challenging personal circumstance, but unlike some other students he never raised these with me before this point,” Prof Browning said.
The student’s results in his first two years of modules ranged from 52% to 92%, but then, in his third year, his marks tailed off, with him attaining scores of between 19% and 53% in four of his papers and not sitting a fifth.
In the May, Mr Armstrong Evans’s mother, Alice Armstrong Evans, emailed Prof Browning to disclose the family were undergoing financial problems.
Prof Browning said in response that he alerted the wellbeing team but because of university policy could not directly discuss a student with their family without permission.
“I tried at all times to support Harry to the best of my ability,” he said.
“To his mother, I tried to respond as fully and as compassionately as possible, given the information and concerns for Harry provided by her, without breaking any rules about what I could say.
“Harry was an adult and as a matter of policy I am expressly forbidden from talking about him without his express and explicit written consent.
“It’s a very difficult issue. There is a tension between respecting the student’s autonomy as an adult and their desire and right to privacy and my own inclination as a parent.
“I would want to know if it was my kid, but my understanding is that it very clearly had not risen to those exceptional circumstances.
“I still think that was still the right call. I have thought about that many times.”
The inquest heard that no-one from the wellbeing team telephoned Mr Armstrong Evans after his exam results – even after a request from his mother.
Mrs Armstrong Evans was so worried about her son that she tried to speak to the wellbeing service, but her two calls were never returned due to failings in a computer record system.
The referrals were passed to a welfare practitioner to respond to but, due to issues with the case management system, the logs were closed when they replied to the admin team asking for further information.
At the conclusion of the inquest, Harry Armstrong Evans’s parents, Rupert and Alice, issued a statement in which they called for the creation of “Harry’s Law” to legislate for universities to have a legal duty of care to students.
“Harry was a beautiful, kind, intelligent and gentle soul. He never had a cross word with anyone,” they said.
“He was our pride and our joy, and his passing is made all the more tragic because it was entirely avoidable.
“For too long, universities have operated in a space where, under the law, they are not obliged to provide any duty of care to the young people at their institutions.
“Even our prisons are obliged to provide a duty of care to murderers locked up for life.
“This absence of responsibility by universities comes at a time when our children, their students, are under the most extraordinary amount of mental and academic pressure, and when they are still transitioning from child to adulthood.
“Legally, they are adults, but emotionally many are not mature enough to process the suffocating stress of exams and, in the case of Harry, when they do raise their hand and ask for help it is often too little, too late. This was exacerbated in the lockdown isolation of his student accommodation.
“The Covid-19 pandemic may be under control but a silent student suicide pandemic still grips Britain’s higher education institutions and for years universities, like Exeter, have preferred to turn a blind eye to deaths of sons and our daughters in, yes, their care.
“That is why we are calling on the Government to intervene in this culture of selective responsibility and silence, and, under proposed changes which we are calling ‘Harry’s Law’.”
Rupert and Alice said the introduction of “Harry’s Law” would create legislation to:
- require coroner’s courts to inform higher education institutions when the suicide of an enrolled student is registered.
- require universities to keep a record of student suicides.
- require universities to publish annually on their website student suicide rates and which faculty the student belonged to – so parents and pupils can judge for themselves whether the environment is right and safe for them.
- 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.
- Legislate that universities do hold 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.
Rupert and Alice Armstrong Evans added: “No parent should outlive their child.
“These simple and inexpensive measures would, we have no doubt, ensure fewer parents are made to suffer the misery that we will live with forever.”
