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Updates & insights

Your views on serious incident reviews following a student death

In this blog post, Levi captures some of the participant views from our Policy Pitstop discussion on serious incident reviews following a student death, that took place on 6th September 2023. (Take a look at this blog post if you would first like to watch a video of the 30-minute presentation I delivered at the start of the event and for a list of relevant links and resources.)


We do not attribute contributions to specific colleagues or HEIs, since our Policy Pitstop events adhere to the Chatham House rule, to help make sure colleagues feel comfortable sharing their experiences and views during the discussion. Some comments, when quoted, are lightly edited to enhance readability, but, hopefully, without altering the intended meaning.


Types of serious incident review

We asked participants which of the three types of serious incident review outlined in our presentation they generally carried out at their institutions.


The categorisation of types of serious incident review as presented to attendees in the briefing of our Policy Pitstop session.

Responses show variations in approach, with the responses indicating that HEIs may currently be tailoring the type of review they carry out depending on the circumstances of the student death.

  • "We tend not to carry out a review, as this is the role of the coroner."

  • “Type 1 for all deaths, and type 2 but only when the outcome of type 1 indicates the need for a Type 2/lessons learned review”

  • “Type 2 - with a bit of 3 when the type 2 review suggests this is needed”

  • “Type 2 is our more common approach, but I feel it needs to be more formalised”

  • “Type 2 informed by a bit of type 1”

  • “A type 3 review would follow when a type 1 or 2 review indicates that it would be useful.”

A couple of participants indicated that their approach to carrying out serious incident reviews is currently under review, and there were two comments from colleagues whose institutions did not carry out serious incident reviews following a student death, except in very specific circumstances.


A multi-agency approach to conducting reviews

Some colleagues commented on the importance of a multi-agency approach:

"We carry out type 1 and 2 serious incident reviews, and we also work with the local adult safeguarding board to support with a wider partnership or serious case review following a student death by suspected suicide. This is often needed when multiple agencies are involved. The limitations of internal reviews is they can pose further questions about the involvement of wider community partners.”
“I have suggested to the Higher Education Mental Health Implementation Taskforce that there needs to be a national steer on the involvement of NHS/public health services for all serious incident reviews.”

In our discussion, we explored some aspects of multi-agency involvement in serious incident reviews. There are clearly significant benefits from such an approach, as it properly reflects the fact that people studying in higher education are not just students.


At the same time, the more we involve external agencies, the more a serious incident review can start to overlap with the reviews carried out elsewhere, such as by NHS services, by a coroner (in England, Wales or Northern Ireland) or by the procurator fiscal (in Scotland). At what point does a university review tread on the toes of a coroner's inquest, for example?


The ongoing national review of how suicide cases are managed in Scotland - where the Scottish Government’s suicide prevention strategy commits to bringing in multi-agency reviews following all deaths by suicide - was also mentioned. Again, this raises questions about how such multi-agency reviews would fit with any serious incident reviews universities are expected to conduct as a matter of course in the future.


One participant explained that their HEI has a suicide prevention strategy that is shared by three universities locally. And as a result, when they carry out reviews, they do so on a peer review basis:

“We don't do our own reviews, we do each other’s. So, if there's an incident in one university, another of us will take the lead on that. This means you can come in with a fresh pair of eyes and look, in a more holistic way, at making systems and processes a bit better. One downside, which I learnt to my cost is that you then get called to the coroner's inquest as a witness, because you are the author of the report, which is an interesting position to be in when it is not your university”.

Involving a student’s family in a serious incident review

Several contributions noted the difficulties when it comes to involving family members in a serious incident review – firstly, because families often want and expect difficult levels of contact from the university:

“I've had experience of two extremes, both in suicide cases - one where the family was very clear that they wanted an investigation because they wanted to know exactly what happened, and another where the family wanted minimal contact and action from the university. In the second case, while the family was very grateful for the support given, there was no university review. It did go to a coroner’s inquest; the university was not identified as an interested party by the coroner and we were asked not to attend.”

Even where family members are involved in a review, the timescales set out in the UUK guidance (which states that stages 1 and 2 of the review should, where possible, be completed within two weeks following the incident) seemed impractical to participants when it comes to family involvement:

“I can't really think of any circumstances in which two weeks would be an appropriate time frame for involving a family in the early stages of a serious incident review…Thinking of one case, our investigation needed time to allow everyone to assimilate what had happened, to make sure that those who needed to know were informed, and to allow some external matters to be resolved first.”
Universities UK's recommended review process expects major stages of review to be completed in two weeks or less - a challenging timeframe, both in relation to involving the family in the review and more broadly for institutions.
“It is key we think about the impact on the family's grief. In one case I can think of, the family were only in a position to absorb information related to their child’s death after a year. They wouldn't have been able to engage if we had said to them just after the death, ‘We would like to do a review. Can we ask a few questions?’ I just wouldn't ask that at that point.”

The impact on HEI staff members

In relation to staff who worked with the student prior to the student’s death, one person made the comment that “There is a timeliness element that we need to consider for staff as well as students. Staff grieve as well.


Several participants supported comments about staff potentially feeling very exposed by a serious incident review – particularly if it asks the kinds of questions suggested in the UUK guidance, which are designed to prompt the staff member to consider, with the benefit of hindsight, what they could or should have done different to support the student who died. If these review processes are not carried out responsibly and with real care and attention, we may be adding significant to the distress or guilt that staff members may already be feeling about the death.


One contributor talked generally about the difficulties of managing student death cases, which may not even be described in our job descriptions as part of our role:

“I'm the facilitator and owner of the process…I often feel like I don't really have provisional support in place when we're not feeling okay. It's something that you take home…something that you can't leave at the door.”

We also discussed the fact that, if you, as a university staff member, are asked to lead on a serious incident review, you may be likely to be asked to give evidence during the coroner’s inquest. Coroners have traditionally tended to be good at saying to universities that the university can decide who is best placed to speak about the case. However, once an HEI appoints a lead reviewer to look into a particular student death, this discretion may disappear, and the coroner’s court may be more likely to specify that the reviewer, as a named individual, should give evidence. One comment made was that “We need to make clear when appointing lead reviewers that this is a likely follow-on responsibility, and support staff through that process as well.”


The planned national review of student suicides

We touched upon the fact that it is not even always clear whether a death is a suicide or not, and this may not be cleared up for weeks or months, if, indeed, there is ever a clear cause of death. One participant described a case in which “the coroner's eventual verdict was not suicide as suspected.” Conducting a review too quickly – for example, to fit with the timescales in the UUK guidance or nationally imposed timescales – may lead to a review being carried out on the basis of the wrong assumption about the cause of death.


When we discussed briefly the planned national analysis of the HEI reviews, as described by the Higher Education Student Support Champion in his briefing this July, we discussed the fact that it may be difficult to collate institutional reviews in a meaningful way, given the diversity of approaches in place within institutions.


A different approach might be for the national analysis to focus only on key comparable, quantitative information about suicides - such as the stage the student was at in their programme, whether the student had engaged with the university’s clinical support team, the student's course attendance rate, etc. - rather than trying to collate the full detailed reports from reviews. This would be more in keeping with the boundaries of a university's role and less likely to involve over-sharing personal and sensitive information.

In a context where there are increasing expectations on universities, participants noted that "a student is not just a student, the student is a whole person".

Several contributors alluded to the fact that a student is not just a student.

"A student is not just a student; a student is a whole person.”

This creates a tension when it comes to seeing the death as a “student suicide” and placing the responsibility on HEIs to investigate the death. The term “student suicide” may, for example, refer to a person who was engaged on a part-time course for just a small proportion of their time, a person who only just started their course days or weeks previously, a person who was in receipt of external (e.g. NHS) support services, or a person who is located hundreds, if not thousands, of miles away from the University’s physical campus. The sources of a student’s distress may or may not be connected with their university experience.


By mandating universities to carry out these reviews, we may be making a flawed initial assumption - and possibly a flawed implicit public statement - that the university was responsible for, or even aware of, the student's distress, when, in many cases, it may not have been.


One further question occurred to participants at our event: if a thorough lessons learned review is deemed to be necessary in every case of a "student suicide", in addition to any coroner's inquest, procurator fiscal process and/or NHS case review, why is the same sort of review not seen as necessary when the suicide involves someone who is not a student - for example, led by the individual's employer?


Thanking our participants

We would like to thank the colleagues – around 50 of you – for joining and participating in this Policy Pitstop event. More information about the event – including a video of our initial presentation – can be found here.


We will be letting colleagues who have subscribed to our mailbase know about our future Policy Pitstop events; these free online discussion events focus on topical and challenging issues in the world of student support.


For colleagues who are looking for more support with managing aspects of a student death:

You are also welcome to contact us to discuss bespoke or in-person training events or to talk about other types of consultancy support, such as a review of your student death procedures.



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