“Matthew was neurodiverse”

The coroner’s concerns

1. Matthew was neurodiverse. It was accepted that this condition was not known by the university at the relevant time, as he was diagnosed after his commencement on his course and did not disclose his condition to the university. In the circumstances, appropriate actions and case specific assistance which might otherwise have been availble to and assisted Matthew were neither implemented in response nor accessed by him. Notwithstanding Matthew’s neurodiverity – which of itself was a barrier to him being able to reach out or to seek help - I am concerned about the level of awareness, understanding and curiosity of accademic staff around the mental health of students, particularly in the post-pandemic climate, where interruptions to their study and dysregulated student life have had a significant impact on their mental health. Whilst it was explained to me that all staff are offered training on mental health management and are provided with guidance on how to support students, I am concerned that aspects of this are not made compulsory for accademic staff. Where a myriad of training options are made availble to staff and often required of them, with very little practical time availble in which to do it, there is a risk that modules and aids with regard to mental health will not be prioritised, followed through or addressed. There is as I understand it no evident monitoring in respect of which staff have viewed or undertaken what training or indeed in respect of who has completed the modules on offer. It remains unclear as to who or how many staff have actually viewed or undertaken the online training around student mental health. Although the process of ‘raising a concern’ by accademic staff is a means by which such matters can be considered and is a process set up and encouraged through the student hubs, I am concerned that in not ensuring that accademic staff are at least armed with the ability to spot or to know when to make initial enquiries of students or are clearly guided on how best to do so (particularly with regard to an understanding of the needs and skills required to liaise with students with neurodiversity), there is a risk that an over-focus on accademic policies and procedures will endure and that those students who are struggling to adhere to them will be missed or overlooked. 2. It was evident to the Court that very positive steps have already been undertaken in planning towards an ‘early warning system’ for students in the accademic year 2023/24. This will allow triggers to be identified and set for accademic absence and changes in study or support behaviours (as is to be trialled in 2023/24). Such steps are to be commended and I hope will proceed at pace. However, I do have concerns that there is and remains an evident gap between the accademic assessment of students and the pastoral support that they receive. I hope this will be addressed and filled – in part in the development of staff training and understanding around mental health and in what circumstances concerns should be raised (as above). Where accademic absence or performance issues are identified, I am not convinced, on the evidence heard at this inquest, that enough has yet been done to also consider how ‘reaching out’ to such students can be most effectively achieved. It was evident that much of the group-focused approaches offered by the universtity or the initaitves where the onus is placed on the student to come forward, may not work. Practically, how best can students – especially those with neurodiverse needs – be compassionately and empathetically approached and engaged with to ensure they receive the help and validation that they probably desperately require? Regulation 28 – After Inquest Document Template Updated 30/07/2021 3. The evidence at this inquest raised concerns over the existance, frequency and accuracy of the recording and minueting of accademic meetings with students, especially those between the student and Personal Accademic Tutor and the Project Supervisor in the third year of study. It was of concern to me that the University was unable to locate or provide clear minutes of supervisory catch ups, progress checks or agreed guidance or actions for Matthew. It was of further concern that the accademic staff supporting and mentoring him in his third year had not provided written evidence of his progress or agreed minutes of actions etc to him. Whilst it is recognised, particularly in a third year of study, that there must be a balance between independence and appropriate support, it would in my view be important for any student and university accadenic team to have a clear record of achievement or progress. This must be able to be reflected back to the student and recorded in such a way as to ensure that both student and tutor are clear and agreed as to progress that has been achieved and as to what needs to be done to move forward. The absence of such information and appropriate support, which can lead to feelings of isolation and desperation, must be avoided at all costs.

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, 2024-0033

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0