Is Our Story Your Story?
Each LEARN family left an inquest believing there was more that could have been done to prevent the death of their child or sibling. Preventing future deaths is the way we will gain meaning from unimaginable loss. If you find similarities in your story might it be helpful to chat with one of us?
Please do not hesitate to share and get in touch.
Stories of Loss
Each life is unique. Each story is different. We may not be able to stop mental ill-heath, we cannot stop life events but we can control our own actions and respond to those who may be struggling by acting with compassion. The 'acts' or 'omissions' in taking action are the common thread running through the stories of the LEARN group members.
Every institution, every workplace, every organisation has a system of oversight - a set of policies and procedures that ensure safety of its members, staff and students. However, alarm bells don't always ring and people don't always act. We use the 'Swiss Cheese Model' to analyse our stories and highlight those moments when our loved ones could have been helped but instead 'fell through the cracks' of the system. We do this analysis because we want to show where systems fail and could be improved. Our goal is to prevent future deaths and ultimately create a more proactive and compassionate culture.
Click on the link within some of the stories to see the 'Swiss Cheese Model' showing key moments and missed interventions.
After a stint in China as an English teacher, Charlie applied to Aberystwyth to study computer science.
He had said that he was doing well on the course, found it very interesting and had made new friends.
But in the summer of 2022 things changed. Charlie was not communicating as often and kept telling his family he was busy. He seemed extremely down and was not himself when he stayed with his family during the Christmas period.
Charlie admitted himself to A&E as a result of his mental health on 25 January 2023. The following day he went to a scheduled counselling session with the university's wellbeing service and said he was feeling suicidal. This was his last engagement with the service and he died days later.
His girlfriend believes Charlie would still be here if he'd had the help he needed. She is one of the organisers of 'The Charlie Asked For Help' campaign which points out the need for clearer communication with wellbeing services, as well as help to register with a GP practice when students start university.
Charlie's mum believes the university should have done a better job of communicating by contacting his family at home or professional mental health services.
Harry Armstrong Evans
07.01.2000 - 24.06.2021
Harry had been an assiduous student of Physics and Astrophysics, attending every lecture, seminar and tutorial at Exeter University until his final year exams. Unexpectedly his grades plummeted when he scored a ‘0’ for one paper. On further investigation a technical problem meant that Harry had been unable to upload his on-line exam. Nobody at the university picked this up.
Harry had never had a bad exam result in his life up to this point. His parents were unaware of what was unfolding but his mum sensed something was wrong. She made contact three times with Exeter University but the staff had ‘lost’ her phone calls owing to a problem with their computer system. Harry’s mum wrote to the tutor but was informed that he was not able to communicate as she was a parent.
Harry had appealed to his tutor for advice as to how to save his degree as he wished to pursue further studies in a masters qualification. He asked if he could retake the exams if his explanation was insufficient. 'Yes' was the answer, but it came with a condition, Harry was advised that the exam result would be capped at 40% of the total possible mark. Harry would not be able to achieve the ‘first’ or 2.1 which had been his goal. Worried that his hope of studying for a masters was over, Harry wrote again to the university but his e-mail went unanswered.
Harry took his life after the end of his final term having deferred six exams.
23.05.2000 - 19.06.2021
Oskar left home happy and excited looking forward to making a career for himself in film. He was not depressed; he had suffered a traumatic brain injury 18 months earlier from being a passenger in a Road Traffic Collision. This disability was declared to the university along with the issues it presented for him such as memory issues. We filled in a form with him when making the declaration, giving 'mum' as the named person to be contacted should anything untoward happen, or if they had any concerns about him, we thought he would be safe and that someone would be looking out for him.
Oskar’s deterioration over an eight-week period was shocking to us. Oskar was assessed at the Northern General Hospital on the 24th of April after being caught trying to take his own life. He was deemed to-be 'low risk' and sent back to his halls a couple of hours later, even though he stated to them that he was not sorry for what he had done.
Oskar had given consent to the Wellbeing unit for his information to be shared with family and the GP, neither party was contacted. Three weeks later Oskar took his life.
22.04.2001 - 05.06.2021
Phoebe struggled with anxiety after moving to university in 2019. Her mum was worried so asked Student Services to contact her if they had any cause for concern. Phoebe disclosed her suicide plan to the University and 3 months later asked 'please, please help me'. She fell behind with work. Her father was diagnosed with terminal cancer. 8 months after her original disclosure Phoebe told her counsellor 'I wish the pain to end'. 20 hours later she took her own life. Student services agreed they would phone but Phoebe's mum was never alerted to her crisis.
Harrison De George
25.06.1997 - 07.12.2020
Harrison, a master’s in aerospace engineering was doing his PGCE and living with friends. He expressed feelings of anxiety and depression, but denied having any suicidal thoughts and was not thought to be high-risk by his doctor. Harrison was worried that Covid would stop him doing enough placement days at the college. With the college doors open again he was due to teach a Monday morning class, but never arrived. The university had no idea that he’d not turned up to his placement and were later informed by the family of his death.
25.04.1999 - 29.04.2020
'Smart, funny with a dry sense of humour, self-depracating and very caring', Romy studied classics and aced her first year at university.
Her friends and family were unaware that she had started to struggle academically until after her death.
The University of Edinburgh failed to escalate her case and provide additional support, despite repeated warnings that she was struggling with her mental health
After a visit to her GP, Romy made 2 “special circumstances” applications to resit her exams without penalty citing mental health issues. As her situation deteriorated there were eight requests for coursework extensions, visits to the student support office looking for help and an appointment with a personal tutor, who noted her appearance and found her very out of character.
Romy was meant to resit exams over the summer but did not turn up and applied to redo the year instead. She continued to struggle and was asked to attend a meeting with her senior personal tutor. She did not reply or attend, yet the university failed to escalate the situation which is the university’s protocol if a student cannot be reached.
It took the university 4 months to complete an investigation as to what had happened. With 21 recommendations for change, they concluded that “more could and should have been done” to address her wellbeing needs, and, given the seriousness of her situation, consideration should have been given to using her emergency contact numbers.
Her family believe that Romy was convinced she would be pushed out of the university. The family feel that their right to parent Romy when it mattered most was denied to them as the university did not use the emergency contact supplied at registration. Romy died just 4 days after her 21st birthday.
20.06.1997 - 09.06.2019
Jared worked tirelessly in secondary school to secure a place at Christ’s College, Cambridge. He chose to sit 5 A levels instead of 3 to realise his dream. Jared excelled; 5 A levels (3 A* Maths, Biology, Chemistry and 2 As Further Maths and Physics). He was successful and secured a place, hoping to complete a masters also.
In 2018, third year, he fell behind in his studies, due to extenuating family circumstances. I rang him morning and night as exams grew nearer and realised, he was extremely unwell. I phoned the porters and asked them to check on Jared, while I drove to the university to collect him. He had hit crisis point and I wondered why no-one had noticed or informed me.
Jared asked to intermit (take a year out) and repeat third year. He was told to graduate with DDH (Deemed to have Deserved Honours) and received a non- classed honour. Jared’s dreams were shattered. He was extremely embarrassed; it was not what he wanted. Almost a year later, he sadly ended his life, at 21 years.
26.01.1998 - 12.03.2019
Theo was a promising English Literature and Creative Writing student. Highly compassionate, 'a great healer' he was a high achiever with Aspergers Syndrome.
He found his first week as a fresher very difficult, and his mother was called for help after he self-harmed. Keen to return to his studies, Theo and his mum organised a manageable plan, signposting both the University and Medical care available, to support his needs. He seemed to be doing well on his return to university but his mental health subsequently deteriorated.
Theo followed the University guidance and made it known to the wellbeing team, giving them written consent to contact next of kin, but the University would not contact his family until it was too late.
He attended a meeting with the university wellbeing team only to be told that the meeting was cancelled because of staff sickness. The meeting was rescheduled for 5 weeks later but in the intervening period Theo reached crisis point. He then managed to get an appointment with his GP who referred him urgently to CRHT, requesting they see him within the 4 hours emergency policy. The coroner summarised what happened next: 'Theo was seen at 8 hours due to service demands. He presented with suicidal ideation. He was concerned about his future accommodation, relationships and his university workload...Reasonable adjustments were not made to take into account Theo’s Asperger’s Syndrome, contact was not made with Theo’s family and he was not referred to the Mental Health Home Treatment Team to enable treatment options to be explored'. The coroner felt the Trust's culture had "led to a loss of compassion in some instances with the view that some suicides are 'inevitable'".
Theo did not attend the delayed Wellbeing Service appointment and this was not followed up by the Service. In a desperate place he was facing a 'bureaucracy' that was unable to help. He took his life the following week, aged 21.
07.11.1991 - 07.01.2019
Kieran was a final year medical student. He had disclosed his suicidal thoughts on a number of occasions to his GP at a campus surgery. These thoughts contained details which made them suicide plans and therefore cause for serious concern and immediate action.
His wider support team including his tutor, the university counselling services, and his family were not contacted to help keep him safe at this very vulnerable time.
With diminishing capacity to make rational decisions, Kieran was instead asked to self-refer for therapy. No checks were made to ensure that he had done so. Kieran took his life in January 2019.
30.07.1999 - 25.09.2018
Daniel had disclosed his mental health to the university. Following the relationship breakdown, Daniel’s girlfriend was very concerned and feared he might harm himself. She contacted student services but the member of the welfare team who checked on Daniel had no access to his records so was not aware of his history.
Daniel ended his life just 3 days after starting university.
Daniel's family friend poet Ricky Nuttall wrote a poem dedicated to Daniel. He called it 'University of Life'.You can listen to the poem here.
05.07.1998 - 05.05.2018
Arriving via clearing Ben narrowly missed out on studying with his girlfriend and brother. He never met his personal tutor but disclosed to staff his ‘anxiety and lack of connectedness’, which should have triggered the university's referral to Wellbeing policy. Unpaid fees and a missed exams led to dismissal – a decision taken with no meeting or check on his mental health. Ben took his own life after 8 months of low engagement with university life.
Natasha passed her 1st year with good marks. In the 2nd year her mental health declined. Natasha's upcoming oral assessment was identified as a risk factor. Her GP & Mental Health Team knew about her social anxiety disorder but did not know the assessment date. The University did not know or adjust for the risk associated with oral assessments.
The university was aware of Natasha's problems with the oral assessment at the start of the 2nd year but still had not come up with a remedy by the end of April, over 6 months later. Natasha disclosed suicidal behaviour but the hand-over to the wellbeing and disability service was incomplete. During this period no consideration was made of her mental health when grading her progress. Her social anxiety was the problem behind her academic performance, and the resulting lower than expected grades in turn took her deeper into crisis.
The chance of shared understanding between academic and support staff was lost in a 10 week delay in getting feedback from the GP. This delay was coupled with the unsafe decision by staff to wait and see how Natasha coped with the oral assessment.
Natasha took her life on the day of the oral assessment.
13.10.1995 - 20.02.2018
Rory was studying engineering at university and his first two years went well, although he struggled with anxiety and concentration issues. This came to a head half way through his final year when he came to a standstill. His family realised something wasn't right as he went out of contact. They tried to notify their concern which was difficult due to perceived data protection. No-one seemed to notice he was disengaging from study. His parents brought him home and encouraged him to defer his studies while he got help for his anxiety and increasing depression.
After a year of improved mental health, with some talking therapy as support, and three temporary internships later, he returned to uni with a fitness-to-study note from his GP. This included a new prescription for anti-depressants. He was issued with a fees notice and asked to set up his modules. There was no transition back to study, no reasonable adjustments or face-to-face meeting to plan his return and see if the workload he had remaining in the last semester was realistic.
On 20 Feb 2018, a couple of weeks in, he took his own life. It's likely he lost hope after seeing how much work had piled up and with looming final exams. His family observed that in a workplace there would have been a proper transition process and support and that this is the difference a statutory duty of care could have made.
36 years old
George’s work was vocational and all his days, evenings and social life centred around what he saw as his life’s work at this high profile organisation. It seemed to friends and family that he had everything to live for.
George had suffered from depression in the past but was in a good place when an inexperienced HR manager decided to suspend him over an historic issue that could have been resolved.
No-one in his office knew he had had depression, and the assumption was that he would be resilient enough to hear the news and go home to an empty flat with no-one to confide in.
The letter handed to him in the suspension meeting stated twice that he was not to discuss the matter with anyone other than his close family. He was told to leave the office and did not discuss what was wrong with friends at work who might have supported him at this critical time. Alone, George let his family know how much he loved them. He took his life just five hours after the meeting. The coroner stated that George had felt unable to ask for help to deal with the situation he found himself in and that had he got that help he might have survived. When George’s mother called the office the next day and shared the news, the HR manager was inconsolable.