“(brief summary of matters of concern) (1) Lily resided at student accommodation provided…”

The coroner’s concerns

(brief summary of matters of concern) (1) Lily resided at student accommodation provided by Student Roost. They describe themselves on their website as ‘a student accommodation provider who puts your wellbeing first. Our aim is to provide the very best experience for you to make the most of student living. Since they were established in 2017, Student Roost has grown to offer 50+ properties across the UK. Student Roost run a 24/7 service including a Night Owl Service which is an excellent idea and provides a 24 hour service to help students with everything from loosing their keys, broken taps, but also their wellbeing. During the course of hearing evidence, it is evident that all of Lily’s extreme acts of self-harm took place at her student accommodation. She took at least 3 overdoses and also carried out 2 acts of ligating which she had to be either untied or cut down from. One of those I heard required CPR. I am therefore surprised to learn that no staff (certainly in the 6 properties offering accommodation within Leicester) had first aid training and that it isn’t mandatory, such that no staff are trained by Student Roost in first aid. It transpires therefore that any immediate first aid provided to Lily was provided by those who fortuitously had that training from other organisations before they joined Student Roost. In the context of this case but also wider than that, members of the accommodation staff could potentially be the first people at the scene of a situation requiring first aid and then emergency services; where death may occur the fact therefore that they receive no training concerns me. (2) I have spent a lot of time in this inquest investigating the information which was known about Lily, about her mental health and who had access to what information in the context of assessing her risk. In September of 2023, Miss Evans, Assistant Coroner sitting within the Rutland and North Leicestershire jurisdiction heard an inquest concerning a student at Loughborough University. Similar to Lily’s case he was under the care of a private psychiatrist elsewhere in the country where he had lived prior to attending university. As a result of concerns in that case (his death occurring 1 year before Lily’) around lack of contact by the Crisis Team at the time of assessment or otherwise with the private psychiatrist, the Coroner wrote to the Leicestershire Partnership Trust to share her concerns. The Trust referenced the Crisis Team Standard Operating procedure in the inquest in September 2023, the Coroner was concerned about the level of awareness that staff members had of any expectation required of them set out within that procedure to seek information from other agencies. I now have sight of the Cris Team Standard Operating Procedure. It sets out the keyworker responsibilities. The section is drafted presupposing that patients are receiving care and treatment from the Crisis Team and only at that point does the responsibility for seeking relevant information from other agencies kick in. Furthermore the emphasis upon that requirement is limited to one line which reads ‘responsibility for referrals and liaising with other agencies involved’. That is anything but clear as to any expectation upon staff to ensure they have at their disposal all of the relevant risk information at the time of making that assessment; nor does it in my view set out any expectation upon staff to proactively Regulation 28 – After Inquest Document Template Updated 16/05/2023 make contact with treating clinicians in the private sector to gain information. It would not capture situations such as Lily’s, who was discharged from the Crisis Team after an 1 hour assessment and therefore was not under their care and treatment, I having found a failure to obtain all relevant information pertinent to her risk in assessing that risk.

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, 2024-0273

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