Preventable Suicide of University Student Case
We were instructed by Mr B arising out of the death of his daughter C who died by suicide in 2022, aged 20.
C was studying for a degree when she referred herself to her local Trust’s Wellbeing Service in November 2021. She reported self-harming and suicidal thoughts. Due to the level of risk, she was referred to the Youth Team who initially declined to see her as she was studying in another part of the country. The referral was re-presented when C explained that she was now living back in her hometown and that she planned to complete her degree on-line
The referral was accepted and discussed at the Youth Team Multi-Disciplinary Team triage meeting. A newly qualified Mental Health Practitioner was asked to telephone C, assess her level of risk and make a safety plan with her. During the call C disclosed that she was deliberately self-harming and she had fleeting thoughts of suicide. She described a plan she had that if she ever did get to the point of wanting to take her own life, she knew a specific spot that she would go to do it and how she would do it.
Following the call, it was decided that there was no risk of suicide as C he had denied any current intention to act on her plan. C was referred to the mental health charity Mind and discharged from further follow up. Mind anticipated being able to contact C in the next 6 – 8 weeks but around 4 weeks later Police Officers arrived at C’s family home to confirm that she had been found dead that morning.
C had not confided in her parents about how she was feeling. Her death was a huge shock to them. They attended a remote Inquest into their daughter’s death and only then became aware that she had sought help but not received it. At the Inquest into C’s death, a Clinical Director and Consultant Clinical Psychologist for the Trust explained that the red flag indicator had been missed in C’s case. C had a clear plan as to how she would take her life if she chose to do so. This should have been followed up and C should have been seen face to face.
In addition, the Trust’s own Patient Safety Incident Investigation Report concluded that due to human and system factor pressures arising from demand and capacity issues, a junior and inexperienced member of staff triaged the referral without adequate support or supervision.
What had not been determined by the Inquest or the Trust’s internal investigation is whether C’s death would have been avoided in the absence of the poor treatment that she received. We obtained a report from a Consultant Psychiatrist. In her view, with a proper assessment it is likely that C would have been referred to the Crisis team and seen within 24 hours. She would have been kept under review and offered medication and psychological support. It was clear from the efforts made by C that she wanted help. Had she received the appropriate support and intervention from professionals, it is more likely than not that the fatal outcome would have been avoided.
A Letter of Claim was served on the Trust and liability was admitted in full for the failings in C’s treatment resulting in her death. A five figures settlement was accepted by her family.
Ashleigh Holt, September 2025