Coroner finds neglect contributed to suicide of University of Bristol student Natasha Abrahart

A Senior Coroner has concluded that a series of failures by mental health services contributed to the suicide of a vulnerable student at the University of Bristol.

The body of Natasha Abrahart, 20, originally from Nottingham, was found in her student flat in Bristol on 30 April 2018. The second-year physics student was due to give an assessed oral presentation to students and staff in a 329 seat lecture theatre that day. 

Academic staff first became aware that Natasha was struggling in October 2017 and said they knew that Natasha “suffered from anxiety and panic attacks” in relation to oral assessments. However, a senior lecture told the inquest that “no changes were made” to her assessment on 30 April.

The University’s GP service had referred Natasha to Avon and Wiltshire Mental Health Partnership NHS Trust in February 2018 following the first of several suicide attempts.

Robert and Margaret Abrahart, Natasha’s parents said:

“Natasha’s social anxiety resulted in a six month struggle with oral assessments at the University of Bristol.  Her anxiety forced her to avoid most of these – for which the University docked her marks.  As a result our bright, capable daughter faced failing academically for the first time in her life.

Our daughter came to Bristol seeking a better, brighter future. Instead, we lost her forever. We will never stop working to ensure that other students don’t endure the suffering she did. We never want any other families to live with the pain we and our friends will face for the rest of our lives.”

Dr Laurence Mynors-Wallis, a senior consultant psychiatrist, was instructed by the Senior Coroner for Avon, Maria Voisin, to review the treatment Natasha received from the Avon and Wiltshire Partnership.

He found there was “an unacceptable delay” in her having a specialist assessment following her referral to the Trust and that Natasha’s “risk of self-harm was not adequately assessed.”

Dr Mynors-Wallis also found that a “failure to provide a timely and detailed management plan for Miss Abrahart represents a causal connection with her subsequent death.”

Gus Silverman, a public law and human rights lawyer at Irwin Mitchell, representing the family, said after the inquest:

“The University owed a duty of care to Natasha. It’s hard to understand how such a deeply vulnerable student received no direct contact from trained members of staff within the University’s Student Services, in which it has invested so much money in recent years.  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 and have should have been removed."

Coroner Maria Voisin recorded a narrative conclusion, finding that Natasha’s death was contributed to by gross failures by the Avon and Wiltshire Partnership.

The family’s solicitors at Irwin Mitchell confirmed that the Avon and Wiltshire Partnership has paid substantial undisclosed damages to the family but has yet to apologise for its admitted failings.

Background

During the six day hearing at Avon Coroner’s Court Dr Adrian Barnes, the Senior Tutor in the School of Physics, told the inquest that the department had identified “a need for pastoral support for Natasha” in October 2017.  Internal University emails read to the court stated “we had a problem of being unable to get…Natasha Abrahart to say anything at all” during her first oral assessment. 

The inquest heard that, while Natasha’s written work was of a high standard, she was docked marks because of what Dr Chris Bell, a Senior Lecturer in the School of Physics, described as “her failure to engage” with oral assessments.  

Responding to questions from the family’s barrister, Tom Stoate of Garden Court Chambers, Dr Barnes said that when he met with Natasha in December 2017 and February 2018 “I never detected an unwillingness to do something. I felt that there was someone there trying and wanting to do something but needing more support in working out how they would do that”. 

After the meeting in February Dr Barnes told the court that he contacted the University’s Disability Service for advice on what “reasonable adjustments” they could make to Natasha’s course but accepted that he never heard back and didn’t chase up the email. 

The court heard that the University was under a legal duty to make reasonable adjustments to its assessments to prevent disabled students from being placed at a significant disadvantage when compared with their non-disabled peers. The court heard that Dr Barnes concluded Natasha was suffering from “a genuine case of some form of social anxiety.”

Barbara Perks, a Student Administration Manager in the School of Physics, told the inquest that on 16 February she met with a friend of Natasha’s who said the student was depressed and had been self-harming. Ms Perks told the Coroner that she contacted the University’s Student Wellbeing Service who sent her a list of online resources that Natasha could access. 

Ms Perks went on to explain that in the early hours of 20 February Natasha emailed her saying “I wanted to tell you that the past few days have been really hard, I've been having suicidal thoughts and to a certain degree attempted it.”  Later that day Ms Perks took Natasha to a University GP who noted that she had made a suicide attempt with “definite intent” was “in a state of acute distress” and was “at high risk of ending her life given her presentation”.

The University employed doctor concluded that Natasha was suffering from “chronic social anxiety with suicidal ideation” and made an urgent referral for her to be seen by specialists at the Avon & Wiltshire Mental Health Partnership NHS Trust.

Under questioning Ms Perks said she “probably” told the Student Wellbeing Service about the email from Natasha. However, the Coroner was told that there was no record of this and the Student Wellbeing Manager who had been assigned to Natasha’s case said that she “was not aware of any risk that would have necessitated my intervention”. During her evidence Ms Perks also said that it was “quite possible” that she had told the Student Wellbeing Manager that Natasha did not want direct contact with specialist advisers, however the court was again told that there was no record of this.  

On 22 March 2018, following a further two suicide attempts, Natasha was visited at home by a Crisis Team. A nurse from the team told the Coroner that Natasha was at “significant risk” and that he wrote to the University GP the next day identifying a trigger for self-harm and suicide as “stress from University” and noted there was “a module which is assessed in an interview format which she finds very difficult”.

On 20 April 2018 Natasha met with a GP at the Student Health Service, who told the court that she didn’t discuss passing on the information about suicide triggers to anyone in the University.

The court heard that on 30 April 2018 internal University emails noted that that Natasha had missed 3 out of 5 oral assessment and that it was “going to be tight” as to whether she passed the module. Dr Barnes told the court that Natasha would not have been able to continue on the course if she did not pass this module. In a statement read at the beginning of the inquest Natasha’s mother said she thought that the previously high achieving student would have seen this as “a huge failure”.

The Coroner was told that the University’s disability policy required staff to provide “interim-support” to students disabled by mental illness, and that this could extend to modifying assessments, but that Natasha was still expected to take part in the assessed presentation on 30 April.

A consultant psychiatrist, Dr Mynors-Wallis, told the court that Natasha’s social anxiety would have made oral assessments “significantly worse” for her and that the planned assessment on 30 April would have been “particularly difficult for Natasha”. He concluded that “the stress of the University course was certainly a factor and among the stresses that Natasha was facing at the time she died”.
 

Failings by mental health services

On day four of the inquest Dr Mynors-Wallis, a senior consultant psychiatrist instructed by the Coroner to review the treatment Natasha received from the Avon and Wiltshire Partnership, told the court that:

• There was “an unacceptable delay” between Natasha being referred to the Avon and Wiltshire Partnership by the University GP on 20 February 2018  and a specialist assessment taking place.
• There was a “poor standard of communication” between the specialist mental health service and the University GP.
• Natasha’s “risk of self-harm was not adequately assessed” by the Avon and Wiltshire Partnership.
• The plan for Natasha to continue on anti-depressant medication prescribed to her by a trainee psychiatrist was “inadequate”.
• The assessment and management of Natasha by the mental health trust was “significantly flawed”.
• The “failure by the specialist mental health team to make an adequate assessment and implement an immediate care plan was a second missed opportunity” to help Natasha in March 2018.
• The delay in allocating a care coordinator to Natasha following a referral from the Crisis Team in March 2018 was “unacceptable” the absence of a system for providing holiday cover was “quite shocking” and the “allocation of an individual to develop such a therapeutic relationship occurred far too late for it to have helped Miss Abrahart”.
• The failure to develop a crisis plan for Natasha in April 2018 was “an important omission”.
• The “failure to provide a timely and detailed management plan for Miss Abrahart represents a causal connection with her subsequent death.”

In correspondence with the family before the inquest the Avon and Wiltshire Partnership admitted there were “missed opportunities” to put in place “an appropriate management plan” and to “provide the Deceased with an enhanced and more assertive level of care”.  

A separate review carried out by the Trust’s Suicide Prevention Lead concluded: “Risk was clearly underestimated. It is important to clarify that what we would term 'red flag' suicide risk factors were all present and visible at the time, and have not been identified solely with the benefit of hindsight. A more structured approach to risk management could and should have occurred earlier on.”

The inquest was reported on by the BBC and the Guardian. 

Tom Stoate is a member of the Garden Court Chambers Inquests and Inquiries Team.