Natasha is dead. How could this happen?
Natasha is dead. How could this happen?
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Latest: Aug. 30, 2019
16-month progress report
Natasha’s inquest lasted eight days (7th-16th May). The senior coroner, Maria Voisin, concluded that there had been a gross failure by the Avon and Wiltshire Mental Health Partnership NHS Trust…Read more
Our daughter was one of eleven students at the University of Bristol who took their own lives in the last two academic years. We are determined to find out why this happened, if anything could have been done to prevent it, and whether things need to change to make students safer.
Who are we?
We are the parents of Natasha Abrahart, who took her own life on 30 April 2018 aged 20. She was a second year physics student at the University of Bristol and the 10th of 11 students at that university to die in this way since October 2016. In the months before her death Natasha told the University, the student GP practice and the Avon and Wiltshire Mental Health Trust that she was suicidal and had acted on these thoughts.
Shortly after Natasha died, another student death was reported in the press, making a total of three deaths in three weeks at the University of Bristol. Still in shock, we suddenly became very aware of other grieving families and devastated friends. Like us they would be asking: “Why did this happen? Could anything have been done to prevent it?” Our initial personal grief and disbelief was intensified to the point of wanting to help put matters right.
It is difficult for us as parents to accept the enormity and awfulness of what has happened. People at Natasha’s funeral asked “Why has this happened?” This is the question we’re now trying to get answered in court. If we understand what happened, we can do something about it. We want answers that will benefit new and returning students, especially vulnerable students who are at risk. To do this we need your support. Please contribute now and share this page with your friends, family and on social media.
The case and what we are trying to achieve
An inquest into Natasha’s death has been scheduled to take place over three weeks in May 2019. This is going to be a painful, distressing and emotionally draining journey.
The inquest will serve three main purposes:
First, it is our one shot at finding out as much as we can about the circumstances in which our daughter died, and whether there were any failings that contributed to her death.
Second, it offers society a really important opportunity to identify any institutional problems which could result in similar deaths, and to highlight a need for these to be fixed.
Third, it should reassure the public that everyone involved is being open and honest about what actually happened and that nothing is being overlooked.
Why do we need legal advice and support?
It is important to understand why we have employed specialist inquest lawyers. First, the inquest process is very complicated: comprising a complex web of laws, rules and procedures, with lots of documents to read. Second, the University, the Mental Health Trust, and the GPs all have lawyers paid for either by insurers or with public money. We don’t have access to such funding and so up until now we have been paying for everything ourselves. We don’t begrudge other parties being legally represented, but this inquest is primarily about our daughter. It would not be a level playing field if we went into court without having our own lawyers present to ensure that appropriate answers are provided to specific questions that we as parents would want asked.
In August we had our first pre-inquest review hearing (PIR). A second PIR is scheduled for 26th November 2018. Although our lawyers have been acting at reduced rates there is a lot of professional skill and effort involved in preparing for such hearings, and even more legal input will be needed in preparing for (and representing us at) the final 3-week hearing in May. The legal costs are already starting to add up.
How much are we raising and why?
We are determined to ensure a full and fearless inquest into Natasha’s death. We need to fully understand the events that led up to her death and, hopefully, to ensure that students around the country are made safer. If possible, this will be achieved by identifying any unsafe practices that are still in place, which, if not corrected, could result in further deaths. To ensure that this happens, it is essential that all interested parties, including our family, have access to properly funded legal representation.
To begin with we are hoping to raise £10,000. This will allow our lawyers to prepare for and represent us at the second pre-inquest review hearing on 26th November. This is going to be a really important hearing as it will be when the Coroner decides:
- The ‘scope’ of the inquest i.e. what it will look at (we would like it to look at a broad range of issues).
- Whether to call a jury (we think this is important).
- Whether this is going to be an ‘Article 2’ inquest, which should mean that it looks at the issues in more detail than might otherwise be the case (we think this is important).
- Which witnesses should be called to give evidence (we have identified a range of witnesses who we would like to hear from).
- Whether any expert witnesses will be called (we think it is important that the inquest has the benefit of independent expert opinion).
In total we will probably need to raise at least £50,000. This would allow our lawyers to do everything that is necessary to support us throughout the inquest process, but £10,000 would be a great start.
This is not only about Natasha
The government has stressed that student mental health must be prioritised. Independent research has recently found that the suicide rate among UK students had risen by 56 per cent in the 10 years between 2007 and 2016. We want to do everything we can to try to stop this horror.
Every parent wants to know that their child is safe when they leave home for the first time and go to university. Every student deserves to be properly supported by their university and mental health services if they say that they are suicidal.
Since the first PIR we have received some wonderful messages of support and encouragement from other parents of university students. This has strengthened our resolve to push for answers. It is too late to help Natasha and any of the other students who have died but we hope that this inquest will make students safer in the years ahead.
Thank you for reading this,
Robert and Margaret Abrahart
Robert and Margaret Abrahart
Aug. 30, 2019
16-month progress report
Natasha’s inquest lasted eight days (7th-16th May). The senior coroner, Maria Voisin, concluded that there had been a gross failure by the Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) to provide Natasha with basic medical care, and that there was a clear and direct link between this failure and Natasha’s death. Her death was accordingly recorded as “suicide contributed to by neglect”.
Regulation 28 - Prevention of Future Deaths (PFD)
Coroners have a statutory duty to issue a PFD report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths. This report is sent to whoever the coroner believes has the power to take such action and the recipient has 56 days in which to respond.
The PDF report from Natasha’s inquest has not yet been published. However:
- Failures by AWP were not included in the report. During the inquest, a detailed action plan to improve their services was presented, which satisfied the coroner.
- The coroner, in her report, was concerned that NICE guidance on the prescribing of antidepressants had not been followed by AWP, or by GPs at the University of Bristol Students’ Health Service (SHS).
- AWP and SHS have both responded to the coroner, stating that they will now routinely offer an appointment after 7 days to patients starting on SSRI antidepressants (if they are thought to be at risk, or are younger than 30).
- The University of Bristol has also agreed to fund the appointment of a permanent Mental Health Nurse who will assist with the required monitoring of patients.
The coroner did not raise any matters of concern about the University of Bristol, since as stated in court, she did not intend to repeat anything that had been included in her previous PFD report from Ben Murray’s inquest.
To be clear, on 2nd May 2019, the coroner had formerly written to Bristol University, the Department of Education and the Minister for Suicide Prevention stating that “….currently the University sector does not carry out an investigation report (such as a root cause analysis or sudden untoward investigation) after a death of a student. Such a written report usually affords an opportunity to review what happened …. and importantly what lessons can be learned …”. “Such a formal process and document most importantly assists in preventing future deaths.”
The associated responses to this earlier report have not yet been published. The need for somebody, other than parents, to perform a proper investigation is something that we have been arguing for. The suggested sector-wide change is to be commended but would necessitate a major shift in responsibility.
Avon and Wiltshire Mental Health Partnership NHS Trust
- Dr Hayley Richards (Chief Executive) formally apologised to us on 23rd May 2019 for the part that the Mental Health Trust played in the death of our daughter.
- Negotiations are still in hand regarding the settlement of an appropriate proportion of our legal costs with AWP.
- All damages or other payments received, in excess of costs, will be used to support the next step in our campaign.
- AWP have encouraged us to assist them in delivering an improved service by:
- inviting us to participate in a multi-agency learning event, in Bristol, currently planned for December 2019.
- involvement in Making Families Count.
This will provide a golden opportunity for us to ensure that important lessons are leaned, from identified failings, and we look forward to seeing appropriate changes implemented. By working together, we anticipate that improvements will go beyond what was considered during Natasha’s inquest. It is important to look not just at what happened, but why it happened, and what can be done to improve services especially communication between the various agencies involved.
University of Bristol
- The University of Bristol are still in denial.
- The coroner, for reasons that we still cannot understand, ruled on 5th April 2019 that “…the scope of the inquest does not include the adequacy of support provided to Natasha by the University”. This ruling prevented any proper scrutiny of its actions being conducted at the inquest and so our search for answers is only half completed.
- The next step in our fight for truth, justice and accountability, will consequently need to be by means of a civil action, and in such respects a formal “letter before claim” was served on the University of Bristol on 9th August 2019. This letter is an important part of the pre-action protocol in civil litigation. It provides details of our intended legal action against the University on behalf of Natasha’s estate, and essentially puts them on notice that court proceedings may be brought if they do not admit liability. Their substantive response is due by 21 November 2019.
There is a compelling need for well-defined university responsibility and accountability. To address such issues, we are now working closely with key individuals, relevant national organisations and other bereaved parents to push for:
- having specific questions raised in parliament.
- a ‘Westminster Hall debate’ on student suicide and potential changes in the law.
- bereaved families to meet with ministers, so that key issues are understood and addressed.
- action by the All-Party Parliamentary University Group: comprising parliamentarians and university leaders who discuss issues concerning higher education.
Importantly, we have developed a strong working relationship with experts at the charity INQUEST. They have supported us throughout our journey, guiding us at each step in the process, and together we are now campaigning for action from members of parliament. Likewise, we strongly support their campaign regarding better access to legal aid for inquests. From our experience, detailed investigations are essential, so that underlying problems can be identified, and currently the depth of enquiry is very much dependent on questions being asked either by members of the family or their lawyers. Families are not automatically funded, whilst other parties are funded by the state, by insurers, or have deep pockets. There is a need to level the playing field. Access to justice should not depend on your ability to pay. Legal aid is vital to ensure that everyone is equal before the law and can enforce and defend their rights. If people are unable to defend or enforce their rights, for whatever reason, then effectively they don't have rights (Richard Miller, Law Society).
The fight continues
The media have been instrumental in raising awareness, and in drawing public attention to relevant issues. This has provided an important catalyst. The annual statistic for student suicide is truly horrific: on average, one every four days! The BBC documentary “Dying for a Degree” highlighted our personal fight for answers. Importantly, other grieving families are now engaging legal support, in their pursuit of truth, justice and accountability. Lack of trust in the system is rapidly becoming a national issue: were any such deaths preventable and, if so, what action is required, now, to avoid similar deaths occurring?
Natasha’s inquest was a year-long process. Lessons have not yet been learned by the University. The necessary changes that we want to see have not yet been agreed or implemented. More generally, along with other bereaved parents, we are also campaigning for: clearly defined responsibilities, auditable internal processes and procedures, detailed post-incident investigations and better communication so that distressed students do not slip through the net but instead get the right help and support from universities and/or NHS services.
We will not go quietly into the night!
THANK YOU FOR SUPPORTING US
Robert and Margaret
Robert and Margaret Abrahart
May 17, 2019
This has been a year of hell. However, despite our grief, we did not fall into the trap of believing that what we were initially being told was the full story. Twelve months later a substantially different picture has been revealed. Individual and systemic failings have been exposed. There are absolutely vital lessons for everybody; lessons that if they’d been learned earlier, may have saved our daughter’s life.
Natasha suffered from social anxiety – an all-too-common mental health condition which nevertheless isn’t sufficiently recognised. It is an overwhelming fear of being judged, negatively, by others – something which is perceived by the individual to be a personal flaw or failing. Typically, people with this condition struggle to seek help, since the very thought of having to admit it, or discuss it with strangers, would provoke an even greater set of fears.
Naturally, any form of oral assessment, such as those required by the School of Physics at the University of Bristol, would present a substantial difficulty for someone in Natasha’s position. Her social anxiety resulted in a six month struggle with a set of one-on-one post-laboratory interviews. Her anxiety forced her to avoid most of these interviews – for which the University docked her marks. As a result our bright, capable daughter faced failing academically for the first time in her life. Finally, on the 30th of April 2018, she was expected to contribute to a group presentation, held in front of 43 fellow students and two academic markers, in a 329 seat lecture theatre. It would have been a truly terrifying prospect and she already had a very fragile state of mental health. Instead of attending that session, she took her own life.
We hope that Natasha’s legacy will be improvements within the Avon and Wiltshire Mental Health Partnership NHS Trust. We have been promised a better post-incident patient safety review process, something that was initially found wanting by our own investigations and analysis. Although we have not received an apology from the Trust (which would be welcome) it has openly admitted failings, and set out what it intends to do to improve its services. It has also paid damages as a result of Natasha’s death which, while insignificant compared to the pain that we feel, has at least helped us to retain specialist lawyers to guide us through the inquest process. It cannot be fair that a grieving family such as ours should have to rely on the kindness of those who donated to our crowdfunding campaign, and our lawyers working at reduced rates, when the other parties to this inquest had access to public money, deep pockets and medical insurance companies. In February of this year we went to Parliament to join with other bereaved parents, siblings and children to call on the government to grant non-means tested legal aid to families in inquest cases. The government turned us down. We ask them now to reconsider.
In contrast with the Avon and Wiltshire Partnership, the University of Bristol is unfortunately still in denial. Throughout this inquest process it has attempted to shut down, block and narrow any meaningful examination of its actions. Through its lawyers it objected to the inquest sitting with a jury, it argued against various witnesses being called, and at pre-inquest review hearing said that there was no “legal or factual basis for intensive scrutiny” of its actions. Unfortunately these tactics worked and before the inquest started the Coroner ruled that the adequacy of support provided to Natasha by the University fell outside of the scope of her inquiry. As a result, whilst the inquest spent four days looking into the role of healthcare services, it spent one morning hearing factual evidence from two University witnesses. Even then the University’s barrister objected to questions that were put on our behalf. However, the documents we were able to obtain in the run up to the inquest, and the evidence that was heard in that one morning, reveal a deeply troubled picture at the University of Bristol. Information wasn’t shared, referrals to student support services were not followed up, there was confusion over who was involved in Natasha’s case and no one took the lead in addressing her obvious difficulties. As a result our daughter struggled on without any meaningful changes being made to the way in which she was assessed, right up until the day of her death, despite the University knowing that she wasn’t coping.
The Vice Chancellor, Hugh Brady, has told the public that the University of Bristol “forensically examines each individual case and looks for lessons to be learned.” Despite this the University’s lawyer told us that it “did not carry out an internal review or investigation concerning the circumstances leading up to the death of Ms Abrahart as any such investigation is the role of the Coroner”. No evidence has been provided of anybody within the University conducting a serious post-incident investigation, similar to the “root cause analysis” that is obligatory in the NHS. The need for such investigations was re-enforced by the coroner at the recent inquest into the death of Ben Murray, a first year student at the University of Bristol who took his life within days of Natasha’s death.
The absence of meaningful investigations by the University has left at least two sets of parents, us and the parents of Ben Murray, to look for the answers ourselves. When a student dies in these circumstances the relevant university should investigate promptly and openly so that lessons can be learned and implemented, evidence secured, and the family can be properly assisted in preparing for the inquest.
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.
Finally, this journey would not have been possible without the help and encouragement of everybody who has supported us: friends and family, our brilliant legal team, the charity INQUEST, and especially the 588 financial backers who contributed to our crowd funding campaign.
We are now actively considering our legal options against the University of Bristol.
This fight to make university a safer place for our children continues.
Robert & Margaret Abrahart
Robert and Margaret Abrahart
April 30, 2019
Progress in March and April
Many thanks to everyone for your generous support.
On 12th April we had our third and final pre-inquest review hearing at Avon Coroner’s Court, Old Weston Road, Flax Bourton, Bristol BS48 1UL.
- The University has engaged a senior barrister, Vanessa McKinlay, Head of Clinical Negligence at St. John’s Chambers in Bristol. So we now find ourselves facing five other lawyers in court. The need for our own team of legal experts could not be clearer.
- Further submissions on scope and type of inquest were considered. The coroner has assured us that she takes her prevention of future deaths duty very seriously and will want to hear all relevant evidence about what caused or contributed to Natasha’s death.
- List of witness statements to be read out in court, and selection of witnesses who will be called to give live evidence under oath, was agreed. There were 30 individuals involved; 14 of whom would be required to answer relevant questions at the inquest.
- Length of inquest was reduced from 3 weeks to 2 weeks (i.e. now 7th - 17th May 2019).
We are now just seven days away from the start of the promised full, fair and fearless inquest. After almost a full year of detailed preparation there are nearly 2000 pages of relevant material.
Our minds are filled with apprehension and uneasiness about the days ahead as we approach some sort of ‘closure’. The last twelve months have understandably been an exceptionally emotional journey, in our non-stop effort to discover and unpack the detailed facts about what really happened to our daughter, whilst she was a student in Bristol. Exposing the full truth, with nothing glossed over, has not been an easy or straightforward undertaking. This horrendous mental and physical challenge has however been made a whole lot easier by your kind words of encouragement and support. Today, on the first anniversary of her passing, it is difficult for us to believe that we are now in the final stages of our prolonged fight for answers. Much of the jigsaw has been identified, but we still need to join some of the remaining pieces together. The inquest, for example, will need to establish not just what transpired but why certain things did or did not happen at Bristol. This will be our best chance to question the key individuals involved, to fill in any missing gaps, and to finally understand the tragic circumstances by which our daughter came to her death.
Robert and Margaret
Robert and Margaret Abrahart
March 5, 2019
Progress in January and February
Solid progress was made in January and February:
- We have now raised £21,522 towards our current target of £50,000. Thank you all so much for your generosity and trust.
- Two substantial articles were published [Sunday Times Magazine (20th January, subscription required); The Guardian (22nd January, available to everyone)]. This generated a short burst of significant additional contributions to our crowdfunding campaign.
- BBC East Midlands Today (26th February) reported on our trip to Westminster in support of Legal Aid for Inquests. Please consider SIGNING and SHARING an associated petition to the Lord Chancellor.
- The university and health services provided further statements and additional documentary evidence. This has filled in several gaps but other important material is still awaited and will need to be disclosed. Each time we dig a little deeper into a specific matter it raises yet another set of questions that should also be answered.
- The coroner’s expert witness report has been completed.
- The requirement for a 3rd and final pre-inquest review hearing has been confirmed. This will now take place at 1 pm on Friday 12th April.
- The full 3-week inquest is still scheduled for 7th-24th May.
Thanks also to everybody who has shared our crowdfunding web page, or either of the two recent substantial newspaper articles. It is important to spread the word about what we are doing.
We are touched that so many people have contributed to our cause and continue to support our campaign for truth, justice and accountability. Some of you have your own devastating stories and our hearts go out to you when we read your comments.
This fight is for everybody, and with your backing, we are now firmly on our way towards establishing exactly what happened to our daughter in Bristol.
Lessons can and will be learnt.
Thank you for helping
Robert & Margaret
Robert and Margaret Abrahart
Dec. 21, 2018
2nd meeting with Mental Health Trust
This week we met with the Executive Director of Nursing and the Clinical Lead for Bristol at the Avon and Wiltshire Mental Health Partnership NHS Trust (‘AWP’). Natasha received various assessments from AWP in the months prior to her death and had been allocated a ‘Recovery Navigator’.
This was our second meeting with AWP, to discuss the findings of an internal investigation, which had concluded that Natasha “did not receive a satisfactory level of care” from the Trust prior to her death.
Following a serious incident, NHS Trusts are required to investigate what went wrong, how and/or why it went wrong, and what might be done to address any weaknesses in service delivery to prevent similar incidents occurring. The investigation is conducted by a Patient Safety Review Team. The standard method of investigation is Root Cause Analysis. On 3rd August 2018 we were sent a copy of an associated Root Cause Analysis Report regarding the care and treatment that was provided to Natasha by the Mental Health Trust.
On 21st September 2018 we had our first meeting with AWP to discuss their Root Cause Analysis Report. We expressed a number of concerns about the methodology, depth of analysis, content and findings of that report.
On 17th December 2018 we met with senior management from AWP to hear their response to the concerns we raised at the first meeting.
Due to the forthcoming inquest in May 2019 we are somewhat limited in what we are able to say about our recent meeting with AWP. However, we were reassured to hear that many of our concerns about the original investigation seem to have been listened to and that further conclusions have now been reached which reflect those concerns. AWP has agreed to provide us with more information in the short term about the steps they intend to take to improve their services. We look forward to receiving this information and hope that the apparent spirit of openness shown by AWP senior management at our recent meeting carries through to AWP’s approach to the inquest.
The NHS have a system for investigation and accountability regarding serious untoward incidents. To our knowledge – no such system operates in our universities.
Robert and Margaret Abrahart
Dec. 6, 2018
2nd pre-inquest review hearing 26 November 2018
Many thanks to everyone who has supported us so generously. This funding campaign was launched at 8:00 am on Thursday 11 October. The Initial target of £10,000 was achieved two weeks later on Thursday 25 October. Your collective contributions covered the legal costs of preparing for, and representing us at, the second pre-inquest review hearing on Monday 26 November 2018.
This was a major achievement, something that every early backer can be proud of. It demonstrated a strong sense of solidarity. It also highlighted a wider public concern about the need to protect students when they are away from home at university
2nd pre-inquest review hearing 26 November 2018
- The inquest will primarily focus on events in April 2018 (the month in which Natasha died) with “background evidence” going back to October 2017. We have asked the Coroner for a written ruling on this as we think a number of important events took place from October 2017 to March 2018 that should be considered properly at the inquest.
- At this stage the Coroner doesn’t intend to empanel a jury for legal reasons, although she will keep this under review.
- At this stage the Coroner doesn’t think that this will be an ‘Article 2’ inquest. This followed legal submissions on behalf of the University of Bristol, the Avon and Wiltshire Mental Health Trust and two GPs from the Student Health Centre (who had contact with Natasha) that they didn’t, as a matter of law, owe Natasha a duty under the Human Rights Act to take appropriate measures in response to any real and immediate risk to her life. The Coroner will keep her decision under review, but we are hopeful that it shouldn’t make a significant difference to the issues she considers at the inquest.
- The majority of witnesses who will be called to give live evidence on the day were confirmed.
- The coroner has agreed to instruct an independent consultant psychiatrist to provide expert evidence on the care provided to Natasha.
- Further statements and documentation are to be provided.
- Provisional date for a 3rd pre-inquest review hearing, if required, is 3rd April 2019.
- Full 3-week inquest is scheduled for 7-24 May 2019.
So, we have now passed the six month stage, halfway through the process of establishing how our daughter died, with a long, difficult and emotionally painful journey ahead of us. Lots of hard work is still required, given the ever increasing mountain of written material which will need to be carefully scrutinised, and in preparing a purposeful set of questions for each individual witness.
Everything will continue to be inspected and analysed by us in ‘forensic detail’ and we are making solid progress in our understanding of what transpired. Later evidence has reinforced our earlier view on what actually happened but significant questions still remain unanswered.
The underlying message that we are hopefully sending out to all other interested parties is straightforward: if you don’t look for problems, or you don’t look in the right places, you won’t find anything wrong. The problems will simply persist.
We remain determined to do our best to ensure that total transparency will eventually be delivered, or as Shakespeare put it in The Merchant of Venice, “truth will out”.
You got us this far - can you help us regain momentum?
Your initial contributions have now been spent, in getting us to this point, but we are still a long way off our final stretch target of £50,000. So please consider making a further contribution, even if it only amounts to the cost of a pint of beer. Please also keep sharing; especially on Facebook. It will also make a big difference if you continue to spread the word: by telling other people about what we are doing; by forwarding this latest news on the outcome of our recent pre-inquest review hearing; and by sending follow-up messages regarding subsequent stages and important developments in our campaign.
Thank you again for everything that you have done so far. It is good to know that we are not on our own in raising awareness and seeking changes on the national stage – a tribute to our very special daughter.
We will of course keep everybody updated on any developments and please do keep sharing.
Thank you for your continuing support and encouragement.
Robert and Margaret
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