Neglect by a mental health trust contributed to the suicide of a Bristol University student with severe social anxiety who was found dead on the day she was due to take part in a “terrifying” oral test, a coroner has ruled.
The senior Avon coroner Maria Voisin criticised the Avon and Wiltshire Mental Health Partnership NHS trust (AWP) for not putting in place a management plan that would have given Natasha Abrahart hope and managed her risk.
After the inquest, Abrahart’s parents also blamed the university, claiming it failed to put in place measures to help their daughter even though staff knew for six months that she was struggling.
Abrahart, 20, was the 10th of 12 students at Bristol University known or suspected to have killed themselves since September 2016. The coroner did not comment on the university’s care in the record of the inquest but Abrahart’s parents claimed the university was in denial over the deaths and said they intended to pursue legal action against it.
Abrahart, who was studying physics, was found dead in her student flat at 2.30pm on Monday 30 April 2018, half an hour after she had been due to take part in a “laboratory conference” that would have involved her giving an assessed presentation to almost 50 fellow students and staff in a 329-seat lecture theatre.
Academic staff in the physics department had known since October 2017 that Abrahart suffered from anxiety and panic attacks when she had to take part in one-to-one oral assessments. The inquest was told that no measures were in place to help her through the ordeal of the laboratory conference.
The inquest heard that Abrahart had three suicidal episodes before she died and she had also been cutting herself. She was referred by a university GP to AWP.
In a narrative conclusion, the coroner said Abrahart’s death was suicide and that neglect had contributed to it. She said: “At the time of her death she was under the care of the mental health team, who had not provided a timely and detailed management plan following a number of assessments by them. That management plan should have been in place by the end of March 2018 … which would have instilled hope and managed her risk.”
In a statement given outside court, Abrahart’s parents, Margaret and Robert, from Nottingham, said they had endured a year of hell. “Individual and systemic failings have been exposed. There are absolutely vital lessons for everybody – lessons that if they’d been learned earlier may have saved our daughter’s life.”
The parents, who raised money to help investigate their daughter’s death through a crowdfunding appeal, receiving donations from more than 500 people, said they were grateful that AWP had set out what it intended to do to improve its services.
But they accused the university of still being in denial. They said: “Throughout this inquest process it has attempted to shut down, block and narrow any meaningful examination of its actions.”
They said they had uncovered a “deeply troubled picture” at the university. “Information wasn’t shared, referrals to student support services were not followed up, there was confusion over who was involved in Natasha’s case and no one took the lead in addressing her obvious difficulties.”
The family’s lawyer, Gus Silverman, of Irwin Mitchell, said: “An apparent lack of information sharing, coordination and compliance with the university’s own policies on supporting disabled students left Natasha exposed to stresses which could have and should have been removed.”
Prof Sarah Purdy, the pro-vice-chancellor for student experience at the university, said: “Staff in the school, along with colleagues from student services, tried very hard to help Natasha, both with her ongoing studies and with her mental health and wellbeing needs.”
It said the university had identified mental health as a key priority more than two years ago. Purdy said: “We have introduced a whole-institution approach to mental health and wellbeing with additional investment in the support we provide our students in their accommodation, in academic schools and through central support services.”
The university said it did try to help Abrahart with the laboratory conference and discussed options such as not taking to the stage, letting others present and not having to answer any subsequent questions.
It said she told a staff member on the Friday before the conference that she was keen to go ahead and understood that any or all of those measures could be implemented.
Julie Kerry, the director of nursing at AWP, said: “We fully accept the findings of the coroner and recognise that we did not act in accordance to best practice in all of the care provided to Natasha. We and our partner organisations know that changes need to happen to some of our processes and ways of working and we are committed to doing this and have already put in place some measures to minimise the risk of a similar incident occurring in the future.”
• In the UK, Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international suicide helplines can be found at befrienders.org
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