The father fighting for change at universities after losing his son to suicide

James Murray never expected to be standing in a courtroom in Bristol on 1 May 2019: the day of the inquest into his son’s death. Ben was 19 when he lost his life to suicide.

He had moved from London to start his studies at the University of Bristol in September 2017. He died eight months later. Two hours before his death, his father met him for lunch. Murray had no idea that his son’s place at university had been withdrawn, that he hadn’t paid his accommodation or tuition fees despite having access to the funds, that he’d missed an exam and that he’d disclosed to a senior tutor that he was struggling with anxiety and couldn’t connect.

“Can you tell me how you decided to dismiss Ben?” he asked the Bristol University representative in the courtroom that day. He had been determined to use the inquest to prevent the same thing happening to other families. A convoluted answer involving progress examination board meetings and spreadsheets followed.

The school and faculty had different ideas; the former wanted to keep him on to the summer, but the latter wanted to dismiss him. Murray says his questions about his son’s mental health and to what extent it was discussed in the meeting were met with silence.

The father was told that if you don’t attend exams, you normally have to provide a note to explain the circumstances. “Are you telling me that you’re not ill until you’ve provided a mitigating circumstances form?” asked Murray.

His concern about students’ health not being taken into account in dismissal meetings is one he voiced in the courtroom: “Can I just recommend to you that when you make a decision about another human’s life that is going to massively impact them, you design an agenda that’s built in a way that you might have a good chance of discussing their health before you make a determination?”

Murray says that inquests are not about apportioning blame, but he describes this point as the seminal moment of the proceedings. “The ‘gotcha’ moment like you see on TV trials, when it’s suddenly clear there was a missed opportunity that, if fixed, might change the outcome for many lives, was realising we should always ask the question: do we know anything about this person’s mental or physical health?” he says.

Ben is one of 13 University of Bristol students believed to have taken their own lives in the past four years, with 11 of these suspected suicides occurring in the 18 months from October 2016.

And this is not just a Bristol problem. Across England and Wales, 95 university students died by suicide between July 2016 and July 2017, according to the Office for National Statistics, equating to one death every four days or a rate of 4.7 deaths per 100,000 students.

Ben’s inquest resulted in senior coroner Maria Voisin issuing a Regulation 28 Report to Prevent Future Deaths (PFD): a document issued when a coroner believes there is a risk of future deaths occurring in similar circumstances unless action is taken.

Murray says he didn’t know much about inquests before this experience, but he was told that PFD notices are a big deal, especially in the case of suicide. “Quite often there is a good chance they’ll say it’s suicide; it’s tragic; then move on to the next case,” he says.

The issuing of a PFD with recommendations for universities, Ucas and government departments was welcome progress in Murray’s determination to ensure the higher education sector learns from what happened to his youngest son.

“I didn’t, but I could have pretty much punched the air when we came out … It felt like the rest of the sector would finally understand what goes on within the university and what could be done differently.”

In her report, Voisin described Bristol as a sector leader in student mental health and wellbeing, following fundamental changes to their policies in recent years, recommending the rest of the sector learn from their example.

The university launched a Student Mental Health and Wellbeing Strategy in late 2018, emphasising their whole university approach. Deputy director of student services and institutional lead on suicide prevention and response at the University of Bristol, Alison Golden-Wright says: “It’s not just about looking at your support services, it’s about looking at your whole institution and how you’re responding to every aspect of the student’s life.”

Since Ben’s death in May 2018, his father has been campaigning for better data-sharing procedures both within universities, and between the institution, its students and their parents and guardians.

At the start of the 2018-19 academic year, four months after Ben lost his life, the University of Bristol committed to delivering suspension letters to students in-person wherever possible.

And it introduced an opt-in policy allowing the university to contact a student’s next of kin if they have serious concerns about a student’s wellbeing. In the first week of registration, 94 per cent of new and returning students at Bristol signed up to this opt-in policy, which is one of the first in the UK.

It has since been adopted by other universities with extremely high uptake from students, including 82 per cent of students at Brunel University. A 2019 Higher Education Policy Institute report found that over 80 per cent of students think it is right for a university to be able to contact a parent or guardian in the case of extreme concerns over a student’s mental ill-health.

Golden-Wright says the university was always able to contact a student’s next of kin in “vital interests”, ie a life or death situation, but the new opt-in policy is a step lower than that.

“It is used when we have serious concerns about a student’s wellbeing. We will try to make sure we’ve spoken to the student about doing it in most cases. We do think that is important because they are autonomous adults,” she says. “It’s used if we’re reaching out to someone and they aren’t responding and we don’t know that we can keep this person safe.”

Murray says that Ben had one conversation with a senior tutor where he disclosed that he was experiencing anxiety and was unable to connect. He was then sent an email with a link to register with the healthcare centre, which his father clicked on months later.

“The first thing it says is don’t have the expectation of seeing anyone quickly because we have thousands of students registering at the same time so we’ll have a delay. Imagine if you’re anxious or depressed and you receive this email,” he says.

Murray says he doesn’t know if his son opened the email or clicked on the link, but there was no follow-up to check Ben registered and was getting the help he needed. “That was the end of the communication on that point.”

He believes we all have a collective responsibility to look out for each other by spotting the signs of someone in distress, having a conversation with them, giving them hope and signposting them to further support if needed. “Mental health is a team sport. We all hold a piece of the jigsaw.”

This is a sentiment echoed by Bristol’s vice chancellor, Professor Hugh Brady, who wrote in a blog discussing the university’s new policies at the start of the 2018-19 academic year: “Mental health is everybody’s business at our university.”

Currently only 37 per cent of students disclose a known mental health condition on their admissions form sent through the Universities and Colleges Admissions Service (Ucas) to a prospective university. 

The senior coroner recommended a move towards destigmatising mental health and ensuring students are made aware that disclosing mental health problems will not affect their chances of a place at university.

Three-quarters of those who die by suicide are unknown to support services, according to Universities UK’s “suicide-safer” guide. Murray believes there needs to be a better system of communication between internal services and departments within universities to stop students falling between the cracks. “Information-sharing policy is really important,” he says.

The precise role of universities in supporting students’ mental health and wellbeing has never been clearly defined. Voisin noted in her report that the primary role of a university is to educate its students, yet it also carries an important pastoral role, particularly in assisting students with the transition from home to university life.

Golden-Wright, who has 17 years of experience in the higher education sector, says the university shares a collective responsibility for students’ wellbeing. “We have a joint responsibility, working with the student at the heart of it, with our colleagues in the NHS, with family and friends if that is helpful for the student, with academics, with services, to support that student to get the best out of their education that they can.”

Professor Brady wrote in his 2018 blog that the university definitely does not have the responsibility of a parent or the NHS: “We are definitely not in loco parentis (‘in the place of a parent’) … Universities, while taking their pastoral care responsibilities very seriously, should not be expected to replace the NHS in provision of mental health support.”

Murray, the recipient of an Honorary Fellowship from Brunel University last year for his work on student mental health, has been working on a project with Universities UK to try to define information sharing policy for the HE sector.

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He says they struggled to create a definition after a year. “If you’re going to come out as a university and say we have a duty of care and our policy is to train everyone in mental health care so that we can spot the signs and then signpost, you just made yourself somewhat accountable and responsible in the eyes of prospective students and parents for safeguarding. And that may scare some vice chancellors.”

He believes that all universities should first decide on their cultural stance and make this clear to students and parents/guardians. This could be on a spectrum from prioritising privacy and adopting a non-interventionist approach, through to viewing students as emerging adults and creating a compassionate and supportive place to study, involving sharing necessary data with nominated friends, parents or guardians.

Murray says concerns about privacy and responsibilities of universities are causing resistance and delays in more universities implementing an opt-in or consent-at-registration policy.

“When it comes to [information-sharing policy] we immediately descend into an academic debate about big brother and erosion of privacy and so on … You fail to agree on information-sharing when you get middle-aged people like myself debating whether or not we’re entering an Orwellian society, instead of focusing on the legitimate use of that data to save lives. This is why the debate roars because you’ve got so many smart but not always progressive people in the sector.”

Murray believes universities should be curating their own information-sharing policy to allow them to contact someone if they have serious concerns about a student. “It’s obvious. It’s a no-brainer,” says Murray. “We have to cut through the noise and I’m exhausted by it because this is such an important part of our economy but such a slow sector and life is so short.”

He says the way to achieve a breakthrough in student mental health outcomes is to involve students themselves in a process of co-creation, as Northumbria University has done in their consultation of several hundred students when designing their opt-in policy. “It’s an empowering and more progressive approach,” says Murray. 

It is not only the lack of communication between a university and a student’s next of kin that concerns Murray; that between the university and student is a cause for concern too. His son was dismissed from the University of Bristol via letter. Drawing on his 30 years’ experience in business, Murray compares this to high-profile cases where people have been fired via text message.

“These business cases hit the national headlines causing disbelief and disgust. Why would a letter be any better?” he asks. “A letter to a vulnerable teenager saying your life vision is in tatters.”

Murray believes that nobody should be dismissed from the university without a face-to-face conversation. “That seems sensible doesn’t it? That would be the humane thing to do.”

The university has since adopted this policy and have also made several other changes to their controversial Fitness to Study policy, which outlines the university’s ability to withdraw a student if they are deemed unable to participate fully in university life due to mental or physical health challenges.

Bristol student mental health advocacy group Support Our Services has campaigned for changes to Fitness to Study over the past few years, attending meetings with senior university staff resulting in many changes to the policy.

These include suspended students no longer being forced to leave halls, being able to enter the Students’ Health Centre rather than being banned from campus as they previously were, and being given their suspension letter in person rather than by letter.

Golden-Wright says the university is continuing to do a lot around this policy, including looking at a change in language to Support to Study, so that it feels more supportive for students. She hopes that the changes will be published later this year.

Another policy change that Murray believes is necessary to prevent further student suicides is the implementation of post-incident reviews to learn from past deaths. “There are thousands of things that universities could do better, but my current beef is that we don’t learn from the past.”

Among Voisin’s recommendations, the senior coroner highlighted that the university sector does not currently carry out an investigation report after the death of a student, which would give an opportunity to review what has happened, what was done well and what areas of concerns there are to learn lessons from.

Murray says that all universities should consider conducting post-incident reviews, both in the case of deaths and failed suicide attempts. He describes a case at Leicester where a janitor found a suicide note and managed to save a life, explaining that a post-incident review here would look at what worked well and how it can be replicated.

“There are pockets of excellence within the sector,” says Murray. He believes increased funding and research into student mental health, including the 10 projects recently commissioned by the Office for Students, provide hope for a better future.

Implementing post-incident reviews, reducing stigma, improving information-sharing and reviewing the dismissal process can and will help to improve student mental health outcomes and save lives. As he continues to work with universities on student mental health policy, the core message Murray wants universities to learn from Ben’s death is to simply learn from the past: “We need the sector to learn from its past mistakes. That’s it.”