A 20-year-old university student who hanged herself was failed by the local mental health trust, an inquest ruled.
Anxiety-ridden Natasha Abrahart took her own life hours before she was due to deliver a presentation to a 329-seat lecture theatre.
A coroner today concluded that mental health services from from Avon and Wiltshire Mental Health Partnership neglected the vulnerable student, a fact that contributed to her death.
The 20-year-old was found dead in her student flat on April 30 2018. She is the tenth of 12 students to take their own life at Bristol University since October 2016.
Physics student Natasha died on the day she was due to give an assessed oral presentation to students and staff.
No failures were found on the part of the university or Natasha’s GP.
Avon Coroner’s Court heard academic staff had been aware since October 2017 that Natasha suffered “anxiety and panic attacks” in relation to oral assessments.
Despite Natasha having been referred to mental health services in February 2018 after the first of several suicide attempts, a senior lecturer said “no changes were made” to her presentation.
Senior Coroner Maria Voisin recorded in a narrative conclusion that Natasha’s death was contributed to by gross failures by Avon and Wiltshire Mental Health Partnership NHS Trust.
Senior consultant psychiatrist Dr Laurence Mynors-Wallis found that there was an “unacceptable delay” in Natasha having a specialist assessment following her referral to the Trust.
Speaking out after the inquest concluded today, Natasha’s parents, Robert and Margaret Abrahart, said they will “never stop working” to ensure this does not happen again.
They 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.”
The Avon and Wiltshire Partnership has paid “substantial”, undisclosed damages to the family, but has yet to apologise for its admitted failings.
During the six-day inquest, Senior Tutor of Physics Dr Adrian Barnes, said that the department had identified in October 2017 that Natasha required “pastoral support”.
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.
But, although Natasha’s written work was of a high standard, she was docked marks because of a perceived “failure to engage” with oral assessments.
Senior Tutor Dr Barnes said that when he met with Natasha in December 2017 and February 2018, he “never detected an unwillingness to do something”.
He continued: “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.”
The court heard that Dr Barnes concluded Natasha was suffering from “a genuine case of some form of social anxiety”.
On February 16, 2018, Student Administration Manager Barbara Perks met with a friend of Natasha’s who said the student was depressed and had been self-harming.
Miss Perks then received an email in the early hours of February 20 from Natasha, reading: “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.
It was 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, from Nottingham, was suffering from “chronic social anxiety with suicidal ideation”.
An urgent referral was made for her to be seen by specialists at the Avon & Wiltshire Mental Health Partnership NHS Trust.
On March 22 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”.
He wrote to the university GP the next day identifying a trigger for self-harm and suicide as “stress from University”.
He noted there was “a module which is assessed in an interview format which she finds very difficult”.
The court heard that on April 30 2018 internal university emails noted that that Natasha had missed three out of five oral assessments.
The email said 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”.
But Natasha was still expected to take part in the assessed presentation on April 30.
Dr Laurence Mynors-Wallis told the court that Natasha’s social anxiety would have made oral assessments “significantly worse” for her.
He said that the planned assessment on April 30 would have been “particularly difficult for Natasha”.
Dr Mynors-Wallis 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”.
He said that there was there was a “poor standard of communication” between the specialist mental health service and the University GP.
Dr Mynors-Wallis said that Natasha’s “risk of self-harm was not adequately assessed” by the Avon and Wiltshire Partnership.
And he added the assessment and management of Natasha by the mental health trust was “significantly flawed”.
His review of Natasha’s care concluded that the “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.
“At the same time we know that Natasha was being badly let down by specialist mental health services who failed to put in place a timely and adequate plan to mitigate Natasha’s risk of suicide.
“The University of Bristol objected to the family’s request for the inquest to sit with a jury and submitted that there was no ‘legal or factual basis for intensive scrutiny’ of its actions.
“There is an unfortunate and uncomfortable contrast between the arguments advanced by the University in this case and its other public pronouncements about wanting to learn lessons from the alarmingly high number of deaths amongst its students.
“It is to be hoped that the university will now reflect carefully on the meaningful changes it needs to make as a result of Natasha’s death.”
Professor Sarah Purdy, Pro Vice-Chancellor for Student Experience at the University of Bristol, said: “Natasha’s death is a tragedy that has affected everyone at the university but in particular the staff and students who knew and worked with her in the School of Physics.
“Staff in the school, along with colleagues from Student Services, tried very hard to help Natasha, both with her ongoing studies and with her mental health and wellbeing needs. This was highlighted and acknowledged during the inquest, with the coroner finding no fault with the university.
“We are very sad that these efforts could not help prevent her tragic death.
“As has widely been acknowledged, mental health is one of the biggest public health issues affecting young people globally – not just those studying at University.
“At the University of Bristol, we identified it as a key priority more than two years ago. We have introduced a whole-institution approach to mental health and wellbeing with additional investment in the support we provide our students in their accommodation, in academic schools and through central support services.
“This has enabled us to provide more proactive support for student wellbeing, both for our students during their transition into University and to help create a sense of community and wellbeing during their time with us.
“This approach is clearly reflected in our Student Mental Health and Wellbeing Strategy, which was launched earlier this year.”
Samaritans (116 123) operates a 24-hour service available every day of the year. If you prefer to write down how you’re feeling, or if you’re worried about being overheard on the phone, you can email Samaritans at [email protected]
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