Daniel Hall
PFD Report
All Responded
Ref: 2021-0381
Mental Health related deaths
Suicide (from 2015)
Wales prevention of future deaths reports (2019 onwards)
All 1 response received
· Deadline: 10 Jan 2022
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
10 Jan 2022
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
Lengthy delays for students at the University of South Wales to access mental health support services even when suicidal ideation has been expressed on more than one occasion and when risk factors (ASD) are known.
Responses
Response received
View full response
Dear Madam Response of the University of South Wales to Regulation 28 Report to Prevent Future Deaths We write with reference to your Regulation 28 Report to Prevent Future Deaths ("the Regulation 28 Report") of 12 November 2021 following the inquest into the death of Mr Daniel Hall on 9 December 2019. On behalf of the University of South Wales ("the University"), I want to express our deepest condolences to Daniel's family. At the outset of this Response, may we assure HM Coroner and the family that the matters set out herein have been carefully and thoroughly considered at every level within the University including our Executive which, we trust, reflects the serious commitment of the University to place student wellbeing at the heart of everything we do. Further, as part of our ongoing commitment to continuous enhancement of our provision, we will be commissioning a specialist independent external review of policies, procedures and interventions around wellbeing, health and safeguarding to ensure that our service continues to provide the very best support for our stakeholders. The Terms of Reference for the review will include benchmarking how we operate against best practice across the Higher Education sector and will inform future enhancements to the established service the University provides. We set out below the University's Response to the recommended actions of HM Coroner as set out in the Regulation 28 Report. Swyddfa'r ls-Ganghellor Office of the Vice-Chancellor Pontypridd, Cymru, CF37 SUP Pontypridd, Cymru, CF37 SUP
G decymru.ac.uk W southwales.ac.uk Mae Prifysgol De Cymru yn elusen gofrestredig. Rhif yr elusen 1140312. IThe University of South Wales is aregistered charity. Registration No. 1140312.
University of South Wales Prifysgol De Cymru ACTION 1: Provide a rapid response counselling/support service when being made aware of an expression of suicide by a vulnerable student. The University continually develops our service provisions. We have enhanced the two routes to students receiving support from the Wellbeing and Disability Service, student self-referral and staff referral. Student self-referral Since the 2019 Autumn term, the University has introduced new specialist Wellbeing practitioner roles to our existing Wellbeing services and increased the overall number of staff in the team by 37%, which has significantly reduced waiting time for students. Wellbeing Advice and Specialist Provision appointments are monitored weekly by the Service Manager, who may increase or alter provision to meet student need. USW processes, which enable rapid response specialist Wellbeing services, have been enhanced since March 2020. Direct and early conversation with a Wellbeing practitioner is facilitated by Student Wellbeing appointments which are booked online. During the Wellbeing Advice Appointment, the trained Wellbeing practitioners, together with the student, assess need and risk there and then, agreeing and initiating a plan of action. Any expression of suicide will be referred rapidly, if the assessment of individual need and risk by the Wellbeing practitioner identifies a need for access to specialist support. Referrals may be made internally and/or to a GP or other Secondary Care mental health services. The existing availability of internal specialist support including Counsellors, Mental Health Advisers and Nurse Advisers has been adapted to ensure we have daily availability reserved for urgent referrals following Wellbeing Advice Appointments. We are piloting a service for students in mental health crisis for direct referral to local Primary and Secondary mental health services. In Autumn 2021, the South East Wales Mental Health Partnership1, established this pilot for enhanced collaboration between university support services and local mental health services in cases where students are presenting as particularly high risk or significantly unwell. The pilot will introduce a new 'University Liaison Service' ("ULS") hosted by Primary Care in the NHS, but based within the participating universities, to support the student needs between the universities, GPs and NHS Mental Health Services. The University is applying lessons learnt through this pilot to its operating principles with other Local Health Board partners. 1 The Partnership consists of Cardiff University, Cardiff Metropolitan University, the University of South Wales, Royal Welsh College of Music and Drama and Cardiff and Vale University Health Board. Swyddfa'r ls-Ganghellor Office of the Vice-Chancellor Pontypridd, Cymru, CF37 SUP Pontypridd, Cymru, CF37 SUP
G decymru.ac.uk W southwales.ac.uk Mae Prifysgol De Cymru yn elusen gofrestredig. Rhif yr elusen 1140312. IThe University of South Wales is aregistered charity. Registration No. 1140312.
University of South Wales Prifysgol De Cymru Staff referring students for support Where University staff have a concern about a student, they can phone the Advice Zone2 or email details of a student to the Wellbeing Service dedicated mailbox where trained Mental Health First Aiders will be able to assist. Specialist Wellbeing Practitioners provide daily duty cover and on receiving a concern, they will provide a same day response to the member of staff and make contact with the student. Chaplaincy3 services are also available and can be contacted , working closely with the student services team and external partners, supporting vulnerable students and staff, including referrals to specialist Wellbeing services where appropriate. Information on how to refer students to Wellbeing support is made available to all staff across the University via the staff portal. This information covers what to do in circumstances of an emergency mental health situation - referral to emergency services, and if there is a cause for concern. In addition, specific resources and training are provided to University staff undertaking particular roles, for example, Personal Academic Coaches who provide students with support through a series of rich conversations regarding their overall academic and professional progress on their course. Course teams monitor student engagement with academic learning and if there are concerns surrounding a students' engagement and/or vulnerability, they will refer to the Wellbeing Service, as above. During the 2020-21 academic year, the University introduced a pilot system to monitor student engagement with digital learning resources. This provides clear information to course teams enabling early identification of students who are not interacting to the required level and may be vulnerable. To date, this has been rolled out to 100 courses across the University. ACTION 2: Antidepressant prescription should not be seen as the resolution to suicidal ideation. Pharmaceutical efficacy may take some time to develop and drug titration may be required. Throughout this time an individual may still be vulnerable to suicidal planning and plan execution. Prescriptions and pharmaceutical remedies are not provided within University services. However, we recognise the benefits of tailoring our services to complement external 2 Advice Zone is a contact service for all student enquiries, providing confidential advice on anything that affects a student's ability to study. It works with USW's range of other services to ensure students receive the overall support they need. 3 The Chaplaincy is an open and inclusive service for the whole university community. It offers confidential and non-judgmental support to staff and students. Swyddfa'r ls-Ganghellor Office of the Vice-Chancellor Pontypridd, Cymru, CF37 SUP Pontypridd, Cymru, CF37 SUP
G decymru.ac.uk W southwa les.ac.uk Mae Prifysgol De Cymru yn elusen gofrestredig. Rhif yr elusen 1140312. IThe University of South Wales is aregistered charity. Registration No. 1140312.
University of South Wales Prifysgol De Cymru services. We have therefore focused on improving our current engagement with external services, allowing our Wellbeing services to act on up-to-date circumstances. The University has extensive liaison with three Health Boards within whose areas our campuses are located. As outlined above, the University is engaged in a project with the NHS to provide additional resource to complement existing provision. Other examples of collaboration with external services includes the University's long running partnership with a GP practice to deliver services to students on campus at Treforest. In 2022, we will be reviewing the communication links and expectations of this relationship, drawing on the learning and standardised measures of mental health severity from the Health Board collaboration. The aim will be to include a requirement for primary care services to inform (with individual consent) University support services of interventions in order that University supplementary support can be synchronized. ACTION 3: Information was provided by - Director of Student Services, at Inquest who explained the University had, in response to Daniel's death, recruited more Mental Health Advisers and had successfully reduced waiting times for support. Nevertheless, I remained concerned that support needed to be more proactively delivered whilst forms requesting support were being processed, especially as during this time Daniel was not attending his course and his well-being was neither being systematically monitored nor checked i.e. someone undertaking a home visit to ensure he was safe. HM Coroner will be aware through our previous statements that Daniel was regularly engaging with the Course Leader and Chaplaincy services while he was not attending his course. Through a series of meetings and correspondence during October and November 2019 we had agreed a plan with him for adjusting the course to enable continuation of his studies. In addition to the enhancements identified under Action 1, the University has committed to adopting a 'whole University' approach to wellbeing using the Universities UK Stepchange framework to integrate services across the University. This framework incorporates all aspects of wellbeing, including mental, physical, social, and financial well being. To manage the enhancement of our Wellbeing services, the University has created a Wellbeing, Health and Safeguarding project under the governance of our Equality and Diversity Steering Group with Executive level sponsorship and oversight. The Wellbeing, Health and Safeguarding projects strands incorporate:
1. To enhance our current Wellbeing services and ensure greater connectivity between them we are completing a review of policies, practices and interventions, Swyddfa'r ls-Ganghellor Office of the Vice-Chancellor Pontypridd, Cymru, CF37 SUP Pontypridd, Cymru, CF37 SUP
G decymru.ac.uk W southwales.ac.uk Mae Prifysgol De Cymru yn elusen gofrestredig. Rhif yr elusen 1140312. IThe University of South Wales is aregistered charity. Registration No. 1140312.
University of South Wales Prifysgol De Cymru synchronizing wellbeing and safeguarding within a 'whole university' approach, considering the need for proactive support for students and mechanisms for systematically monitoring student and staff wellbeing.
2. In August 2021 we committed to adopt the University suicide safer and self-harm strategy in accordance with guidance from Universities UK. A task group has been set up under this project to oversee the implementation and ensure compliance.
3. Since October 2021, to build on our existing Wellbeing provision, we have been working to help students and staff better understand the range of support services and resources the University has available using a range of communication channels. We will continue the development and co-creation (with students and professionals) of those wellbeing, health and safeguarding resources.
4. From September 2021 we improved and extended our existing programme of training and development for students and staff, including safeguarding, ASIST, mental health first aid and other bespoke sessions through physical delivery sessions and digital platforms. The University recognises it is not a first response organisation nor is it a primary care agency and should not be expected to provide emergency or clinical services nor domiciliary visits. Those services are provided by GP, NHS and other public services. Our services, as outlined above, have been devised to ensure the University can take action when we are made aware of suicidal and other high-risk intentions. This includes referring the matter to external clinical and specialist services best qualified to support the student. We trust that this Response provides assurance that action has already, and new actions continue to be, taken with oversight from the University Executive to address the matters raised by HM Coroner. We are committed to continuously improve our services.
G decymru.ac.uk W southwales.ac.uk Mae Prifysgol De Cymru yn elusen gofrestredig. Rhif yr elusen 1140312. IThe University of South Wales is aregistered charity. Registration No. 1140312.
University of South Wales Prifysgol De Cymru ACTION 1: Provide a rapid response counselling/support service when being made aware of an expression of suicide by a vulnerable student. The University continually develops our service provisions. We have enhanced the two routes to students receiving support from the Wellbeing and Disability Service, student self-referral and staff referral. Student self-referral Since the 2019 Autumn term, the University has introduced new specialist Wellbeing practitioner roles to our existing Wellbeing services and increased the overall number of staff in the team by 37%, which has significantly reduced waiting time for students. Wellbeing Advice and Specialist Provision appointments are monitored weekly by the Service Manager, who may increase or alter provision to meet student need. USW processes, which enable rapid response specialist Wellbeing services, have been enhanced since March 2020. Direct and early conversation with a Wellbeing practitioner is facilitated by Student Wellbeing appointments which are booked online. During the Wellbeing Advice Appointment, the trained Wellbeing practitioners, together with the student, assess need and risk there and then, agreeing and initiating a plan of action. Any expression of suicide will be referred rapidly, if the assessment of individual need and risk by the Wellbeing practitioner identifies a need for access to specialist support. Referrals may be made internally and/or to a GP or other Secondary Care mental health services. The existing availability of internal specialist support including Counsellors, Mental Health Advisers and Nurse Advisers has been adapted to ensure we have daily availability reserved for urgent referrals following Wellbeing Advice Appointments. We are piloting a service for students in mental health crisis for direct referral to local Primary and Secondary mental health services. In Autumn 2021, the South East Wales Mental Health Partnership1, established this pilot for enhanced collaboration between university support services and local mental health services in cases where students are presenting as particularly high risk or significantly unwell. The pilot will introduce a new 'University Liaison Service' ("ULS") hosted by Primary Care in the NHS, but based within the participating universities, to support the student needs between the universities, GPs and NHS Mental Health Services. The University is applying lessons learnt through this pilot to its operating principles with other Local Health Board partners. 1 The Partnership consists of Cardiff University, Cardiff Metropolitan University, the University of South Wales, Royal Welsh College of Music and Drama and Cardiff and Vale University Health Board. Swyddfa'r ls-Ganghellor Office of the Vice-Chancellor Pontypridd, Cymru, CF37 SUP Pontypridd, Cymru, CF37 SUP
G decymru.ac.uk W southwales.ac.uk Mae Prifysgol De Cymru yn elusen gofrestredig. Rhif yr elusen 1140312. IThe University of South Wales is aregistered charity. Registration No. 1140312.
University of South Wales Prifysgol De Cymru Staff referring students for support Where University staff have a concern about a student, they can phone the Advice Zone2 or email details of a student to the Wellbeing Service dedicated mailbox where trained Mental Health First Aiders will be able to assist. Specialist Wellbeing Practitioners provide daily duty cover and on receiving a concern, they will provide a same day response to the member of staff and make contact with the student. Chaplaincy3 services are also available and can be contacted , working closely with the student services team and external partners, supporting vulnerable students and staff, including referrals to specialist Wellbeing services where appropriate. Information on how to refer students to Wellbeing support is made available to all staff across the University via the staff portal. This information covers what to do in circumstances of an emergency mental health situation - referral to emergency services, and if there is a cause for concern. In addition, specific resources and training are provided to University staff undertaking particular roles, for example, Personal Academic Coaches who provide students with support through a series of rich conversations regarding their overall academic and professional progress on their course. Course teams monitor student engagement with academic learning and if there are concerns surrounding a students' engagement and/or vulnerability, they will refer to the Wellbeing Service, as above. During the 2020-21 academic year, the University introduced a pilot system to monitor student engagement with digital learning resources. This provides clear information to course teams enabling early identification of students who are not interacting to the required level and may be vulnerable. To date, this has been rolled out to 100 courses across the University. ACTION 2: Antidepressant prescription should not be seen as the resolution to suicidal ideation. Pharmaceutical efficacy may take some time to develop and drug titration may be required. Throughout this time an individual may still be vulnerable to suicidal planning and plan execution. Prescriptions and pharmaceutical remedies are not provided within University services. However, we recognise the benefits of tailoring our services to complement external 2 Advice Zone is a contact service for all student enquiries, providing confidential advice on anything that affects a student's ability to study. It works with USW's range of other services to ensure students receive the overall support they need. 3 The Chaplaincy is an open and inclusive service for the whole university community. It offers confidential and non-judgmental support to staff and students. Swyddfa'r ls-Ganghellor Office of the Vice-Chancellor Pontypridd, Cymru, CF37 SUP Pontypridd, Cymru, CF37 SUP
G decymru.ac.uk W southwa les.ac.uk Mae Prifysgol De Cymru yn elusen gofrestredig. Rhif yr elusen 1140312. IThe University of South Wales is aregistered charity. Registration No. 1140312.
University of South Wales Prifysgol De Cymru services. We have therefore focused on improving our current engagement with external services, allowing our Wellbeing services to act on up-to-date circumstances. The University has extensive liaison with three Health Boards within whose areas our campuses are located. As outlined above, the University is engaged in a project with the NHS to provide additional resource to complement existing provision. Other examples of collaboration with external services includes the University's long running partnership with a GP practice to deliver services to students on campus at Treforest. In 2022, we will be reviewing the communication links and expectations of this relationship, drawing on the learning and standardised measures of mental health severity from the Health Board collaboration. The aim will be to include a requirement for primary care services to inform (with individual consent) University support services of interventions in order that University supplementary support can be synchronized. ACTION 3: Information was provided by - Director of Student Services, at Inquest who explained the University had, in response to Daniel's death, recruited more Mental Health Advisers and had successfully reduced waiting times for support. Nevertheless, I remained concerned that support needed to be more proactively delivered whilst forms requesting support were being processed, especially as during this time Daniel was not attending his course and his well-being was neither being systematically monitored nor checked i.e. someone undertaking a home visit to ensure he was safe. HM Coroner will be aware through our previous statements that Daniel was regularly engaging with the Course Leader and Chaplaincy services while he was not attending his course. Through a series of meetings and correspondence during October and November 2019 we had agreed a plan with him for adjusting the course to enable continuation of his studies. In addition to the enhancements identified under Action 1, the University has committed to adopting a 'whole University' approach to wellbeing using the Universities UK Stepchange framework to integrate services across the University. This framework incorporates all aspects of wellbeing, including mental, physical, social, and financial well being. To manage the enhancement of our Wellbeing services, the University has created a Wellbeing, Health and Safeguarding project under the governance of our Equality and Diversity Steering Group with Executive level sponsorship and oversight. The Wellbeing, Health and Safeguarding projects strands incorporate:
1. To enhance our current Wellbeing services and ensure greater connectivity between them we are completing a review of policies, practices and interventions, Swyddfa'r ls-Ganghellor Office of the Vice-Chancellor Pontypridd, Cymru, CF37 SUP Pontypridd, Cymru, CF37 SUP
G decymru.ac.uk W southwales.ac.uk Mae Prifysgol De Cymru yn elusen gofrestredig. Rhif yr elusen 1140312. IThe University of South Wales is aregistered charity. Registration No. 1140312.
University of South Wales Prifysgol De Cymru synchronizing wellbeing and safeguarding within a 'whole university' approach, considering the need for proactive support for students and mechanisms for systematically monitoring student and staff wellbeing.
2. In August 2021 we committed to adopt the University suicide safer and self-harm strategy in accordance with guidance from Universities UK. A task group has been set up under this project to oversee the implementation and ensure compliance.
3. Since October 2021, to build on our existing Wellbeing provision, we have been working to help students and staff better understand the range of support services and resources the University has available using a range of communication channels. We will continue the development and co-creation (with students and professionals) of those wellbeing, health and safeguarding resources.
4. From September 2021 we improved and extended our existing programme of training and development for students and staff, including safeguarding, ASIST, mental health first aid and other bespoke sessions through physical delivery sessions and digital platforms. The University recognises it is not a first response organisation nor is it a primary care agency and should not be expected to provide emergency or clinical services nor domiciliary visits. Those services are provided by GP, NHS and other public services. Our services, as outlined above, have been devised to ensure the University can take action when we are made aware of suicidal and other high-risk intentions. This includes referring the matter to external clinical and specialist services best qualified to support the student. We trust that this Response provides assurance that action has already, and new actions continue to be, taken with oversight from the University Executive to address the matters raised by HM Coroner. We are committed to continuously improve our services.
Action Should Be Taken
• Provide a rapid response counselling/support service when being made aware of an expression of suicide by a vulnerable student.
• Antidepressant prescription should not be seen as the res olution to suicidal ideation. Pharmaceutical efficacy may take some time to develop and drug titration may be required. Throughout this time an individual may still be vulnerable to suicidal planning and plan execution.
• Information was provided by , Director of Student Services, at Inquest who explained the University had, in response to Daniel’s death, recruited more Mental Health Advisers and had successfully reduced waiting times for support. Nevertheless, I remained concerned that support needed to be more proactively delivered whilst forms requesting support were being processed, especially as during this time Daniel was not attending his course and his well-being was neither being systematically monitored nor checked i.e. someone undertaking a home visit to ensure he was safe.
• Antidepressant prescription should not be seen as the res olution to suicidal ideation. Pharmaceutical efficacy may take some time to develop and drug titration may be required. Throughout this time an individual may still be vulnerable to suicidal planning and plan execution.
• Information was provided by , Director of Student Services, at Inquest who explained the University had, in response to Daniel’s death, recruited more Mental Health Advisers and had successfully reduced waiting times for support. Nevertheless, I remained concerned that support needed to be more proactively delivered whilst forms requesting support were being processed, especially as during this time Daniel was not attending his course and his well-being was neither being systematically monitored nor checked i.e. someone undertaking a home visit to ensure he was safe.
Report Sections
Investigation and Inquest
On 16 December 2019, I commenced an investigation into the death of Daniel HALL. The investigation concluded at Inquest on 2 November 2021. The medical cause of death provided by pathologist, Dr. , Royal Glamorgan Hospital was: and
The Coroner’s short-form conclusion was that of “suicide”. The family’s concern at inquest related to the University’s long waiting list for Mental Health Adviser support; a failure to expedite Daniel for mental health support knowing that he had expressed suicidal ideation and suffered ASD; and the lack of safeguarding by the University.
The Coroner’s short-form conclusion was that of “suicide”. The family’s concern at inquest related to the University’s long waiting list for Mental Health Adviser support; a failure to expedite Daniel for mental health support knowing that he had expressed suicidal ideation and suffered ASD; and the lack of safeguarding by the University.
Circumstances of the Death
These were recorded as :- Daniel Hall 20 years was a 2nd year student at the University of South Wales studying a BSc in Computer Gamer Development. He suffered from Autistic Spectrum Disorder (previously k/a Asperger’s Syndrome) and had successfully completed his 1st year studies. Fellow student, was his good friend and with whom he shared accommodation. Together they had travelled throughout Europe. He was aware of Daniel’s depression and kept a watchful eye over him. Upon commencing his 2nd year, Daniel had made enquiries about benefiting from the Disabled Student Allowance (DSA) and his application was being progressed by the University. On 29 September 2019 and 23 October 2019 Daniel had face to face meetings with Nurse Adviser, as a part of his DSA Needs Assessment. On both occasions he expressed suicidal thoughts.
signposted Daniel to the ‘Request for Support’ form and the Samaritans. Following completion of these forms Daniel received confirmation on 17 and 22 October 2019 that his name had been placed on a waiting list to see a Mental Health Adviser. Due to ill-health and absences of the University’s three Mental Health Advisers, there were ~200 students awaiting mental health support. Daniel was 16th on the waiting list to be seen.
Daniel was prescribed antidepressant medication by his GP on 30 October 2019 but failed to attend his follow-up appointment on 27 November 2019. , noting this failed appointment arranged for Daniel to be seen by the GP on 29 November 2019 and again on 11 December 2019. His antidepressant was providing little ‘mood elevating’ cover.
On 15 November 2019 a referral was made for Specialist Mentor support and was allocated to support Daniel on 21 November 2019 and she introduced herself to him at a meeting on 3 December 2019. There is no attendance note of this meeting or arrangements made for further contact.
On 18th November 2019, Daniel purchased a . In spite of continued support from his sister and friends, Daniel
9 December 2019 at his student accommodation. During the 7-week period between expressing suicidal thoughts to Nurse Adviser, and completing his suicide plan, Daniel had contact with a number of University administrative, teaching, nursing and medical staff yet he lacked receipt of any meaningful mental health support or any ‘one to one’ safeguarding.
signposted Daniel to the ‘Request for Support’ form and the Samaritans. Following completion of these forms Daniel received confirmation on 17 and 22 October 2019 that his name had been placed on a waiting list to see a Mental Health Adviser. Due to ill-health and absences of the University’s three Mental Health Advisers, there were ~200 students awaiting mental health support. Daniel was 16th on the waiting list to be seen.
Daniel was prescribed antidepressant medication by his GP on 30 October 2019 but failed to attend his follow-up appointment on 27 November 2019. , noting this failed appointment arranged for Daniel to be seen by the GP on 29 November 2019 and again on 11 December 2019. His antidepressant was providing little ‘mood elevating’ cover.
On 15 November 2019 a referral was made for Specialist Mentor support and was allocated to support Daniel on 21 November 2019 and she introduced herself to him at a meeting on 3 December 2019. There is no attendance note of this meeting or arrangements made for further contact.
On 18th November 2019, Daniel purchased a . In spite of continued support from his sister and friends, Daniel
9 December 2019 at his student accommodation. During the 7-week period between expressing suicidal thoughts to Nurse Adviser, and completing his suicide plan, Daniel had contact with a number of University administrative, teaching, nursing and medical staff yet he lacked receipt of any meaningful mental health support or any ‘one to one’ safeguarding.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.