Dear Ms. Hamilton-Deeley I write on behalf of the University of Sussex in response to your Regulation 28 Report to prevent further deaths dated pt February 2019. This followed the conclusion of the Inquest into the circumstances of the death of Daniel Alexander Jeremiah Bowen on 21st September
2018. The Report to prevent future deaths and the concerns raised in it have been read and considered by the University of Sussex's Chair of University Council, and the Vice-Chancellor, , together with other key parties across the University. I wish to assure you the University takes its responsibilities and the well-being of students and staff extremely seriously, and we have a comprehensive suite of initiatives underway to address the concerns that you have identified. Your Report raised several concerns, each of which will be specifically addressed. Coroner's Concerns: During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: ­ (1) Academic Advisor- Better use should be made of the person in this post for each school. There was a wasted opportunity for the academic advisor to be involved in face to face meetings with Daniel and help him when he was struggling to get his work in on time and to deal with his academic pressures. In the circumstances, I heard that if work was late a penalty would be imposed. This seems ridiculous; why hit a man when he is alreadydown? STUDENT EXPERIENCE Director's Office IUniversity of Sussex ISussex House IBrighton B N 1 9 RH I United Kingdom

(2) With regard to communication - this appeared to be deeply flawed amongst the huge number of University departments and units. The health clinic incorporating amongst other things a pharmacy and the counselling service, was excellent offering free access to students. The system failed - Daniel was not in the link between his GP/counsellor and the student support unit. If this link had been complete I do not believe Daniel would have died when he did. Within the Record of Inquest your finding's state: Had his medical condition been flagged up to the Student Support Unit in March or April 2018 IFINO from the evidence and on the balance ofprobabilities thathe would have hadaccess to invaluable input andsupport targetedfor his specific needs. Had Daniel been given this support it is likely that the outcome for him would have been different. This was a failed opportunity to help him. University Response: The University takes the well-being of its campus community very seriously and offers a range of services to support students throughout their studies. The following outlines the University's structure, student support provision and new initiatives. The University Structure The Vice-Chancellor ( is the senior academic officer and, as Chief Executive, is responsible to the University Council (the governing body), for management of the University. He is supported by an executive group, which includes the Provost, three Pro- Vice-Chancellors, the Chief Operating Officer, the Director of Finance and the Director of Human Resources. The Heads of the Schools of Studies at the University of Sussex report to the Provost. The University has twelve academic schools, each with a Head of School, and academic officerships including a Director of Student Experience (DoSE). Academic staff within each School also act as academic advisers to a cohort of students, and the School DoSE provides oversight for the academic advising system. The University managed services include counselling and therapeutic services, disability and mental support, practical advisory support and academic support, the latter being primarily delivered within our academic Schools as outlined above. In addition, the University has a long standing contractual relationship with a General Practitioners Surgery, embedded in-situ on the campus and located within the same vicinity as the University Counselling Service and independent Pharmacy. Together, the School based academic advisory system and the centrally managed professional pastoral services are designed to offer holistic support to our students throughout their academic journey at University. In circumstances when a student is struggling academically or facing challenges that affect their academic performance or attendance, the student is offered support both informally, and more formally where necessary, and is supported via the School Student Progress Committee (SSPC). Strategic Review In November 2018 the University Council agreed and published the Education and Students strategy: 'Learn to Transform'. This provides the strategic direction for teaching, learning and the student experience up to 2025, and in line with the Strategic Framework of the University 2

("Sussex 2025 11 ). The Learn to Transform Strategy includes a series of pertinent actions as outlined below with timelines: Activity/Action Timeline for completion Creation of a Well-being and Mental Health Strategy September 2019 Introduction of an on line student support tool to offer all students 24/7-year-round access and oversight of vulnerable or at-risk students September 2020 (expedited to Jan 2020} Fundamental review of assessment and feedback mechanism to ensure inclusive practice, effective learning experiences and achievement of fair outcomes June 2021 Utilise learning analytic and business intelligence software to provide real time data, informing practices and allowing for targeted interventions. September 2021 Reconfiguration of pastoral support The University is reconfiguring its student support provision from separate teams into thematic areas. The objectives of this reconfiguration are:
• To enhance each student's experience through the provision of effective and efficient cohesive support services and activities across the whole University.
• To deliver a fit for purpose structure within a framework that is flexible and can adapt to change and evolve in a planned and strategic manner.
• To encourage harmonisation and more streamlined processes to take effect across the University.
• To make better use of resources by reducing duplication, clarifying roles and responsibilities and consolidating good practice. The reconfigured structures and services will begin to take effect during the 2019-20 academic year and should enable student access to appropriate support and engagement activities, when and how they require it, and without the need to know the University's support structures in advance. Student Centre A purpose built Student Centre has been commissioned and the building is scheduled to open in January 2021. The Centre will be the primary location for students accessing services face to face, and will be the main access point for information, advice and guidance. It will enable students to access friendly, consistent and professional student focused services across campus and digitally. Communication and Data Sharing Following Daniel's death, the University has reviewed and improved its data sharing and appropriate access to case notes and systems to improve the flow of information across the professional service areas. Professional service staff have improved access to necessary information, links and active referral between constituent areas such as: the Student Support Unit (that works with disabled students and those with specific learning differences and mental health conditions), Student Life and the Counselling Service, to facilitate more cohesive support to students and remove barriers to service access. 3

The University is also continuing to work with the GP's Practice towards improving data sharing about patient/student service users, to ensure pertinent information and knowledge is available to expert practitioners, working together to support students and mitigate the risk of serious self-harm as far as it is possible to do so. Online Student Support Tool Communication and data sharing will be further improved by the introduction of an on line communication platform, offering students access to student support on a 24/7 basis. This should remove the need to hold duplicate student information at a local level and provide professional service staff with a clear line of sight to better support service users. The procurement, development and implementation of this system has been expedited from September 2020 to January 2020 following the outcome of the Inquest. Academic Advising System The University accepts that improvements to the academic advising system are required; consequently, the University is reviewing its delivery model for the academic advisory system. An alternate delivery pilot is already taking place this academic year (September 2018 to July 2019) in one school to improve the current offer to students. An evaluation of this pilot model will take place in the Summer with further work, and additional pilots taking place during the 2019-20 academic year. Following evaluation, roll-out of an improved academic advising system is expected from 2020-21 academic year onwards. Regulatory & procedural monitoring and review The University regularly reviews its academic regulations and procedures, including the Principles underpinning this governance. As is general practice across the higher education sector, the University sets deadlines for submission of coursework. When a student is late or misses a submission for a deadline a penalty can be applied. When there are known reasons for late submission, a student may submit a request for exceptional circumstances, with evidence (e.g. medical), where appropriate. Students with reasonable adjustments in place due to a disability or specific learning difference have an additional seven days to submit work without penalty. When the University is unaware of such circumstances, a penalty will be applied. The examination and assessment regulations are reviewed on an annual basis, and specific consideration will be given to the late submission and penalty clauses. Any change to these regulations will take effect from pt September 2019. Immediate Action Taken Examination/ Assessments Results Upon receipt of the Regulation 28 Report in early February 2019, a temporary system was immediately adopted to identify repeating/re-sitting students for whom the School DoSE (lead academic adviser) considered to be vulnerable. This was based upon information held within each School through ongoing contact with their students. Each student was contacted by telephone irrespective of the outcome of their results and offered academic advice. In addition, the University wide services were available to offer appropriate support (e.g. disability support, counselling). From Summer 2019 a university-wide pilot system of support will be in place. Release of assessment and examination results will now be at the start of the week rather than just before the weekend. This will facilitate a 'We are Here' Campaign whereby key academic staff will be available during the week following release of results in order to ensure that 4

students can access appropriate academic advice easily and quickly. This will be underpinned by University wide services offering a wider range of enhanced advice for those students who require it. "Enlitened" Pilot In recognition of the increasing usage of digital platforms, social media and smart phone applications (apps) by current and future student population; the University is taking part in a prototype pilot of an app on smartphones/tablets. Designed by an external partner, this App is designed to encourage positive student engagement and well-being and is designed to enhance a sense of belonging and connection from a digital platform. The App has been piloted with the School of Psychology since March 2019 and, subject to a positive evaluation of this pilot, it will be rolled out across the University from September 2019. Imminent Risk Protocol An Imminent Risk Protocol has been developed as an additional safeguarding measure to enable expert staff to initiate an immediate case meeting (within 2 working hours) if they consider or anticipate that a student will be at serious risk of harm to themselves or others within a 24-48 hour period. The protocol is time specific and action based, and designed to ensure protective factors are in place as well as mitigate risk as far as it is reasonably possible to do so. This Protocol will be launched on 29th April 2019. In Conclusion I trust that this response and actions taken to date will provide the reassurance and information that you seek. The University remains deeply saddened by Daniel's death and it is hoped that you, the Chief Coroner, and Daniel's family will recognise the University is doing everything it is reasonably possible to do in order to +keep our student and staff community safe from harm.