Department for Department Business; Energy for Education & Industrial Strategy The Rt Hon Chris Skidmore MP Mrs Karen L Dilks Minister of State for Universities, Science_ HM Senior Coroner Research and Innovation_ Newcastle upon Tyne Coroners Victoria Street Civic Centre London Barras Bridge SW1H OET Newcastle upon Tyne +44 (0) 20 7215 5000 NE1 SQH weducalion gOv Uklhelplcontaclus enquiries@beis govuk Email: coroneradmin@newcastlegov uk MgKUk November 2019 w Dlky , Thank you for the letters from your office of 12 December 2018 and February 2019, and the associated Regulation 28 report relating to Edward Farmer. In your report, you asked that consideration be given to a national campaign addressing the risks of alcohol consumption within a short period, how to identify persons at risk, the importance of timely medical intervention and the inherent risks of initiation events Your letter of 4 February supported the proposed action detailed by the former Education Secretary in his letter to yoU Of 15 January, namely that government departments and bodies the education and health sectors would work together to design the measures most to achieve the desired outcome of preventing future such tragedies as the death of Edward Farmer. The outcome of that action is the comprehensive guidance published on 23 September by Universities UK and Newcastle University, Initiations at UK Universities, to raise awareness of the dangers of initiations and excessive alcohol consumption among students (see: httpsILww universitiesuk ac uklnewsIPagesINew-advice-for-universities-and-students-on- dangers-of-initiations aspx The launch of this guidance was publicised by national media, including BBC Television News, BBC Online and the Times, the i, the Guardian the Metro and the Independent newspapers. The guidance includes: Higher education institutions' duty of care and other statutory obligations to students Recommendations to the higher education sector in 10 areas including staff training , disciplinary processes, reporting systems, focusing on prohibited behaviours, and Q?s from likely

awareness raising: This includes how training activities should point out the signs of dangerous consumption of alcohol. Advice that interventions should be developed and administered at points in a student's time at university (e.g: UCAS application, open days, induction enrolment and re-enrolment). Information on the National Union of Students' 'Alcohol Impact' campaign, which is a whole-institution programme to create the conditions for a social norm of responsible alcohol consumption by students A suite of initiatives for tackling initiations in student sport, designed by British Universities & Colleges Sport (BUCS) the national governing body for higher education sport in the UK Signposting to the UK Chief Medical Officers' Low Risk Drinking Guidelines which provide information about the health risks associated with different levels and patterns of drinking to enable the general public, including students, to make informed choices about their drinking_ The above has been achieved through a determined collective effort by stakeholders across the higher education sector and government to take fully considered action to mitigate the risk of a similar such tragedy happening again. OJA CL THE RT HON CHRIS SKIDMORE MP key days, L6I,

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Response of Newcastle University and Newcastle University Students’ Union to the Coroner’s report on the death of Edward James Farmer, December 2016

1. Context a) This report is submitted in response to the Coroner’s report of 12 December 2018, sent to Professor Chris Day (Vice-Chancellor & President, Newcastle University) and Mr Simon Gerry (Chief Executive, Newcastle University Students’ Union) b) The report was made under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. c) The nature of the recommendations in the report, and the close collaboration between the University and the Students’ Union, make it appropriate to submit a single, joint response on behalf of both parties. In light of the specific nature of the formal relationship between the University and the Students’ Union, some of the actions described in this report are / will be collaborative, and others the specific responsibility of the relevant party. This is made clear in the information provided below and the Appendices to this report. d) In very brief summary, in the context of this report: the University is responsible for University-wide induction of new students, general awareness-raising, communication and disciplinary action against individuals or groups who commit misconduct. Staff training also falls within the remit of the University. The Students’ Union is responsible for oversight of the affiliated student clubs and societies, including training, health and safety, key elements of awareness-raising, financial support and the application of appropriate sanctions when societies / clubs do not comply with the requirements.

2. The Coroner’s Report The Coroner’s investigation into the death of Edward James Farmer in December 2016 raised a number of Matters of Concern, together with some recommended actions which are addressed in the Action Report and Plan attached as Appendix 1 to this response.

3. Approach taken by the University and Students’ Union The University and Students’ Union acknowledge the validity of the Matters of Concern raised by the Coroner, and welcome the recommendations regarding possible actions. In the approaches described below, and in the attached Action Report and Plan, we have taken care to address the Coroner’s recommendations, alongside other relevant issues which have emerged during our discussions, to ensure that our response is as comprehensive and effective as possible. a) Following the Inquest, in October 2018, the University took some immediate interim actions, which are recorded in Appendix 1. b) A Student Initiations Group was established, jointly chaired by the Vice-Chancellor and the Academic Registrar, with membership including the Newcastle University Students' Union Chief Executive, relevant Faculty and Professional Service staff, Students’ Union staff and Sabbatical Officers, Presidents (or representatives) of key student societies / clubs, and alumni representation. c) The work of this Group includes the establishment of some Definitions, Principles and Values, which are attached to this report as Appendix 2

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d) The Group identified four Workstreams and established working groups to address the key issues and make specific recommendations relating to the following themes:

Group 1: Defining ‘initiations’ and tackling traditions and cultures This group clarified and articulated the nature of activities that are considered unacceptable and considered the issue of cultures and expectations which are perceived to drive some events (eg the tradition of ‘initiations’ associated for many years with the Agriculture Society). Group 2: Raising awareness to reduce risks: education, campaigns, training (students and staff) This group considered how best to communicate with and educate staff and students about the risks associated with excessive alcohol consumption including the specific risks of death and serious illness resulting from unacceptable and dangerous behaviours. Group 3: Expectations, policies, discipline and sanctions This group clarified the University’s expectations and prohibitions in terms of unacceptable behaviours at student socials (including dangerous initiations), and how these expectations are communicated. It reviewed the University’s disciplinary procedure and protocols for dealing with such activities and clarified, for communication to students and staff, the sanctions applicable. Group 4: Working with the city, the local community, the police and other outside organisations This group worked with Newcastle City Council, Northumbria Police, the Licensing organisations and other external bodies to raise awareness of the issues associated with excessive alcohol consumption by students (and others). A particular focus has been to increase awareness and enforcement of regulations governing licensed premises selling to visibly drunk patrons and also the practice of ‘proxy’ sales where patrons can buy on behalf of others.

4. Emerging issues/ constraints in responding to the Coroner’s report In considering the matters of concern and recommended actions in the Coroner’s report of December 2018, the University and the Students’ Union have identified a number of important issues, some of which have an impact on the response to specific recommendations: a) The unacceptable behaviours which fall under the auspices of this report go beyond ‘initiations’ per se, and include any organised event, ceremony or ritual which could be reasonably perceived as involving coercion or manipulation that results in a risk or occurrence of physical or mental detriment to students or other parties. This could apply to any organised social activity, including ‘initiations’, taking place at any time (i.e. not just associated with the beginning of the year). b) The University and Students’ Union seek to achieve the right balance in offering a positive, welcoming and enjoyable student experience whilst effectively communicating the key messages about behaviours and risks. c) The recommendation that compulsory training be provided for all academic staff may need to be balanced against the practicalities and challenges of doing so. Many academic staff have no day-to-day interactions with students, and other (eg professional service) staff also have an important role in academic units and central Student Services. Our initial focus is therefore to focus on the training of key staff who are in a position to influence students and who have the opportunity to be vigilant. We

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will also explore other (eg digital) channels through which we may be able to raise the awareness and vigilance of all University staff, whilst recognising that compulsory participation may be impossible to achieve. d) Following the conclusion of the work of the Student Initiations Group, the University’s Alcohol and Substance Misuse Working Group will oversee and monitor this area of work for longer-term sustainability and impact. This will ensure that the actions agreed now become embedded in the normal practices of the University and Students’ Union and that we can be pro-active in taking forward our plans for culture change with successive generations of students and Students’ Union sabbatical officers. We recognise that culture change takes time, and that the matters of concern raised in the Coroner’s report are not unique to Newcastle University, but reflect wider societal challenges. We hope that our work will also help to inform the wider debate across the university sector through the Vice-Chancellor’s work with Universities UK. e) Newcastle University and the Students’ Union are fully committed to doing everything the law expects from us when aiming to take appropriate and proportionate steps to manage and control the risks to our students. However, we are mindful of the need to recognise and remind ourselves that our students are independent adults, upon whom we must rely to some extent by expecting them to take some personal responsibility for their own actions and behaviour.

5. Conclusions This report concludes the response of Newcastle University and the Students’ Union to the Coroner’s report of 12 December 2018. Appendix 1 summarises actions taken to date, planned actions and timescales for completion.

Professor Chris Day, Vice-Chancellor and President, Newcastle University Mr Simon Gerry, Chief Executive, Newcastle University Students’ Union , Director of Student & Academic Services (Academic Registrar) 28 March, 2019

From Jo Churchill MP Parliamentary Under Secretary of State for Prevention; Department Public Health and Primary Care of Health & Social Care 39 Victoria Street London SW1H OEU Your Ref: KLDILDIFARMER/1895 020 7210 4850 Our Ref: PFD 1161031 Mrs Karen L Dilks HM Senior Coroner; Newcastle upon Tyne Civic Centre Barras Bridge Newcastle upon Tyne 0 5 NOv 2019 NEL 8QH ()iks ecl In your letter of 12 December 2018, you asked that consideration be given to a national campaign addressing the risks of alcohol consumption within a short period, how to identify persons at risk, the importance of timely medical intervention, and the inherent risks of initiation events. In the response to you dated 22 January 2019, the then Minister for Public Health; Steve Brine MP, explained that the Department of Health and Social Care would work with colleagues across Government and others to determine the action that could be taken to respond to the risks highlighted in the Prevention of Future Deaths report. On 26 June 2019,a national roundtable event was held at Newcastle University to discuss the issues you raised: This meeting was attended by representatives the Department of Health and Social Care, the Department for Education, Public Health England and other bodies representing higher education and sport. As a result of this meeting, guidance was published on 23 September 2019 by Universities UK and Newcastle University to raise awareness ofthe dangers of initiations and excessive alcohol consumption among students The guidance can be accessed on the Universities UK website at: Www universitiesuk ac uklnews/Pages/New-advice-for-universities-and-students-0n- dangers-of-initiations aSpx: Iam aware that Chris Skidmore, Minister of State at the Department for Education is writing to you with further detail about the guidance. from

With regard to wider health messages, Public Health England is engaged in a number of actions targeted at young people about the dangers of excessive alcohol consumption through the 'Rise Above' and Talk to Frank' campaigns. The Rise Above social marketing programme aims to equip 1l to 16-year olds with the skills required to reject or manage risky behaviours, including drinking alcohol. It reaches young people through social media and provides lesson plans accredited by the Personal, Social, Health and Economic (PSHE) education Association use in secondary schools Further information is available on the Rise Above website FRANK is a drugs information website which is widely used by young people and provides guidance on the risks associated with alcohol consumption and how to manage them. The website provides a help service by phone, text; live chat and email for people who are concerned about their own, or others alcohol consumption. Further information is available on the FRANK website: Public Health England sits on an oversight group advising the National Union of Students (NUS) on its alcohol impact project The NUS alcohol impact project is a voluntary scheme for higher education institutions The project aims to provide a range of activities and services to students to promote alternatives to alcohol and help foster a healthy attitude and respect for alcohol. Summary reports, surveys and other associated research from the project is available at alcoholimpact nus org uklresearch: In addition; the One You' social marketing campaign engages people to make and sustain changes to improve their physical and mental health: The campaign focuses on promotion of well, quitting smoking, physical activity and reducing alcohol consumption: One You provides information, advice and online tools, including the How Are You' health quiz, website, email programme, and a suite of mobile apps. The overarching communication objective of One You is to reduce unhealthy behaviours as well as prompt uptake of healthier behaviours [ hope this response demonstrates the collective effort by stakeholders across the higher education sector and across Government to raise awareness and prevent a similar tragedy from happening again. Thank you for bringing these concerns to my attention: Yuol , JO CHURCHILL public for eating again KegedL?

From Steve Brine MP Parliamentary Under Secretary of State for Public Health and Primary Care Department of Health & 39 Victoria Street London Social Care SWIH OEU 020 7210 4850 Your Ref: KLDILD/FARMER/1895 Our Ref: PFD-1161031 5 IAN 2019 Ms Karen Dilks HM Senior Coroner; Newcastle upon Tyne HM Coroner's Court Civic Centre Barras Bridge Newcastle NEI 8QH 2 2 JAN 2019 QJus Ms Dilks Thank you for your correspondence of 12 December to Matt Hancock about the death of Edward James Farmer. Iam replying as Minister with portfolio responsibility for Alcohol: I have noted carefully the matters of concern raised in your report: [ understand that you have also copied your report to Damian Hinds, the Secretary of State for Education: In your report you request that consideration be given to conducting a national campaign of the risks of consuming alcohol within a short period; how to identify persons at risk; and the importance of timely medical intervention. The death of Edward Farmer is tragic and careful consideration is needed on how best to address the issues raised in your report: Isuggest our approach should be the same as the one suggested by the Secretary of State for Education; in that any action on this is deferred until the Department of Health and Social Care has had the chance to work with colleagues across Government and in other health sector bodies. Can I take this opportunity to thank you for highlighting this important issue to me; [ will write back to you on how best we can prevent similar deaths in the future. WI STENE BRINE

± 2018-OO49994POSoS ;D Rt Hon Damian Hinds MP Secretary of State Sanctuary Buildings Great Smith Street Westminster London SW1P 3BT tel: 0370 000 2288 wwweducationgov.ukJhelp/contactus Mrs Karen L Dilks HM Senior Coroner Newcastle upon Tyne Coroners By email: coroneradmin@newcastle.ciov.uk Your ret: KLD/LD/FARMER/1 895 15 JAN 2019 Thank you for your letter of 12 December, enclosing the Regulation 28 report relating to Edward Farmer. I understand from one of your officers that the report was also sent to the Secretary of State for Health and Social Care, the Vice-Chancellor of Newcastle University, the Chief Executive of Newcastle Students’ Union, the National Union of Students, Northumbria Police and local licensing authorities. You ask that consideration be given to a national campaign addressing the risks of alcohol consumption within a short period, how to identity persons at risk, the importance of timely medical intervention and the inherent risks of initiation events. Given the particularly tragic circumstances of Edward Farmer’s death, I am keen to ensure full and thorough consideration is given to how best to raise people’s awareness of these issues and encourage them to take sensible decisions. This thinking will enable the right decision to be made on whether a national campaign would be the most effective approach for the prevention of future such tragedies. I would therefore like to agree with you that a response with the details you require on proposed action is deferred until my department has had the opportunity to work with colleagues in the health and education sectors on designing the measures most likely to achieve the desired outcome over a sustained period. I look forward to presenting a fully considered approach to preventing similar deaths.

Thank you for writing on this important matter. 44 Damian Hinds Secretary of State for Education CC:

Dear Mrs Dilks Re: Investigation into the death of Edward James Farmer Thank you for your letter of 12 December 2018. I would like to take this opportunity to express my condolences to the family and friends of Edward following the tragic events on 12 and 13 December 2016. life cut short is one too many_ and I am sure the circumstances relating to Edward's death make it even more difficult to come to terms with_ As you may know, NUS is a confederation of students' unions, comprising c98% of all further and higher education students' unions in the UK, totaling 538 students' unions_ Through our representative structures we are the collective voice of seven million students_ We work to promote and defend the student interest across all aspects of society_ The behavior change campaigns we run are primarily delivered to individual students through our work of developing their respective Students' Unions_ Before respond to your proposal for a new national campaign, I will outline our work to date on the issue of promoting responsible consumption of alcohol by students.
1. Campaigns work We have been publicly opposed to initiation ceremonies for many years and sought to highlight the issue though the student voice of our full-time student officers: In addition, we have produced training resources on the development of students' union rules, procedures and systems that address contentious issues, including initiations (http Llstudentopportunities nus org_uk/2014/O6/05/the-unions-rules-systems- proceduresL)_ In 2013 we published guidance on bar crawls, both for students' unions and the police (see two attached documents: Guidance notes for students" unions commercial bar crawls- and 'Guidance Notes for Law Enforcement Officers Bar Crawls' ) , so that students' unions could intervene when commercial bar crawl companies were not meeting their legal duties: The guidance underlines our opposition to that kind of activity. Our work on tacking the lad culture, which substantively started in 2014, has extensively cited the initiation ceremonies and irresponsible consumption of alcohol as issues. This includes our report That's What She Said' (WWWnus orguk/PageFilesL12238/Thats%2OWhat%2OShe%2OSaid%20- %2OFull%2OReport%20(1)pdf) , which later featured prominently in discussions at our Lad Culture summit: This work led to various resources and tools for students' unions to National Union Of Students (United Kingdom): Company No. 08015198 Any key

help them develop policies and procedures to tackle issues pertaining from lad culture WWW nusconnect_org_uk/liberation/women-students/tackling-lad-culture)_ and at a national level was the impetus for further work by UUK WWW universitiesuk acukLpolicy_ and-analysiskreports/Documents/2016/changing-the-culture pdf) , BUCS (WWW bucs_orgUklathlete asp?section=18767&sectionTitle= %23TakeAStand) and others. It is a matter of regret that much of the media coverage characterises our work as being the police or snowflakes:
2. Best Bar None Best Bar None is an accreditation scheme, supported by the Home Office, which promotes responsible management and operation of alcohol licensed premises. The scheme includes questions in the prevention of crime and disorder, public safety, prevention of public nuisance, protection of children from harm, social responsibility and a large section on training which ensures all venues are training their staff in areas: Entrants are required to show a raft of documentation and policies that cover things like safe alcohol retailing, challenge 25, conflict management and dealing with customers who are vulnerable The entrants go through a four hours assessment which is both a review of documentation but also a chance for the assessor to check staff members understanding, through speaking to staff and asking them questions_ This work has been ongoing for a number of years. As early as 2004 we led on taking the regional police-led pilot in Manchester to scale nationally through our members students' unions. This academic year we have 55 students' unions working towards their annual accreditation: Last academic year a similar number took part, with 37 achieving level accreditation, and all students' unions that entered gaining accreditation. We proactively support entrants on an ongoing basis through a Facebook workplace page and run communities of practice sessions throughout the year: Participating students' unions can assess the Drinkaware library of resources There are criteria, all of which are mandatory for accreditation, that are particularly relevant to your enquiry: E46 Drinks Promotions Mandatory Code; E47 Drink Promotions Risk Assessment; E17 Responsible Alcohol Retailing; E18 Duty of Care Policy Safeguarding. More information on the criteria, and national scheme, can be found here: httpi LLbbnuk comL_
3. Alcohol Impact established Alcohol Impact as partnership with the Home Office four years ago, through an E80k grant for one year, and now run it as a self-funded programme, funded by universities, supported in a non-financial way by the Home Office. Alcohol Impact seeks to reverse the social norm of irresponsible alcohol consumption by students, especially first years. It is supported accreditation programme which brings the students union and university together as partnership through shared actions to change norms and behaviours. Alcohol Impact does have a mandatory criterion on initiations: IN039: The partnership has taken action to moderate or prevent alcohol-related initiation ceremonies. All partnerships also must out an annual innovative intervention, and these can, and sometimes do, relate to preventing initiation ceremonies: To date thirty-one universities have are taking part in Alcohol Impact, delivering a broad array of actions that collectively help to change student attitudes and behaviors on alcohol consumption. We have substantive evidence that the programme has led to reductions in alcohol-related incidents on campus, as detailed under the summary reports section of our website (https:LLalcoholimpact nus org_uk/research): We are also in the process of publishing a new detailed report showcasing outcomes and case studies from the last few years of the Programme, which will be released in February 2019. fun key gold four We carry

It should be noted that, Newcastle University Students Union disaffiliated from NUS and is not currently a member, As with all our programmes, Alcohol Impact is only formally open to students unions that are members of NUS. Newcastle University Students' Union would need to reaffiliate to NUS to formally take part: They can, however, freely access the criteria, and our extensive resources, as they are all openly published on our programme website: https:Llalcoholimpact nusorg uklabout_ As part of Alcohol Impact we run our annual Students and Alcohol Survey (https:[Lalcoholimpact nus org ukLresearch) , which provides national snapshot of how students think about, and consume, alcohol and provides us with baselines of attitudes and behaviours that we are working to change, and evidence of change at participating institutions. also run an annual Students and Alcohol Conference which, this year, is happening on Wednesday 27 February in Manchester (WWW cvent com/eventslstudents-and-alcohok- 2019/event-summary-acb2la2c18cc4503838clbaba3b6834e aspx) It is showcase event for participants to present their innovative interventions and find ways to collaborate on this agenda: You are welcome to attend the event if you would Iike to find out more about the programme: If you could me in touch with Edwards family I will extend an invitation to them as well.
4. Drink Rethink new pilot, Drink Rethink, funded by the BUPA Foundation, is a preventative approach which aims to reduce high-risk drinking behaviour among students by training student ambassadors to use an evidence-based behaviour change tool (Identification and Brief Advice IBA) to deliver an alcohol intervention on campus. This academic year we recruited and trained twenty-one student ambassadors to engage their fellow students and oversee the completion of the Alcohol Use Disorders Identification Test (AUDIT), followed by the provision of brief advice through leaflets appropriate to the level of risk identified by the AUDIT The ambassadors delivered a total of 250 hours of engagement across three weeks, at sites across the University of the West of England and Keele University_ A total of 576 students were engaged in completing the AUDIT and receiving brief advice through specific leaflets appropriate to their risk level. 149 students who opted not to participate in the AUDIT received general information leaflets, meaning a total of 725 students engaged at some level; The end of funding report from our pilot can be viewed here In relation to your proposal for a campaign, our portfolio of activity has together generated significant interest, support and momentum on the issue of responsible alcohol consumption by students_ In part, we believe this is because NUS is student-led, which helps build partnerships on this work between student representatives and students_ Similarly , the structure of Alcohol Impact creates partnerships between students' unions and their institutions on responsible consumption: This partnership working is coupled with an evidence-based and strategic approach to reversing the social norm of irresponsible consumption, which is grounded in academic theory, which is well received by universities. As such, rather than create a new national campaign, our preference would be to re-engage sector stakeholders on our existing work in this area, predominantly through Alcohol Impact, as national campaign overarching our other initiatives, as clearly has momentum and wider support, is proving to be impactful, and is much in the student interest, I aware that the Department for Education have responded requesting time to prepare a sector response: To progress this, we would welcome a high-level meeting, at the earliest opportunity, with the Home Office, Department for Education, Public Health England, Universities UK and the Office for Students to explore we can work together on this important issue and will look to convene such meeting before the end of March 2019_ We very put Our very am how

We will use the meeting to explore what others are doing, or planning to do, on responsible alcohol consumption, and assess the appetite for US to work together on this, ideally by collectively rallying around Alcohol Impact so we can take it to scale, engaging other universities, such as Newcastle, in this agenda: As part of any sector-wide partnership on responsible consumption, we would welcome discussion and action relating to the specific issues you raise around increasing the awareness of risk and provision of advice. I am aware that the Department for Education have responded Yours sincerel RpL Acting Chief Executive