What have coroner’s reports said about student suicide?

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Many of the issues reflect those highlighted in Student Minds’ Learning from the University Mental Health Charter: An analysis of Outcomes Reports – the key difference being that in this case, we can trace a line between some of the failings identified and the death of a student.

But it’s not the only source of national, qualitative data.

The UK coroner system, governed by the Coroners and Justice Act 2009, requires inquests to determine who died and where, when, and how the death occurred – without addressing why, particularly in suicide cases.

But when potential systemic risks emerge during inquests, coroners are required to issue Reports to Prevent Future Deaths (PFDs), which require recipient organizations to respond within 56 days with planned preventative actions. The reports and responses are typically published on the Judiciary website.

For university student deaths, inquests are often brief and procedural, with coroners unlikely to identify broader concerns unless specifically prompted by family questions or presented evidence.

That places the emotional and investigative burden on grieving families to highlight institutional failings, making it difficult to prevent similar tragedies across institutions and creating an urgent need for reform in how systemic risks are identified and addressed in the inquest process.

As such, there’s a strong argument for centralising and tracking coroner recommendations in higher education, given that there’s no oversight body currently ensuring implementation of actions from Reports to Prevent Future Deaths.

It’s a gap is particularly concerning for suicide prevention, where institutional responsibility remains ambiguous and scrutiny is limited compared to healthcare providers.

And while the reports are publicly available on the Judiciary website, they’re categorised by cause of death rather than student status, making pattern identification difficult.

Collecting the reports in one location would reveal recurring themes and systemic issues, and enable both universities and policymakers to make proactive, informed decisions to prevent tragedies and hold institutions accountable for student safety and wellbeing.

To assist with that process the For The 100 group – which is advocating for improved student safety at universities and whose name references the approximately 100 students who die by suicide each year – has compiled 30 PFDs related to student suicides, with the earliest report issued in 2015.

The collection only includes cases where the inquest has concluded and the coroner deemed further action necessary to prevent future deaths – and actions are not limited to higher education institutions, and may also involve other agencies such as accommodation providers, healthcare services, or government departments.

The group hasn’t analysed them, and nor have we in any great detail – but I have identified several recurring themes in the reports that deserve attention.

Breakdown in communication and follow-up

Throughout the collection, coroners pointed to universities’ failure to act when a student went quiet. Whether it was a string of missed lectures, unanswered emails, or failure to submit coursework, many institutions saw disengagement as the student’s problem rather than a potential warning sign.

There were no systematic flags, and often no one took responsibility for following up – particularly when students fell between academic and support teams. In some cases, this lack of follow-up spanned months.

That theme is strongly echoed in the national review of student suicides, which found that one-third of reports identified academic non-attendance, with most responses limited to passive emails rather than proactive outreach.

Coroners commonly recommended trigger-based systems for escalation, mandatory contact after repeated disengagement, and designated responsibility for follow-up when students disappear from view.

Gaps in pastoral care and unclear responsibilities

In numerous cases, there was no individual clearly responsible for a student’s welfare – particularly among postgraduate students, international students, and those on clinical or placement-based courses.

Even where wellbeing services existed, students didn’t always know how to access them – and academic staff often assumed someone else was “handling it”. In some tragic cases, no one was.

The national review highlights a need to improve pastoral systems, particularly for students outside standard structures, with several reports specifically calling for better personal tutoring and scheduled check-ins.

Coroners often recommended universal allocation of pastoral contacts, training for staff in these roles, and clearer institutional policies for who takes ownership of wellbeing.

Delays or inadequacies in mental health referrals

Several students had expressed suicidal ideation or serious mental health distress – but were not seen in time. Coroners criticised both universities and NHS services for slow referrals, overly high thresholds for intervention, or discharge without follow-up.

Some students were referred but never contacted; others waited weeks for an appointment they never lived to attend. In more than one case, coroners found that with faster or more proactive care, the death might have been avoided.

The national review found that although 70 per cent of students were known to university support services, many did not receive timely or effective help, and poor triage was a recurring concern.

Coroners recommended clearer referral pathways, real-time coordination with NHS services, and systems that trigger welfare contact if a student misses or declines help.

Poor data recording and monitoring

Records of key contacts – academic meetings, wellbeing appointments, or disciplinary procedures – were often inconsistent, incomplete, or lost entirely. Some staff made notes on paper, others in private systems, and others not at all.

As a result, in many cases no one had a complete view of a student’s situation. In a few cases, records were not transferred when a student changed course, campus, or housing, meaning new staff were unaware of serious risks or past incidents.

This issue was mirrored in the national review, which noted failures in information systems, poor record keeping, and inconsistent monitoring of missed appointments or disengagement.

Coroners frequently called for better-integrated IT systems, centralised records accessible across departments, and mandatory documentation of student contact, especially where concerns had been raised.

Lack of escalation procedures

Universities frequently lacked any kind of clear, step-by-step pathway to escalate concern. Staff spotted signs of difficulty – missed deadlines, odd behaviour, self-harm – but didn’t know what to do with that information.

One coroner described a student “trapped in administrative inertia,” with support pending but never arriving. There was often no threshold at which multiple missed appointments or exam failures would automatically trigger a welfare response. And where procedures existed, they were often misunderstood, unused, or undermined by ambiguity over who should act.

The national review similarly highlighted failures to identify and respond to compound risk factors, particularly in support to study processes and academic-related concerns.

Coroners urged the creation of cross-institutional escalation protocols with fixed intervention points, and training to ensure all staff know how and when to raise the alarm.

Barriers to disclosure

Despite significant mental health histories, some students did not disclose their diagnoses. A number of the reports identify UCAS and institutional forms frequently positioning mental illness as a “disability” – language that many students rejected or found stigmatising.

Coroners noted that this framing led to under-disclosure, preventing staff from putting reasonable adjustments or support in place. Several students died without the university ever knowing they had been previously hospitalised or had attempted suicide.

The national review observed that 17 per cent of serious incident reports involved pre-entry disclosures, but also found evidence that support was often delayed or not implemented at all.

Coroners recommended rewording disclosure questions, reviewing how mental health declarations are handled pre- and post-enrolment, and introducing checks for gaps in adjustment plans.

Inadequate staff training

Academic and frontline staff were repeatedly found to lack the confidence or competence to identify and respond to signs of distress. In one case, a tutor failed to act after a student expressed suicidal thoughts in an email; in another, staff assumed a neurodivergent student was “just shy” rather than seriously unwell.

Training was either optional, generic, or delivered once with no refresher. Some universities had no mental health training at all for teaching staff, despite growing expectations to spot and respond to risk.

This was a major concern in the national review, which supported mandatory suicide prevention and mental health awareness training for all student-facing roles.

Coroners variously called for compulsory, role-specific training that includes recognising distress, referring students, and understanding the particular risks faced by neurodiverse students.

Isolation and social ostracism

While not present in every case, several coroners highlighted the profound role of social isolation – particularly where students had been excluded or stigmatised by peers. In one instance, a student had been the target of online abuse from fellow residents.

In another, a disciplinary process had led to social exclusion without any accompanying support. These experiences left students doubly isolated: first by their mental health, then by the absence of institutional empathy or peer connection.

The national review found that 12 per cent of reports mentioned social isolation, and supplementary evidence from families raised concerns about unaddressed social ostracism.

Coroners recommended proactive social inclusion strategies, monitoring of peer-led bullying or exclusion, and pastoral check-ins for students facing disciplinary or reputational crises.

Miscommunication of academic outcomes

For some students, the final straw came in the form of confusing, incorrect, or badly timed academic feedback. Coroners found that students were sometimes told they had failed when they had not – or were left uncertain about their status, causing enormous distress.

One report recounted a case where the student died hours after receiving an email suggesting they would be withdrawn from their course – when in fact they had already passed. Others were caught up in complex appeals processes with little support or explanation.

The national review confirmed that exam stress, deadline pressure, and perceived academic failure were key stressors in many cases, and endorsed guidance on compassionate communication.

Coroners often urged that academic outcome communications be human-checked, accompanied by clear explanations and support offers, and never automated where failure or withdrawal is concerned.

Failures in accommodation response

Where students lived in university or privately-managed halls, staff were often untrained in identifying distress or knowing when to raise the alarm. Several students were last seen alive by accommodation staff who noticed they “seemed quiet” or had stopped leaving their rooms – but no one followed up. In other cases, delays in welfare checks meant students were not found until days after death.

Coroners called for better protocols, clearer escalation routes, and proper training for residential teams, especially night staff and cleaners.

This theme was echoed in the national review, which found that 23 per cent of incidents occurred in university-managed accommodation, and recommended reviews of safety, staff training, and access to means.

Coroners typically recommended structured welfare check policies, clearer expectations for residential staff, and integration between housing teams and central wellbeing services.

As I said above, this isn’t a systemic analysis and there are a raft of other issues. It’s also the case that some of the recommendations may reflect a perception of what’s possible from a coroner rather than a higher education expert.

But in a PFD, the coroner highlights a set of circumstances with the potential to cause future deaths – if the issues are not addressed, in their expert view, the risk of similar deaths remains.

For the 100 is calling for a comprehensive and ongoing review of the reports to help identify necessary structural and institutional changes to better protect students and prevent future tragedies. It’s hard to disagree.