Sarah Clarke
16 May 2022 · Coroner Karen Henderson · Surrey
The coroner's concerns
1. higher incidence of mental health difficulties, self-harm and suicide
“students have a higher incidence of mental health difficulties, self-harm and suicide exacerbated by multifactorial issues such as being effectively itinerant with work and other social pressures”
2. significant mental health difficulties exacerbated by bereavement and personal difficulties
“[the deceased] was known to have significant mental health difficulties exacerbated by a recent bereavement and other personal difficulties”
3. lack of steps to reassure safety from self-harm
“CWB staff did not take steps to reassure themselves that [the deceased] was safe from self-harm”
4. insufficiently robust organisation and systems to manage, treat and safeguard high-risk students
“The organisation and systems at the CWB were insufficiently robust to appropriately manage, treat and safeguard students known to have mental health problems and be at high risk to themselves”
5. lack of implementation of national suicide reduction guidance
“National guidance issued in September 2018 to reduce the incidence of suicide in the student population had not been implemented by CWB”
6. lack of internal or external regulatory oversight of service provision
“There was no internal (by CWB) or external regulatory (by US) oversight as to the service provision at CWB before [the deceased]'s death or indeed after her death”