Coroner raises concerns after university student's death

The report was published following an inquest in Leicester

A coroner has raised concerns about a student accommodation service and the mental health care given to an 18-year-old student who died at the University of Leicester.

Lily Jahany was studying medical physiology and living in Student Roost accommodation when she took her own life in December 2022.

The student had a “lengthy and complicated psychiatric history”, her inquest was told.

Assistant coroner for Leicester City and South Leicestershire, Fiona Butler, has issued a Prevention of Future Deaths report (PFD) to Leicestershire Partnership NHS Trust (LPT) and Student Roost, following the hearing.

While Ms Butler could not rule the failings “more than minimally, trivially or negligibly contributed to Lily’s death”, she said lessons needed to be learnt.

Ms Jahany, who had bipolar affective disorder diagnosis, as well as suffering from post-traumatic stress disorder, depression and anxiety, had performed "extreme acts of self-harm" in her accommodation before her death.

Lack of training

Ms Butler found that the Student Roost company did not require its staff to have first aid training at the time in question, the Local Democracy Reporting Service said.

She added in the report she was “surprised to learn” no staff in Leicester’s six Student Roost accommodation blocks had first aid training and it was not mandatory.

Accommodation staff “could potentially be the first people at the scene of a situation [in their flats] requiring first aid and then emergency services”, the report read.

Ms Butler labelled the lack of suitable training “concerning”.

Student Roost said it was taking the findings “seriously” and intended to introduce emergency first aid training in all of its properties.

A spokesperson said: “In addition, we are aware of the mental health concerns felt by students across the UK and have invested in mental health first aid training.

"Currently we have over 50 team members within our head office and property teams who are qualified mental health first aiders, which we build on each year to further support residents and team members.

"Our dedicated resident wellbeing team also provides 24/7 onsite support for residents.”

Ms Jahany was studying at the University of Leicester

Further failings were found in the handling of Ms Jahany's care by the Leicestershire Partnership Trust (LPT).

Ms Butler said the student was being treated privately for her mental health difficulties and that her medical records were therefore held privately rather than in the national system.

This had the effect of misleading those treating her in Leicester about the extent of her wellbeing risk, Ms Butler said.

However, she added this also placed a “greater duty and emphasis” on LPT staff to ensure they had all the information they needed to “be able to properly and fully assess Lily’s risk”.

There were failures in LPT’s efforts to “obtain the full extent of Lily’s mental health challenges”, she added.

While LPT sets out the need for staff to take responsibility liaising with other agencies involved in patients' care, Ms Butler said its policy, did not “set out any expectation upon staff to proactively make contact with treating clinicians in the private sector to gain information”.

She added it “would not capture situations such as [Ms Jahany's], who was discharged from the Crisis Team after a one hour assessment and therefore was not under their care and treatment”.

An LPT spokesperson said: “Our sincere condolences go out to Lily’s family and loved ones.

"We are committed to providing the best quality care for our patients and will ensure we learn from Lily’s death.”

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