A coroner has strongly criticised the University of Exeter over the suicide of a 21-year-old student, claiming it had failed to respond effectively to his “cry for help” after a “disastrous” set of exam results and in light of his despair over being isolated during Covid.
Guy Davies, the assistant coroner for Cornwall, said Harry Armstrong Evans’ death had been due to a “mental health crisis” and was preceded by a “catalogue of missed opportunities coupled with systems failings” that meant the student did not receive the support he needed.
Less than a month before his death last year, Armstrong Evans, 21, told his tutor in an email that isolation during the pandemic had affected his mental health and his performance in his third-year physics and astrophysics exams.
The coroner said this was a cry for help but said it did not lead to any direct engagement between the university and Armstrong Evans or his parents.
The coroner said he would send a report to the university as part of his duty to flag up issues that could prevent future deaths. This would include his concerns about training on mental health issues, whether the computer system used by welfare services was “fit for purpose” and how information about students who could be suffering was shared.
Outside court, Armstrong Evans’ family said their son was a “beautiful, kind and intelligent soul”. They said a “silent student suicide pandemic” gripped Britain and for too long universities had operated in a space where by law they were not obliged to provide a duty of care to students.
During the two-day inquest in Truro, Armstrong Evans was described as a shy, diligent student who did well in his first and second year exams, but in January 2021 he had a “disastrous” set of results and his ambition of postgraduate studies seemed in tatters.
His family became alarmed at his state of mind and on 7 May 2021 – seven weeks before he died – his mother, Alice Armstrong Evans, called the university’s wellbeing team and left a message saying her son was “not in a good place mentally”.
But the inquest heard that a welfare consultant pressed the “wrong” button on the computer system and accidentally closed the case. “I’d never phoned up before,” said Alice Armstrong Evans. “I thought they would take more notice. It never crossed my mind someone would lose the information.” She rang back about a week later but again the case was apparently accidentally closed.
On 28 May, Armstrong Evans sent an email to his academic and pastoral tutor, and the welfare team explaining that isolation during the pandemic, along with family difficulties, had affected his mental health.
He wrote: “I have been in isolation in my virtually empty hall of residence. I’ve spent so much time isolated by myself in my flat with almost no human contact. It really has had an adverse effect on my mental health. I really struggled to think straight and the exams for me were a horrible culmination of my stresses.”
His tutor emailed Armstrong Evans offering his help and suggesting a meeting over a coffee. But he told the inquest he had not had in-person training on suicidal ideation and could not recall receiving formal guidance on spotting “red flags”.
By the time Armstrong Evans was found dead at the family home near Launceston, Cornwall, on 24 June 2021 neither academic staff nor members of the welfare team had actually spoken to him.
Alice Armstrong Evans, told the inquest more should have been done to help her son. She claimed that 11 students at the university had killed themselves in the past six years, including another young man in the physics and astronomy department. The university has said not all of the 11 deaths have been confirmed as suicides by a coroner.
The head of physics and astronomy, Tim Harries, said Browning and other staff had tried to help Armstrong Evans and that he did not believe more suicides happened at Exeter than at other universities.
Mark Sawyer, the head of wellbeing at the university, said despite the calls from Alice Armstrong Evans and the student’s email, he had not been considered an “immediate risk.” He said: “There was nothing indicative of an urgent mental health crisis,” and argued that directly speaking to Armstrong Evans on the phone might have been intrusive.
Alice Armstrong Evans and her husband, Rupert, are campaigning for the government to adopt what they are calling “Harry’s law”, under which universities would have to publish the annual student suicide rate, and the faculties in which those students were based.
The inquest came as Universities UK, representing 140 universities, said clearer policies were needed on how and when to involve relatives, carers and trusted friends when there was considered to be a serious risk to a student’s welfare.
A group of parents, including the mother and father of Natasha Abrahart, a University of Bristol physics undergraduate who had severe social anxiety and killed herself a day before she was due to give a “terrifying” oral exam, have called for the government to introduce new laws to protect students.
In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is at 800-273-8255 or chat for support. You can also text HOME to 741741 to connect with a crisis text line counselor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org
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