Key Learnings from External Reviews of Student Suicides at UK Universities 2018-22
Warning: The content of this blog post relates to suicide and self-harm which may be triggering for some readers. If you are looking for support with regards to your own mental health, please contact the Samaritans for free on 116 123. Full NHS mental health guidance can also be viewed here.
Over the last four years I have had the privilege of being invited by four UK universities to review (as an external consultant) the tragic deaths of a total of 8 students. It has been an honour (and a responsibility) to talk to many colleagues and students during these reviews, and explore what happened prior to such heart-breaking deaths, and to examine if anything could or should have been done differently, from the institution’s point of view.
I hope, of course, that for each university my findings, learnings and subsequent report have been helpful and of practical use, but it may also be of help to others working in the higher education sector to consider my broader findings, so here I share with you a general overview of common themes that have emerged in my work. I hope they will be useful.
What I have found
It goes without saying that for each university, and each shocking suicide, there will have been specific and unique circumstances to consider, but when reviewing student mental health it is fair to say that common themes often emerge, and these may be of widespread interest to all, to benefit the longer term wellbeing of students everywhere.
Below I will share what university teams generally do very well, and also what challenges frequently arise for them. Suicide is complex and whilst there is no single factor that leads a student to take that fateful step, there are occasionally circumstances or missed opportunities which, if pre-empted (and with the benefit of hindsight), could potentially prevent a similar situation from arising in future (although this is sadly never guaranteed).
What universities generally do well
University staff are generally compassionate and professional in their dealings with students, and frequently go the ‘extra mile’ to help and support them through difficult times.
Staff are dedicated and engaged, want to offer their best, and welcome training in mental health, although because of other workload commitments they sometimes feel unable to attend training, or do as much as they would like to help.
Universities provide a variety of support services for student wellbeing and mental health, and many regularly review their offer, to ensure they remain responsive and relevant to current students’ needs.
Many universities provide rapid access to expert in-house, same day advice for non-wellbeing staff, so that academics and others can discuss cases and concerns (via a dedicated phone number or email address) with a specialist university mental health worker or senior student wellbeing team leader.
Multiple mental health and wellbeing policies and protocols are available to staff, though not all universities have a ‘Suicide Safer Policy’ in place yet. Most are developing one as part of a wider programme of suicide prevention in their institution.
What universities could review to ensure that they provide a ‘Whole University’ approach to student mental health
1. Improve communication between all university teams and departments about student wellbeing and those students causing concern.
Communication across many universities is not as joined up as it could be, although most staff are keen to improve links with colleagues, to support students in difficulty or with complex needs. Unfortunately they are often challenged by understandable confusion about confidentiality or role boundaries. In some cases academics do not talk to each other about a particular student causing concern, or assumptions may be made by staff members in the library, security, or chaplaincy teams, that another team is caring for the student. This is also understandable but can lead to students falling through the gaps.
Recommendation: To tackle this, suicide prevention needs to be ‘everyone’s business’ (as recommended in the Universities UK Guidance) and appropriate training emphasising this could be rolled out consistently across all university departments.
2. Review staff workload as it is sometimes a barrier to provision of wellbeing support for individual students.
All staff interviewed (academic, wellbeing, security) noted the rising demand for mental health support, complexity of cases and workload involved in caring for students. This comes on top of other workload, for example academic staff coping with increasing numbers of students to teach, research and funding pressures, and the demands of multiple league tables.
Staff wellbeing also needs to be addressed more proactively for the whole university community and to achieve a ‘Whole University’ approach to mental health and suicide prevention, as recommended by Universities UK.
Recommendation: All staff may be called upon to support a student in distress, so a wide variety of approaches needs to be implemented to ensure this can happen, including training appropriate to roles, rapid access to expert advice, staff wellbeing support and resources, and easy referral pathways for staff to guide students towards the help they require.
3. Upskill risk assessment, suicide risk triage and use of safety plans.
Clinical and suicide risk assessment is sometimes variable, and occasionally still leans towards a ‘high /low risk’ continuum despite the well-recognised ‘Low Risk Paradox’ and the NICE recommendation not to use Risk Assessment tools and scales to predict future suicide.
A good history includes both questioning about risk factors, to ascertain context and vulnerability, and discussion of protective factors, to seek ways forward. A lack of modern suicide prevention training for some clinical staff may have led to an underestimation of risk when seeing a student for assessment, and a lack of recognition of the multiple risk factors that can be present in a student’s life, such as being autistic, LGBTQ+, having an eating disorder or a past history of self-harm alongside the risks associated with academic failure or financial issues. This accumulation of risk is sometimes inadvertently misjudged, with the unfortunate consequence being a lack of appropriate or rapid enough intervention being offered to the student. This can lead to a tragic outcome.
Safety plans are also inconsistently used or recommended but could provide a useful support option for the suicidal student and refresher training on these may be useful for many staff.
Recommendation: Up to date and evidence-based suicide prevention training for all staff undertaking clinical triage is an essential part of a university’s training approach. The work of Professor Rory O’Connor is particularly helpful here. His book When it is Darkest is highly recommended.
4. Apply ‘Return to Study’/Retention policies and procedures consistently.
It is not uncommon for some students to become too unwell to study or live at university but inconsistent application of ‘Support to Study’ or similar policies can mean that they remain at university even where they deteriorate.
It also happens that students who have suspended studies decide to return the following academic year, despite not being objectively well enough to do so. The student might turn up at the beginning of term or start attending lectures, despite not having completed the relevant ‘Return to Study’ process (which would require medical or other evidence of recovery). This can prove catastrophic when they deteriorate, or if they are isolated and Student Support Services are unaware of their need for support. Universities are generally pretty good at implementing ‘Support to Study’ policies, but often less good at following ‘Return to Study’ procedures.
Recommendation: An audit of this in your HEI could be a helpful exercise.
5. Improve compassion in delivery of difficult news to students.
Some universities are still informing their students by letter when they have failed exams or are being asked to withdraw from university. In some circumstances these letters (bearing very difficult news) have been pushed under the door in the hall of residence for the student to find when they arrive home, usually alone. This has occasionally proved to be not only upsetting but potentially a final straw in that student’s recent run of poor experiences, leading to a catastrophic reaction.
Recommendation: All universities could review both the intimidating language used (often overly academic or legal) and the method of delivery of such news, so as to create a much more compassionate delivery in person, with appropriate support and discussion of options. This is perhaps less likely to lead to a terrible outcome and may instead create hope and opportunities the student may not have considered. Such a role could be carried out by a Retention Officer, specially trained to deliver difficult news, including Formal Warnings and Misconduct letters.
6. Review partnership working – internal and external, and boundaries with NHS.
There are often multiple opportunities for teams within universities to work more closely together, whether as a Suicide Prevention team (co-ordinating and leading strategy, reviewing training needs, and implementing ‘suicide safer’ policies) or as Case Review Management Groups/ Complex Case team. A bereavement officer is also a helpful consideration for many HEIs.
I also found an almost universal challenge in working with the local NHS, be that primary care and on campus GP practices, or secondary care mental health services. There were difficulties in communications, confidentiality, clinical boundaries (whose responsibility is the acutely unwell student?) and out of hours crisis care.
This can lead to an over-reliance on security teams who, despite excellent training, often feel like ‘the 4th emergency service’, which they don’t feel qualified or confident to provide. They often have to manage a lot of risk, usually out of hours, whilst their own personnel resources are strained.
Recommendation: Partnership working, and in particular mental health crisis management, is an area that all universities could benefit from addressing via, for example, local and regional partnership working groups with NHS services, being careful to include local general practice, of course. Many areas are now working on this, which is reassuring to see. More guidance and case histories can be found here.
7. Review website resources and support
Many university websites do not have a ‘Need Wellbeing Help Now’ button available on the home page to make access to immediate advice and support easy for students (or staff).
University websites are often complex to navigate, and Student Support Services are not always easy to find even when specifically searched for (by an external consultant!).
Recommendation: Review the Search function, and ‘Rapid Access’ options, so that students who feel suicidal can quickly find the resources they need, allowing universities to improve their online support. This could of course link to any non-university resources that are provided for students, such as TogetherAll or others.
University teams provide a hugely compassionate and professional array of services for a complex variety of student mental health needs, and do so with grace, patience, and flexibility. Very rarely a student will get into so much difficulty that they feel (tragically) that there is no other option than to take their own life. I allocate no blame for this, every case is unique and complex, but if there is any opportunity to prevent a suicide then all of us working in the higher education sector will certainly embrace it, and I hope that this blog will be useful to you as a part of that process.
Finally, I want to thank you all who support students every day, for everything that you do. I know how hard you work and what you do matters very much indeed.
About the author
Dr Dominique Thompson is an award winning GP, young people’s mental health expert, TEDx speaker, author and educator, with two decades of clinical experience. She is author of The Student Wellbeing Series (Trigger Press), and co-author of How to Grow a Grown Up (Penguin Random House). She has done two TEDx talks; ‘What I learnt from 78000 GP consultations with university students’ and ‘Understanding Why’. She is a Clinical Advisor for NICE, RCGP and Student Minds and lead clinical advisor for Being Well, Living Well (Epigeum).
