“The decision to go to William’s room was hampered by the lack of a clear protocol for the…”
Dated 14 Dec 2015, from the coroner for Exeter and Greater Devon. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 8 Feb 2016. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated14 Dec 2015
- Deadline8 Feb 2016
- Published on judiciary.uk14 Dec 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University of Exeter | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Devon Partnership NHS TrustNamed in the report as “Devon NHS Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— 1. The decision to go to William’s room was hampered by the lack of a clear protocol for the involvement of the relevant agencies and the Police. 2. The respect for the autonomy of the student in running his/her private life appeared to take precedence over a real concern for welfare, resulting in delays in attendance at the scene and a reluctance to take the decision to force entry. It aopears that the Students Union’s opposition to any erosion of the students’ human rights (to privacy) was a factor. 3. There is a real risk of future deaths of students in distress for lack of timeous intervention because of the current restraints.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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