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Inquest finds local mental health services "neglected" Natasha Abrahart

Photo: Abrahart Family

The University of Bristol student took her own life last April.

A Senior Coroner has concluded that a series of failures by mental health services contributed to the suicide of a vulnerable student at the University of Bristol.

The body of Natasha Abrahart, 20, originally from Nottingham, was found in her student flat in Bristol on 30 April 2018.

The second-year physics student was due to give an assessed oral presentation to students and staff in a 329-seat lecture theatre that day. 

Academic staff first became aware that Natasha was struggling in October 2017 and said they knew that Natasha “suffered from anxiety and panic attacks” in relation to oral assessments.

However, a senior lecturer told the inquest that “no changes were made” to her assessment on 30 April.

The University’s GP service had referred Natasha to Avon and Wiltshire Mental Health Partnership NHS Trust in February 2018 following the first of several suicide attempts.

Robert and Margaret Abrahart, Natasha’s parents, 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.”

Dr Laurence Mynors-Wallis, a senior consultant psychiatrist, was instructed by the Senior Coroner for Avon, Maria Voisin, to review the treatment Natasha received from the Avon and Wiltshire Partnership.

He found there was “an unacceptable delay” in her having a specialist assessment following her referral to the Trust and that Natasha’s “risk of self-harm was not adequately assessed.”

Dr Mynors-Wallis also found that a “failure to provide a timely and detailed management plan for Miss Abrahart represents a causal connection with her subsequent death.”

Coroner Maria Voisin recorded a narrative conclusion, finding that Natasha’s death was contributed to by gross failures by the Avon and Wiltshire Partnership.

The family’s solicitors at Irwin Mitchell confirmed that the Avon and Wiltshire Partnership has paid substantial undisclosed damages to the family.

Julie Kerry, Director of Nursing at Avon and Wiltshire Mental Health Partnership (AWP) NHS Trust, said: “We are deeply sorry for Natasha’s death and would first and foremost like to offer our sincere condolences to her family

“We fully accept the findings of the Coroner and recognise that we did not act in accordance to best practice in all of the care provided to Natasha.

“I want to assure Dr and Mrs Abrahart that we are an organisation that wishes to change things for the better to improve our services for our patients.

"We and our partner organisations know that changes need to happen to some of our processes and ways of working and we are committed to doing this and have already put in place some measures to minimise the risk of a similar incident occurring in the future. These include:

  • Systems and processes in place to ensure patients get the help they need in a timely way
  • Structures in place to develop and improve our ways of sharing information and communicating across our multiple partners
  • Enhancing our suicide prevention work to support timely risk assessments and care plans

“We will continue to work with our partner organisations including the University, CCG and our national partners to make further changes and improvements to the way we work together.

“We have met with Dr and Mrs Abrahart to share what we are doing and to involve them in further changes and I hope that we can continue to work together to ensure we have better practice and systems in place to minimise the possibility of this sort of tragedy happening again.

“Once again on behalf of the Trust I offer my sincere condolences to Natasha’s family.”

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.
“We have also played a key role in the development of a UUK Suicide Safer Strategy for universities which is being adopted nationally to ensure measures are put in place to provide the best possible support and early intervention measures for students.
“We continue to challenge ourselves to improve our processes, procedures and support on an ongoing basis.
“Like all universities, schools and colleges, we are deeply concerned by the increase of mental health issues amongst our young people nationally.

"Complex mental health challenges cannot be addressed by universities alone, and we cannot be expected to replace the NHS.
“We are, however, fully committed to working with our partners in the NHS, charities and across the HE sector in a collaborative effort to ensure we are providing the best possible support to our students.
“The steps we are taking are part of a journey that will evolve over time.

"Much has already changed in the past two years, but new activities and initiatives will emerge as we learn from our work here at Bristol, and as all parts of society understand more about these complex challenges.

“At the conclusion of this inquest our thoughts remain with Natasha’s family and friends, and those affected by her death at the University.

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