A review of student suicides suggests that standards are now necessary

For years, bereaved families have fought for answers – and change – after losing their children to suicide at university.

Arguably the most high-profile have been Bob and Margaret Abrahart, who led this charge after their daughter Natasha died in April 2018 at the University of Bristol.

Despite her severe social anxiety, Natasha was required to give oral presentations that filled her with dread, and in 2022, a judge ruled that Bristol had discriminated against Natasha under the Equality Act by not making reasonable adjustments.

But he did not find the university owed a general duty of care to avoid causing psychiatric harm – noting that:

…if a relevant duty of care did exist… there can be no doubt that the university would have been in breach.

That distinction prompted the Abraharts and other bereaved families to launch the “#ForThe100” campaign, named after the estimated annual student suicide toll. Their petition for a statutory duty of care gathered over 128,000 signatures and triggered a Westminster Hall debate in 2023, where MPs across parties voiced support.

The skills minister at the time, Robert Halfon, rejected the call for statutory change. Instead, as part of a higher education mental health implementation taskforce, he announced an independent review of student suicide deaths – a “watching brief” approach that effectively deferred the question of legal responsibility while monitoring the sector.

The review has now been published – and it reveals a catalogue of missed opportunities, systematic failures, and inadequate protections for vulnerable students.

It also evidences the patterns identified by campaigners for years – poor monitoring of disengagement, communication silos between academic and support services, inadequate training for staff, and safety concerns in university accommodation.

The big question now is whether the evidence will drive the legal and cultural shifts needed to protect students and prevent future deaths – or whether it will become yet another well-intentioned PDF on the ever-growing pile of guidance that relies on voluntary implementation.

A review of student suicides

The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) team from the University of Manchester was commissioned to conduct the review. Their approach was methodical – all higher education institutions in England were asked to submit redacted serious incident reports for suspected suicides and serious self-harm incidents occurring during the 2023-2024 academic year.

The response was robust. Of the 115 Universities UK members, 113 (98 per cent) provided a nominated contact, and 110 (96 per cent) responded with information about serious incidents during the academic year. That does at least suggest that universities recognise the importance of addressing student suicide, even if some remain hesitant about legal frameworks for doing so.

In total, universities reported 107 suspected suicide deaths and 62 incidents of non-fatal self-harm during the 2023-2024 academic year. Of these, 104 serious incident reports (79 for suspected suicides and 25 for self-harm) were submitted to NCISH for analysis. As such, it is the largest collection of detailed individual-level data on student suicide ever compiled in the UK.

The team then analyzed those reports against established standards, including both the Universities UK/PAPYRUS/Samaritans guidance for conducting serious incident reviews, and NCISH’s own 10 standards for investigating serious incidents. They examined student characteristics, identified risk factors, evaluated the quality of investigations, and assessed the recommendations and action plans arising from these reviews.

Pressure and disengagement

In 38 per cent of cases, students were experiencing academic problems or pressures. These ranged from exam-related stress (10 per cent) to anxiety about falling behind or meeting deadlines (19 per cent).

Nearly a third (32 per cent) of reports identified evidence of non-attendance – a critical warning sign that was often met with inadequate response, if it was noticed at all. The most common intervention was an automated email from administrators, rather than proactive personal outreach.

The report argues that that represents a significant missed opportunity for intervention – calling for students who are struggling academically to be recognised as potentially at risk, with an enhanced focus on providing a supportive response, as well as increased awareness of support at key pressure points in the academic calendar, especially during exam periods.

The review also found that while 21 per cent of students were or had been part of “support to study” procedures or equivalent, there were clear instances where a cause for concern had not been appropriately escalated.

The report identifies a need for additional or more robust processes for monitoring student engagement and non-attendance, including recommendations to review attendance triggers, the development of consistent approaches to responding to non-attendance, and the implementation of earlier interventions when disengagement is identified.

The timing of incidents reinforces the connection to academic pressure, with peaks occurring in March and May – coinciding with assessment and exam periods – and notably fewer incidents during holiday periods, suggesting that academic stressors play a significant role in student distress.

One thing I’d add here is that it really shouldn’t be a given that students in the UK all progress and complete at the same pace – that we are the country in the OECD whose students complete the fastest and drop out the least has some obvious downsides that the LLE, and a large dose of culture change, really ought to tackle.

The other thing worth considering is culture. In our work on student health last month, academic culture popped up a significant but often overlooked determinant of student health in survey responses, with students describing patterns of overwork, presenteeism, and a “meritocracy of difficulty” that rewards suffering over learning outcomes.

Students’ comments revealed how unhealthy work patterns are normalized within academic environments, with concerns about overwhelming assessment deadlines, high-stakes exams disadvantaging students with health conditions, and the glorification of struggle across disciplines. Students also highlighted the disconnect between wellbeing messaging and impossible workloads, articulating a desire for intellectually challenging environments that don’t lead to burnout – as well as both personal and systems empathy.

Their solutions included workload mapping, identifying assessment bottlenecks, flexible assessment strategies offering multiple ways to demonstrate learning, staff training on setting healthy work boundaries, health impact assessments for curriculum design, accessibility-focused policies, clear distinctions between challenging content and unnecessary stress, student workload panels with authority to flag unsustainable demands, and revised attendance policies to discourage presenteeism during illness. They are all worth considering – as are projects like the one referenced here.

Mental health, neurodiversity and support services

Nearly half (47 per cent) of reports identified mental health difficulties as a factor prior to the incident, with 31 per cent noting diagnosed mental health conditions. Most commonly, these were depression and anxiety disorders (20 per cent).

Significantly, 30 per cent of reports described a diagnosis or suspected diagnosis of neurodiversity, including attention deficit hyperactivity disorder (ADHD), autism spectrum disorder, or dyslexia. Of these neurodivergent students, only 14 described reasonable adjustments or support/inclusion plans tailored to their needs, and 12 per cent also had a mental health diagnosis. That suggests big gaps in support for students with overlapping mental health and neurodevelopmental needs.

Especially concerning is that 70 per cent of students were known to university support services before their death, most often wellbeing services. These weren’t cases where students were suffering in silence – they had actively reached out for help within the university system. In many cases, students had multiple touchpoints with support services, but there were often gaps in follow-up, inadequate assessment of risk severity, and insufficient intensity or continuity of support.

It’s partly the silo problem again. The report identified plenty of problems with information sharing in 24 per cent of cases, where critical details about a student’s mental health were not communicated between clinical, pastoral, and academic staff. Communication breakdowns meant that while a student might disclose suicidal thoughts to a counselor, personal/academic tutors remained unaware of the severity of their situation, continuing to apply normal academic pressures.

Similarly, when academic staff noticed concerning changes in attendance or performance, this information wasn’t consistently shared with mental health professionals who could have intervened.

The review specifically recommends improving information sharing internally and externally but notes that (often unfounded) concerns about confidentiality prevent effective coordination – leaving vulnerable students to navigate fragmented support systems and tell their story repeatedly to different university staff. What I’d note is that recommendations and guidance on this have been around for years now – universities clearly need to go further, and faster.

And the realities of the funding system, the state of the sector’s finances and the resultant staff-student ratios in plenty of departments also need an honest conversation. If it’s noticing that matters, other students also need to be in the mix as well as academic staff.

Location and transition

Where location was known, 23 per cent of incidents occurred in university-managed accommodation – suggesting serious safety concerns in spaces directly controlled by institutions. The review specifically recommends reviewing the safety of university-managed accommodation, including physical safety, high-risk locations, the criteria for welfare checks, and signposting for support, particularly out-of-hours.

I’d suggest that that should probably reflect, via the codes of practice the firms will be required to join to escape the regulation in the Renter’s Rights Act, standards in private halls too – although that would, of course require a modicum of coordination between DfE and the Ministry of Housing, Communities and Local Government.

Almost three-quarters (73 per cent) of students were undergraduates, with over a quarter (27 per cent) in their first year of undergraduate studies, backing up previous research that has indicated that the first year represents a particularly vulnerable transition period – often leaving home, managing independent living, forming new relationships, and adapting to university-level academic demands.

The review suggests these changes create a perfect storm of risk factors – first-year students often lack established campus support networks while losing daily contact with home support systems, may struggle with imposter syndrome or academic uncertainty, and frequently hesitate to seek help, believing their struggles are just “normal” adjustment issues.

The problem is then compounded by institutional factors – with no prior academic record to contextualise changes in engagement and larger first-year class sizes, warning signs frequently go unnoticed by staff. The review specifically calls for enhanced induction processes and early intervention systems for first-years, recognising that proactive support during this critical transition period could significantly reduce suicide risk.

I remain convinced that near-universal systems of group social mentoring found on the continent could have a major role to play here – they’re even in the legislation in Finland – but I also wonder whether the other notable OECD comparison, that (together with Belgium) we have pretty much the youngest bachelor’s entrants in the world, could also do with some significant thought.

DfE has, of course, had a previous run at coordinating a national piece of work on transition support and standards – but the less said about that the better. We almost certainly need something more consistent, substantial and credit-bearing – I sketched out what that could look like here.

International students

International students accounted for nearly a quarter (24 per cent) of all submitted reports – a disproportionately high percentage given their representation in the overall student population. The overrepresentation could suggest additional challenges, including potential cultural and language barriers, social isolation, and distance from established support networks.

In many ways, they face much of what home students face, with unfamiliar academic and cultural expectations, (often) studying in a second language, managing complex visa requirements, and coping with significant financial pressures due to higher fees and limited work rights piled on top. Many also experience intense pressure to succeed from family members who may have made substantial sacrifices to fund their education.

The review found that cultural differences significantly impacted how international students experienced and expressed mental health difficulties. In some cases, cultural stigma around mental illness prevented students from seeking help, while in others, language barriers made it difficult to effectively communicate distress to university staff. The report also noted particular difficulties with international students who were isolated within their own cultural groups, making it harder for wider university systems to identify warning signs.

Despite the overrepresentation of international students in suicide cases, the review found minimal evidence of culturally sensitive support services or targeted outreach. Many just applied a one-size-fits-all approach to wellbeing support that failed to account for diverse cultural understandings of mental health.

The review specifically recommends that universities develop more culturally competent services and proactive engagement strategies for international students – particularly those from countries with significant cultural differences from the UK.

There’s a reason why new Office for Students Condition E6 on harassment and sexual misconduct specifically requires approaches that are tailored to a provider’s specific student population, and that systems and processes to help prevent and respond to harassment and sexual misconduct are accessible to international students. It’s true on this issue too.

Investigation quality and university response

Following a death by suicide, the review found significant gaps in postvention support – the care provided to those affected. While 41 per cent of reports showed evidence of support for peers following a suicide, there was significantly less support for affected staff (18 per cent) and bereaved families (9 per cent).

The review recommends that anyone affected by a student’s death by suicide should be offered or signposted to appropriate support – acknowledging that effective postvention is itself a critical component of preventing further deaths.

The review then found wide variation in how universities investigate student deaths and respond to them. In three-quarters (76 per cent) of all reviewed cases, families were not involved in any aspect of the suicide investigation process. While 72 per cent of reports indicated that the family was contacted after the death to offer condolences, only 11 per cent of families contributed to or were offered involvement in the investigation process. And just 6 per cent of reports had been shared with the families.

As the report notes, families provided:

…moving accounts of feeling excluded from the process of finding out what happened to their loved ones, and some had a perception that the university was evasive and reluctant to answer important and painful questions.

The exclusion of those who knew the student best not only denies families closure but also prevents universities from gaining valuable insights about circumstances outside the institution.

It also raised significant questions about who conducts these investigations and their qualifications to do so. In 35 per cent of reports, information on the lead reviewer was not available. Only 13 per cent explicitly stated that the lead reviewer had no prior involvement with the student – a fundamental principle of independent investigation.

There was also little evidence that those conducting the reviews had specific training or expertise in suicide prevention or investigation. As the report notes:

…completing a serious incident review is an additional strategic-level responsibility, with no status of its own within someone’s job role.

Most reviews focused narrowly on the university’s own processes and records, rarely seeking information from external sources. Despite 60 per cent of reports indicating the student had contact with other agencies (such as healthcare providers), only 6 per cent of these included contributions from those organizations in the review process.

The gathering of information “did not generally extend to records and contributions from other agencies” such as primary care, secondary mental health care, and the criminal justice system. This was true even where the university was aware that those agencies had played a critical role in the student’s care. This inward-looking approach created significant knowledge gaps that could have been filled with input from families, health providers, and other external sources.

The report also notes that there were examples of gaps in the chronology with little or no information between the student’s last contact with the HE provider and the incident. Without a comprehensive understanding of the student’s circumstances, universities can’t effectively identify all factors contributing to suicide risk.

This won’t come as a surprise to anyone working in HE, but while 79 per cent of reports identified learning to help prevent future incidents (generating almost 300 recommendations in total), the implementation process was often weak. Over half (53 per cent) identified specific actions, but 18 per cent of these lacked clear owners and 40 per cent had no timescales for delivery.

That raises questions about whether these recommendations are ever fully implemented or simply filed away. Learning points were “inconsistently assigned or scheduled,” with a lack of institutional commitment to following through on identified improvements. Without accountability mechanisms and clear follow-up processes, there’s little assurance that these recommendations will lead to meaningful change.

Learning from tragedy

The review makes 19 specific recommendations across four categories – safety concerns, suicide prevention within university systems, amendments to guidance, and wider system messages. They are comprehensive – but they largely represent guidance rather than enforceable standards.

The first recommendation, for example, calls for “mental health awareness and suicide prevention training” to be available for all student-facing staff, with consideration for making such training mandatory – acknowledging the critical role staff play in identifying and responding to students in distress.

But the report stops short of recommending that training be required – using the softer language of “consideration” for mandatory training. It’s a recommendation I’ve read hundreds of times over the years, and in the financial and redundancies state the sector is in, it would be hard to believe that it’s going to happen without a requirement that it does.

That’ll be why OfS is now requiring it in E6 for harassment and sexual misconduct, and why that includes a line on “no saying you can’t afford it – if you can’t afford it, don’t provide HE”. Something similar should surely apply here.

Meanwhile recommendations 3 and 4 address academic pressures, calling for students struggling academically to be “recognised as potentially at risk” and for increased support at key academic calendar points. They are a shift toward viewing academic processes not just as educational tools but as potential risk factors for mental health – a perspective that aligns with campaigners’ arguments for a duty of care that encompasses the whole student experience.

Although as I said above, some system-structural issues relating to age and pace ought be on the list inside DfE’s reform plans for proper consideration.

While it stops short of recommending a duty of care, it does call for “a duty of candour” to be introduced to the HE sector, setting out organisational responsibilities to be open and transparent with families after a suspected suicide. That would include a duty to provide information on what happened, at the earliest point.

As it stands, Keir Starmer promised that such a duty, to apply to public authorities including universities, would appear by 15 April – the anniversary of the Hillsborough disaster. But it’s a deadline that was missed – with rumours that officials have been attempting to water it down and questions over whether it would apply in internal investigations as well as statutory inquiries. A decision will need to come soon.

Mark Shanahan, on behalf of the LEARN Network, argues that universities are learning communities, but it is unclear from the research whether the learning leads to change. If nothing else, they’re supporting the idea that the exercise becomes annual:

In some ways, it’s a vindication to see the concerns of bereaved families confirmed, when many feel so excluded when they try to find out what happened to their sons and daughters. Without families’ strength and persistence this report would not have been commissioned. We need to see it repeated annually if lessons are to be learned over the longer term.

Given that so few University Mental Health Charter Awards have been achieved (just two in 2025), the network also argues that a legal duty of care by universities towards students, delivered by statute and/or regulation is the only way to accelerate the changes advocated in this report.

Duty of care?

The review comes, of course, amid ongoing confusion about what a “duty of care” would actually mean in a university context. The current government position, articulated by DfE minister Janet Daby, is that “a duty of care in HE may arise in certain circumstances” which “would be a matter for the courts to decide.”

It’s a vague position that contrasts sharply with the certainty provided in other contexts – like as the duty of care employers owe to their employees or that schools owe to their pupils – and means students enter university without clarity on what protections they can expect, while universities operate without clear standards for their responsibilities.

As Bob Abrahart argues:

…students and universities need instead to know where they stand.

The review signals pretty clearly that the ambiguity has real consequences – inconsistent practices, missed warning signs, and preventable tragedies. Valuable recommendations will mean nothing if their implementation remains voluntary without a statutory framework.

And as I’ve argued before on the site, when students have rights and know their rights, they’re better able to contribute to decent conversations about how they might be implemented practically. The rest is all “in an ideal world”, and we’re very much not in an ideal world right now.

A more comprehensive statutory duty of care would establish clear standards for prevention, requiring universities to take reasonable steps to avoid foreseeable harm. It would not, as opponents suggest, treat students as children or make universities responsible for all aspects of student wellbeing. It would provide clarity on the reasonable expectations students can have of their institutions, and ensure consistency across the sector.

The review has shown where the problems lie – now ministerial courage is needed to implement solutions that are universally applied. The 107 students whose deaths formed the basis of this review deserved better. Future students deserve the protection of clear, enforceable standards that their staff get.