IT system failure led to mother’s concerns for son being missed weeks before he took his own life

When a mother phoned her son’s university with concerns about his welfare just weeks before he took his own life, her pleas for help were never replied to due to failings in a computer record system, an inquest heard.

Alice Armstrong Evans was so worried about her 21-year-old son Harry that she tried to speak with the University of Exeter’s wellbeing service.

She explained the third-year physics and astrophysics undergraduate had been concerned about passing his degree following disappointing module results.

He was also anxious about his family’s finances with fears they would lose their home after his father lost a court case and faced legal bills.

Cornwall Coroner’s Court heard he was found dead at his home in Launceston in June last year having taken his own life.

Mark Sawyer, head of wellbeing and welfare services at the University of Exeter, told the inquest the referrals were passed to a welfare practitioner to respond.

But due to issues with the case management system, the logs were closed when they replied to the admin team asking for further information.

“What happened in this case, the voicemail message was put in a particular area of our case note system and the welfare team were advised of a referral through our inquiry system,” Mr Sawyer said.

“Unfortunately, the voicemail could not be attached to the inquiry which went to our welfare practitioners which said: ‘Please find attached a referral.’

“What happened at this point was the practitioner wrote back (to) the administrative team who had sent over the inquiry and said: ‘Where’s the referral?’

“But the practitioner, because of the technicalities and the challenges we face in utilising various aspects of the case management system, the practitioner utilised the wrong function to ask that question.

“They did it as answering the inquiry and the way that was answered unbeknown to the practitioner was to close down the inquiry, and when it went back to the administrative team, they saw the inquiry was closed and therefore the issue was not picked up that there was a request for further information.”

Mrs Armstrong Evans made a second call to the service later that month and was passed to a welfare practitioner to respond out-of-hours.

The inquest heard Mrs Armstrong Evans had only left her daytime contact details and when the practitioner replied to the admin staff asking for an alternative phone number, the log was closed.

“Because of these technical challenges about which button you press in the system, now we have become alerted to that, we have put in a completely different system for tracking student wellbeing inquiries,” Mr Sawyer said.

“The university is willing to look at a different case record management system so that we can really not have these issues from the technicalities associated with the current system.”

Asked if this was as a result of Mr Armstrong Evans’ death, Mr Sawyer replied: “It is very much so, and as a result of a recognition of an issue that was not clear, and I think the challenge for practitioners is that practitioners use certain parts of the system and administrators use a different part and it is quite difficult to understand both sides of the system.”

The student later emailed his personal tutor and the wellbeing service expressing concerns about his isolation during lockdown, his declining mental health and worries about his exams.

Mr Sawyer said there was nothing in the email to indicate Mr Armstrong Evans was in a crisis and required an immediate response.

“There were no obvious red flags to any of us at that time in May,” he said.

Mr Armstrong Evans’s father, Rupert, asked Mr Sawyer whether he thought the university owed his son duty of care.

Mr Sawyer replied: “It is very hard for the university to manage the expectations upon it and its capacity to really deliver care in what I understand to be the meaning of ‘duty of care’.

“In many ways we accept a limited and voluntary responsibility to signpost students when risk becomes apparent.

“If red flags come in then we are not really there as an education institution to directly assess and provide effective monitoring and risk management.

“We try very hard on the information we have to give good advice to students around signposting.

“What was apparent to us in this whole tragic case was that at no point did any of us recognise or notice any red flags for Harry’s safety.

“In many ways from what I could see in the evidence bundle we were all unable to notice any red flags.”

Mr Armstrong Evans asked: “Do you now accept there may be a lot of students who maybe in trouble who simply don’t reach out?

“I would say in Harry’s case his only sin was that he was shy or embarrassed to ask for help.”

Mr Sawyer replied: “Our heartfelt sympathies and the loss of any student in our community is enormously devastating for staff and students and we can only imagine what it is like for yourselves.”

He said the university tried to make services as accessible as possible to students.

Mrs Armstrong Evans told the inquest she had been reassured that a member of the wellbeing team would contact her son.

“I spent a long time on the phone with an administration officer who said someone would get in touch with Harry,” she said.

“I put my faith in the statement that someone would be in touch with him. I see that now as the biggest mistake of our lives.”

She added: “Harry would not be the type of person to go asking for professional help.

“He had been in boarding school from a young age, and I would describe him as a stiff upper lip type and he would be unlikely to approach someone to discuss his personal feelings.

“I believe if a professional counsellor or therapist had approached him and asked if he wanted to talk then I know he would have done so because he needed some outside support – not just to his mother and father to talk to.”

Her husband said as parents they did not have the full picture of the difficulties their son was going through.

“I had no idea that he would go on and take his own life, especially as there were no outward signs,” he said.

“As his parents I can state without hesitation that if we had been aware of his situation everything would have been resolved.”

Assistant coroner Guy Davies adjourned the inquest to a date to be fixed for him to record his conclusion.

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