National review of higher education student suicide deaths (May 2025)

Download the report from Manchester University

A long-awaited review commissioned by the Department for Education examines university-led investigations into serious fatal and non-fatal incidents involving students over the course of one academic year (2023-2024). The LEARN Network responds to its findings.

Two years ago, many harrowing testimonies collected from families and friends bereaved by student suicide were labelled ‘anecdotal’ by the HE sector during an evidence-gathering session hosted by the Petitions Committee in Parliament. The collective voice of those testimonies has now been vindicated by universities themselves in a new research report: National review of higher education student suicide deaths published on 21st May.

It is with mixed feelings that The LEARN Network welcomes the review therefore. While the Manchester research team deserves considerable credit for doing their job thoroughly,  we are also only too conscious that this thoroughness reveals investigations into 107 individual students thought to have died by suicide, each one a tragedy for those bereaved, and into a further 62 serious non-fatal incidents.

Systemic failures

Sadly, the findings do not surprise us, but they are certainly shocking in places - especially for families who assume their young adults will receive a reasonable level of care when they go to university. In terms of preventative practice, once again we can see clear evidence of the same red flags being missed and signs of systemic failures, e.g.

• student disengagement: the report evidences a lack of proactive follow-up by personal or pastoral tutors, assuming an auto-email notification is enough. One third of the reviews (32%) identified non-attendance as a common factor.

• communication silos: student support services and academic staff are still not communicating with each other (or with relevant external agencies/nominated contacts) to flag students who are struggling with mental health or other difficulties. Many of the reviews referred to students already known to student services.

• known risk factors - e.g. the first year of study, assignment deadlines and exams, interruptions to study, design of campus accommodation - are not being mitigated.

• a lack of training in mental health or suicide prevention for student-facing staff, which would help them identify students who need more help.

Each of these factors was identified by bereaved families in the detailed evidence supplied to Parliament in May 2023. There is no consolation in that, but it shows that these concerns were and still are painfully real. They can no longer be dismissed by the sector.

Now we know - universities rarely consult bereaved families 

It's astonishing that universities tell us in this report that they rarely consult the bereaved families of students during their investigations. Some assume it would be 'inappropriate'. Meanwhile families and friends tell us that they feel excluded from the process - so are they actually being asked to contribute? 

The research team has rightly identified a flawed focus on internal investigations, which means universities tend not to identify knowledge gaps that could be resolved with assistance from outside. GPs are also seldom asked for information that could assist. The researchers’ call for a duty of candour in the HE sector is a must.

Are lessons really being learned?

Universities are learning communities, but it is unclear from the research whether those leading their reviews of serious incidents are sufficiently independent or competent to take on the task. Even when learning points are identified researchers found that actions were inconsistently assigned or scheduled. It begs another question - are the lessons from these reviews really implemented or just stored on dusty shelves?

Let’s be clear - without families' strength and persistence this report would not have been commissioned by the Department for Education. We need to see it repeated annually if lessons are to be learned over the longer term.

While we agree with many of the recommendations of the report, The LEARN Network takes issue with the proposed pace of change. Mental health and suicide prevention awareness training must be mandatory (not just ‘considered’ or ‘available’ for student-facing staff if they're expected to be informed and proactive in their response to disengaged or struggling students). 

Given too that so few University Mental Health Charter Awards have been achieved since it was introduced (just two in 2025), we believe that a duty of candour (as recommended by the report) and a legal duty of care by universities towards students, delivered by statute and/or regulation, are the only ways to accelerate change.

Jacquie Shanahan

for The LEARN Network

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