Preventing Student Suicide at Universities – a Case Report

In 2016 our son Naseeb Chuhan, who was aged 21 and in his first-year studying Human Geography at Leeds Beckett University (LBU), sadly took his own life. We spent the next seven years investigating the circumstances relating to Naseeb’s death and found ourselves having to hold organisations to account for what happened. Our aim has always been to encourage learning and generate positive change to prevent such suicides.

In 2023 we produced ‘Preventing Student Suicide at Universities’, which is a detailed Case Report of our findings and recommendations. If you would like to access a copy, please use the links below .

Naseeb was an intelligent, thoughtful and inquisitive young man. He had a creative imagination, strong sense of social justice and cared deeply about this world. Our beautiful son had a rich interest in the environment, history, politics, the arts and he loved reading, listening to music, playing squash and cycling. Naseeb was very sociable, he had a sharp sense of humour and enjoyed the company of a wide range of friends. All who knew and loved Naseeb have been shocked and deeply saddened by his death.

Throughout the ‘Preventing Student Suicide at Universities’ Case Report we refer to our son as experiencing ‘mental distress’ and having his coping resources overwhelmed by a combination of both academic and debt crises. The report highlights major problems with key organisations in terms of basic levels of care and accountability for students, clients and patients and makes clear recommendations for their rectification. This is based on all the relevant evidence obtained and research undertaken leading up to the inquest into Naseeb’s death, what happened at the inquest and the subsequent complaints and advocacy processes we have been involved in.

Our research discovered:
– Significant concerns relating to academic and pastoral care at the University
– Irresponsible lending practices by payday loan companies
– Failures in duty of care by the GP alongside systemic healthcare failings
– Failure to adequately risk assess Naseeb by LBU Student Wellbeing Service

Naseeb died at the end of the academic year, well documented as a high-risk time for student suicides. Our investigations revealed that before he died, Naseeb was about to fail his first year at university. Naseeb had performed well in the first term and in stark contrast, for five months from January 2016, he hardly attended university and did not complete any further work. By the time Naseeb died he had eight consecutive pieces of work outstanding from January 2016 onwards. The University did not contact our son about his absence and non-submission of work over this entire period.

The evidence shows the University struggled to clarify what, if any, attendance policy was in place at the time our son was studying there. Moreover it did not have any systems in place to regularly monitor student attendance, engagement or performance. This meant no one was aware that Naseeb was approaching an academic crisis near the end of the academic year. Not even the senior staff member with specific responsibility for academic and pastoral care from whom Naseeb tried to get help earlier in the same month that he died. At this meeting no support or review was put in place for Naseeb.

We discovered the University did not have any early alert systems in place. It was not even collecting, recording and analysing basic data that would be able to identify students in need of support and also those with the potential for higher risk and vulnerability.

After Naseeb died the University did not conduct a review and refused to investigate a comprehensive complaint we submitted about our concerns relating to academic and pastoral care and also the University Wellbeing Service. We then found that investigating such a complaint was outside the remit of all the organisations with any responsibility for overseeing universities (UUK, OIA and OfS). This means the University could not be held to account for the negligence revealed by our research.

In addition, Naseeb was facing an escalating debt crisis having accumulated a total of 12 concurrent loans and with no way of paying the money back. After the inquest into Naseeb’s death, in 2018 the Coroner issued a ‘Prevention of Future Deaths’ Report to the Financial Conduct Authority (FCA) which placed them under duty to take action to address the poor conduct and damaging behaviour of payday loan companies. This is a significant outcome as we believe it to have been only the second time that such a report has been issued to the FCA.

It had been established via a series of complaints to the Financial Ombudsman Service that most of the payday loans were given to Naseeb irresponsibly. These loans were deemed to have been unaffordable, encouraged dependency and were being given back-to-back, all of which breached the FCA’s regulations. Over the next two years we produced two reports for the FCA which detailed how their regulations were not able to prevent irresponsible lending to have taken place. Despite the FCA agreeing with our concerns there has not as yet been any meaningful change to their regulations.

Shortly before he died, Naseeb tried to obtain support from a GP and then the University Student Wellbeing Service. Throughout his entire life Naseeb had only seen a GP once before for a sprained ankle. Despite Naseeb presenting with clear indicators of potential suicide risk, the GP did not risk assess him adequately. A GP Expert Witness report, which was accepted at the inquest into Naseeb’s death, identified failures in duty of care by the GP.

On that morning, the University Student Wellbeing Service also failed to adequately risk assess Naseeb. The independent expert analysis we commissioned regarding Naseeb’s presentation at LBU Student Wellbeing Service clearly states that enough information was present “to indicate a potentially high risk of self-harm, for which further assessment ought to have taken place quickly“. Worryingly we discovered that the actual question about risk to self on the University Student Wellbeing Service’s registration form had been previously removed.

Our subsequent engagement in complaints processes with both the General Medical Council and the British Association for Counselling and Psychotherapy spanned a number of years. Unfortunately during this process both organisations demonstrated a concerning and inadequate understanding of risk assessment in relation to self-harm and suicide.

There is a growing body of evidence-based research that suicide is preventable. A central part of our work has been having to hold organisations to account for their actions and the issues we have exposed represent significant failings, without which we believe our son would still be alive.  

Preventing Student Suicide at Universities Case Report

Our Member of Parliament Andrew Western is supporting the dissemination of the Case Report. Following a petition for Higher Education statutory duty of care towards students there was a parliamentary debate on this issue on 5th June 2023. At the parliamentary debate Andrew Western MP presented a number of the concerns in our Case Report about the severe level of neglect Naseeb experienced whilst at university. A link to where he begins to speak is at https://www.youtube.com/live/XHwbEG7Oi-E?feature=share&t=3611  .

We are members of ForThe100 campaign for a Higher Education Statutory Duty of Care towards Students, and the LEARN Network .


The ‘Preventing Student Suicide at Universities’ Case Report can be accessed from the following links:

Full Case Report ‘Preventing Student Suicide at Universities’, about 90 pages long including a 10 page executive summary

Executive Summary of the Case Report ‘Preventing Student Suicide at Universities’, including recommendations

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