A coroner has strongly criticised the University of Exeter over the suicide of a student, claiming it failed to respond effectively to his “cry for help” after a disastrous set of exam results that followed months of isolation in near empty halls of residence during the pandemic.
Guy Davies, the assistant coroner for Cornwall, concluded that Harry Armstrong Evans’s death was due to a “mental health crisis” preceded by a “catalogue of missed opportunities coupled with systems failings” leaving him without the “safety net” the Russell Group university should have provided.
Less than a month before he was found dead, Armstrong Evans, 21, told his tutor in an email that isolation during Covid 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 it did not lead to any direct engagement between the university and Armstrong Evans or his parents. Davies said: “This court has heard evidence of the terrible consequences of academic pressures on students and the need for universities to provide a safety net … in Harry’s case the safety net did not operate.”
The coroner said he would send a report to the university as part of his duty to flag up findings that could prevent future deaths. This would include concerns about training on mental health issues, whether a computer system used by welfare services was “fit for purpose” and how information about students was shared.
Outside court, Armstrong Evans’s family described him as a “beautiful, kind and intelligent soul”, adding: “His passing is made all the more tragic because it was entirely avoidable.”
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. “Even our prisons are obliged to provide a duty of care to murderers,” they said.
The student’s mother and father, Alice and Rupert Armstrong Evans, 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.
They say that 11 students at Exeter have killed themselves in the past six years, including another young man in the physics and astronomy department. “For years, universities like Exeter have preferred to turn a blind eye to deaths of sons and our daughters in yes, their care,” they said. The university says not all of the 11 deaths have been confirmed as suicides by a coroner.
During the two-day inquest in Truro, Armstrong Evans was described as a diligent student but in January 2021 had a “disastrous” set of results.
His family were not told about his results but became alarmed at his state of mind and in May 2021 – the month before he died – Alice Armstrong Evans twice called the university’s wellbeing team expressing concerns. On both occasions staff pressed a button accidentally closing the case.
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.”
His tutor 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.
The coroner said the relationship between universities and students was not akin to a doctor and patient but they did have “safeguarding obligations”.
He concluded that Armstrong Evans’s email was a “cry for help” clearly requiring a “proactive response” beyond what actually happened – a “stream of emails” inviting him to fill in online forms.
“Nobody from Exeter University reached out to Harry – there was a total absence of personal engagement,” the coroner said. “Emails do not amount to personal engagement.”
The coroner also said the university should have considered contacting Armstrong Evans’s family, thereby “fully mobilising” his support network, but said some staff did not fully understand they were allowed to do this in some circumstances.
He also said the inquest had exposed an absence of in-person training for academic staff on mental health and concluded that the accidental closing of Armstrong Evans’s case twice was a “systems failures” that meant alarm bells were not sounded.
The university said it provided student support services seven days a week on campus and in the community, including throughout the pandemic.
Mike Shore-Nye, registrar at the University of Exeter, said: “We continually review and improve the wellbeing support we provide based on evidence and learnings, including from tragic cases such as Harry’s. We will consider the coroner’s detailed conclusions in this case and make sure we learn the lessons.”
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
