Xuanze Piao

PFD Report All Responded Ref: 2020-0230
Date of Report 11 November 2020
Coroner Tom Leeper
Coroner Area Coventry
Response Deadline est. 17 February 2021
All 1 response received · Deadline: 17 Feb 2021
Coroner's Concerns (AI summary)
The university failed to hold a face-to-face meeting or contact the guardian/parents of an under-18 overseas student before sending a critical email indicating course removal risk, revealing a lack of clear communication policy.
View full coroner's concerns
(.1) The University did not have a face to face meeting with Xuanze, a student under the age of 18, prior to sending him the email dated 29/11/2018 indicating that he was at risk of being removed from the course and that he should attend a meeting to discuss this on 03/12/2018;

(.2) In the absence of a face to face meeting with Xuanze, the University did not contact either Xuanze’s Guardian or Parents prior to sending Xuanze the email dated 29/11/2018 indicating that Xuanze was at risk of being removed from the course and that he should attend a meeting to discuss this on 03/12/2018; Evidence was given at the inquest that in the case of an overseas student under 18, notwithstanding both prolonged absence from academic commitments and a persistent omission to respond to email requests that the absentee student should make contact with the university, there was no procedure or policy in place either for a face to face meeting with the student or, in the absence of such a face to face meeting, for contacting that student’s Guardian or Parents, prior to the email being sent indicating that the U.18 student was at risk of being removed from the course and that he should attend a meeting to discuss this.
Responses
Coventry University Education
11 Nov 2020
Action Planned
Coventry University is undertaking a full review of its policy and procedures relating to students who are under the age of 18, expected to be complete by January 31, 2021. They have also put in place an additional process for responding when international students under 18 fail to engage with their course, including a face-to-face meeting with a welfare advisor. (AI summary)
View full response
Xuanze Piao (died 3 December 2018) Coventry University’s Response to the Report to Prevent Future Deaths Dated 11 November 2020

Coroner’s Concerns: (1) The University did not have a face to face meeting with Xuanze, a student under the age of 18, prior to sending him the email dated 29/11/2018 indicating that he was at risk of being removed from the course and that he should attend a meeting to discuss this on 03/12/2018. (2) In the absence of a face to face meeting with Xuanze, the University did not contact either Xuanze’s Guardian or Parents prior to sending Xuanze the email dated 29/11/2018 indicating that Xuanze was at risk of being removed from the course and that he should attend a meeting to discuss this on 03/12/2018.

Response: Coventry University has a number of attendance/engagement and welfare policies and procedures in place which apply to international students who are under the age of 18. The policies and procedures result in contact being made with the students in a number of different ways and on many different occasions. The policies and procedures also ensure that students are provided with information about welfare services and given many opportunities to inform the University of any issues or concerns. If any concerns are identified either from the student or other sources at any time (including health professionals, family, friends, students and/or staff) then steps will be taken to address these concerns – this can include meetings with welfare advisors, home visits and/or appointments with mental health advisors or immediate contact with the police/health services and/or parents/guardians. In relation to Xuanze Piao, prior to his arrival at University, he was contacted by the Student Engagement Centre which has been created to provide pro-active advice and support to students. He was initially contacted by telephone on 30 August 2018 and then on 18 September 2018. When he did not answer, he was sent an email providing contact numbers so he could call with any questions that he had. As part of the enrolment process, on 25 September 2018, Xuanze had a “Welfare Check”. This was a face to face meeting with an international student advisor. During this meeting the international student advisor checked that Xuanze was settling in well, had everything he needed and had no issues or concerns. Students who are under the age of 18 are required to have a guardian in the UK. As part of the meeting, Xuanze’s guardian was contacted by the international student advisor. Xuanze was provided with information about the support services available at the University and was encouraged to contact international student advisors if he had any concerns. He also confirmed that he knew how to contact the emergency services. Xuanze attended some lectures and workshops in October 2018. During those sessions, he received face to face teaching and was encouraged to speak to course staff if he had any issues or concerns. On 31 October 2018, Xuanze’s course director sent him an email noting that there had been a number of absences recorded for him, asking if the faculty could assist with any problems, giving him the details of the next teaching sessions and encouraging him to attend.

Students who are under the age of 18 are required to have contact with an international student advisor once a month until they become 18. The contact usually takes the form of a telephone call in the first instance and the advisors will seek to identify any welfare concerns during the call. Xuanze was called by an international student advisor on 1 November 2018 and he confirmed that there were no problems or concerns. Around that time, the University’s StREAM leaner analytics system sent an alert to the Student Engagement Centre highlighting Xuanze’s low engagement with the University’s online learning systems. When such an alert is triggered, the Student Engagement Centre seeks to contact students to check that they are well, to ask if they need any advice or support and to encourage them to engage more with their studies. The Student Engagement Centre therefore contacted Xuanze by telephone on 2 November 2018. Xuanze explained that he had had some “family issues” which had impacted on his engagement with the course but said that those issues had been solved. He insisted that there were no ongoing issues or concerns and was reminded of the services and support available. As Xuanze was an international student, the University was his Tier 4 sponsor. If a student missed 10 consecutive contact points, the University was expected to withdraw sponsorship and report the student to the Home Office unless the student had permission to miss a contact or for other exceptional purposes. The University therefore sent emails to Tier 4 students whose attendance had fallen below a specified level. The emails reminded students of the obligation to attend and engage, informing them of the consequences of non-engagement and providing details of the support available and how it could be accessed. Emails were sent to Xuanze on 8, 15 and 22 November
2018. As he did not respond, on 29 November 2018, he was invited to a face to face meeting to ascertain if there were any reasons for non-attendance before a decision would be made about withdrawing him from the course. The above short chronology demonstrates that there was contact with Xuanze in a number of different ways and on many different occasions during his time at the University including face to face teaching, face to face meetings, telephone calls and emails. He was given substantial information about welfare and support services that were available at the University and was encouraged to make contact if there were any issues. He was specifically asked about his welfare on 25 September 2018 in a face to face meeting and then on 1 November 2018 and 2 November 2018 by telephone. Each and every time he said that there were no welfare or health concerns. Xuanze did not respond to emails relating to his low engagement with his course but, before making any decision about withdrawing him, the University invited him to a face to face meeting to discuss the situation. The University’s attendance/engagement and welfare policies and procedures therefore already provide for face to face meetings and welfare checks and those policies and procedures were followed in this case. However, the University is committed to continuous evolution and welcomes any proposals, comments or suggestions about the development of its policies and procedures. The University is undertaking a full review of its policy and procedures relating to students who are under the age of 18. This is expected to be complete by 31 January 2021. The University will provide a copy of the new policy to the Coroner when it has been finalised. In relation to the concerns raised by the Coroner, the University refers to the chronology set out above. The University also confirms that it has already put in place an additional process for responding when international students who are under 18 fail to engage with their course where

this results in them failing to meet the conditions of their visa and thereby puts them at risk of being withdrawn from their course. Those students are identified on engagement reports and the International Student Compliance Team consider what action is required in each case. In particular, where any such student is at risk of being withdrawn from their course, a face to face meeting (which may have to be undertaken virtually during the pandemic) will be organised between that student and a welfare advisor specifically to assess whether there are any welfare issues or concerns and, if so, to decide what action should be taken. This assessment will include consideration about whether the student’s parent or guardian should be contacted. No steps to withdraw the student from the course will be taken by the University until the welfare meeting has taken place.

6 January 2021
Sent To
  • Coventry University
Response Status
Linked responses 1 of 1
56-Day Deadline 17 Feb 2021
All responses received
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Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On 11/12/18 an investigation was commenced into the death of Xuanze Piao. The investigation concluded at the end of the inquest on 06/11/20. The determination of the inquest as to the medical cause of death was a massive head injury and multiple trauma owing to impact with a train, and as to conclusion, suicide.
Circumstances of the Death
In Autumn 2018, Xuanze was a student attending Coventry University enrolled on a degree course in Architecture. He was aged 17, having been born on 10/12/2000 in the Heping district of Shenyang, China. He was living in student accommodation.

At Coventry University he was categorised as a Tier 4 overseas student. Due to his age and nationality he was required to have a guardian within the UK. A condition of his UK student visa was that he attended his university course. Xuanze’s attendance on his university course was limited. Because of the amount of the course he missed he was sent a number of emails requesting his attendance at meetings with staff to discuss his absence. He did not respond to these invitations which resulted in an email being sent to him on 29/11/2018, indicating that he was at risk of being removed from the course and that he should attend a meeting to discuss this on 03/12/2018; removal from the course would in turn have affected his permission to remain in the UK on his student visa. There was no face to face meeting with Xuanze in advance of the email being sent to him on 29/11/2018, and neither Xuanze’s family nor his guardian were informed that Xuanze was not attending his university course, nor were they informed of the meeting he had been requested to attend to discuss his removal from the course.

On 03/12/18 shortly before 5 a.m. Xuanze left his student accommodation and went to Coventry Railway station. He walked to the end of platform one and proceeded along the side of the tracks. Approximately 500 meters outside of Coventry Railway station heading south, Xuanze was struck by a passenger train which caused him to sustain catastrophic injuries. He is likely to have died instantly as a result of the collision and his life was formally declared extinct at 07:35 hours. The inquest conclusion is suicide.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.