National review of higher education student suicides: resources for institutions

This article discusses suicide. If you are affected by its content, you can contact the Samaritans for free on 116 123 or visit samaritans.org for confidential support.

In May 2025, the Department for Education’s National Confidential Inquiry into Suicide and Safety in Mental Health published the National review of higher education student suicide deaths (the Review). Researchers from the University of Manchester contacted all Higher Education institutions and asked them to provide information on whether their organisation had completed a serious incident investigation into a suspected suicide or incident of self-harm in the 2023/2024 academic year and, if so, to submit a redacted version of the report. 110 Higher Education institutions responded. A short summary of some key findings of the Review:

• Three quarters of the student deaths were undergraduates, with nearly a quarter of these being in their first year. Most commonly, students were enrolled as studying at the time of the deaths and were already known to university support services.
• Reports from institutions often mentioned academic problems and a small number of students were subject to disciplinary procedures. Around a third of all cases identified evidence of non-attendance, which was generally met with an email from the programme administrator. Almost half of the reports identified mental health difficulties as a potential factor for the incidents.
• The Review made a number of recommendations, including mandatory mental health awareness and suicide prevention training for all staff; increased input from the students’ families; and the introduction of a duty of candour to be open and transparent with families. The Office for Students has noted it will “carefully consider any recommendations which relate to our work”.

Any death among a university’s student community is a tragedy. As the introduction to the Review states: “the figures and graphs in this report relate to real, often young, lives lost and families devastated. The serious incident reports we examined are individual tragedies and demonstrate the need to improve prevention”.

The Review should prompt universities to reflect on their policies and processes for preventing and responding to student suicides and incidents of non-fatal self-harm. This article sets out some key considerations for institutions on preventing student suicides, conducting effective investigations after a suicide, navigating inquests and supporting staff, and draws together a number of resources we have previously produced on the topic.

While we attempt to provide some general advice on key components below, tricky issues are likely to arise, and institutions should seek tailored, specialist advice as needed.

Duties of care and reasonable adjustments

Following the death of Natasha Abrahart, the then government rejected a proposal from a subsequent petition for the creation of a statutory duty of care for students in Higher Education. Instead, it commissioned an independent review of student suicide deaths, which became the Review. Many will be aware of the Abrahart case but in brief summary, Natasha suffered from “severe depression with prominent anxiety features” and died by suicide while studying at the University of Bristol.

As part of her course, Natasha had been required to conduct an oral assessment which, following a claim brought by Natasha’s parents, the County Court found was “the primary stressor and cause of Natasha’s depressive illness” that led to her suicide. The County Court and High Court found that the University failed to make a reasonable adjustment in respect of these examinations.

It was argued on Natasha’s behalf that universities owe a general duty to take reasonable care not to cause injury, including psychiatric harm and injury to their students. The County Court denied that such a duty existed, the High Court refused to rule on the issue, and the Government has not provided clear guidance on its position as to whether such a duty should exist or what it includes. However, universities should be mindful of two key things:

First, as in Natasha’s case, universities are under an obligation to make reasonable adjustments for disabled students, and mental health problems may constitute a disability, requiring providers to address the question of reasonable adjustments in the context of competence standards; and

Second, institutions should ensure they safeguard the wellbeing of their staff who are impacted by any student death by suicide. This point was also made in the Review, noting that only 18% of reports by institutions showed evidence of support for affected staff members. Institutions must be mindful that the general duty of care of an employer to their members of staff includes protecting them from psychiatric injury, and the Review recommends support should be offered or signposted for anyone affected by a student’s death by suicide.

If you would like to read more about Natasha’s case and a statutory duty of care  please see our previous blog High Court rules university is legally responsible for student suicide without finding duty of care.

Effective prevention of student suicides

Key recommendations from the Review commented on methods of suicide prevention. A good starting point for universities is the Office for Students’ briefing on Suicide prevention. Its advice focuses on themes including:

• Take a whole provider approach – ensure that suicide prevention is an institutional priority. Staff should be trained in suicide awareness and prevention. There should be internal systems to allow for appropriate sharing of information. On this point, institutions often feel some uncertainty over the sharing of safeguarding information relating to students, worrying that data protection considerations prevent them from doing so, when in reality the picture is more nuanced. For more information on information sharing and student wellbeing, providers can read our previous blog on sharing safeguarding information.
• Work in partnership with the wider community – work with local partnerships, mental health experts and voluntary organisations to allow sharing of knowledge and expertise.
• Centre the needs of students – promote mental health awareness, signpost available support and encourage openness. The guidance notes that universities should establish a policy on sharing information with family and friends.
• Develop postvention plans and support – consider in advance how to respond to a student death by suicide. Ensure that friends, peers and staff impacted by the death are supported.

For more on the Office for Students’ guidance, please see our previous blog OfS advice on suicide prevention and additionally our blog on UUK's Guidance for suicide prevention in universities.

Conducting an investigation following an incident

The Review was critical of certain elements of the investigations universities carried out following a student death by suicide. There were concerns about the extent that investigations were not led by independent, senior members of staff; a lack of clarity on the period covered by the investigation; and that the students’ families did not tend to be involved.

Universities should tackle investigations into student deaths by suicide with the same robust approach as they would any other investigation. Universities should ensure that investigators are appropriately senior and independent and have very clear terms of reference for the investigation.

Dealing with such sensitive topics can give rise to particularly tricky issues. Investigators may encounter hostile witnesses from fellow students or family members, or deal with people who have significant trauma following a suicide or non-fatal event of self-harm. Universities should, so far as possible, adopt a trauma-informed approach and support such witnesses in giving their best evidence.                                                    

For more on conducting effective investigations generally, please see our previous blogs Are you ready to launch a workplace investigation?; New EHRC harassment guidance: trauma informed investigations; and Achieving best evidence from witnesses in investigations.

Navigating an inquest following a student suicide

We have recently written a dedicated piece for universities on navigating an inquest. While universities will naturally want to focus all efforts on preventing deaths by suicide, it is necessary to have a plan of action should the worst-case scenario come to fruition. Should a student die by suicide, it is possible that an inquest could be held.

An inquest is a critical legal procedure aimed at determining the circumstances surrounding a sudden or unexplained death. The inquest is an inquisitorial, fact-finding process. The role of the coroner is not to apportion blame, but to establish the facts and, where appropriate, make recommendations to prevent future deaths. The coroner must answer four statutory questions: (1) who died; (2) where they died; (3) when they died; and (4) how they died.

Inquests will likely be an unfamiliar process for many individuals at universities, and pose their own unique challenges. Due to the subject matter, they often attract press interest and the coroner has a very limited ability to exclude the media and the public. Further, members of staff may be called to give evidence during the inquest and will be expected to give an open and honest account to assist the coroner. Those members of staff will also need support in going through a difficult process.

Universities who need to navigate through an inquest are strongly encouraged to take expert advice.

Many thanks to trainee Alex Evans for their help in writing this article.

This publication is a general summary of the law. It should not replace legal advice tailored to your specific circumstances.

© Farrer & Co LLP, June 2025