National review of higher education student suicide deaths

Date of publication: May 2025

This report provides findings from the national review of higher education student suicide deaths. We examined serious incident reports of suspected suicide deaths and incidents of non-fatal self-harm submitted by higher education providers (including universities, colleges, professional schools and institutes of technology) for the academic year 2023 to 2024 (1 August 2023 to 31 July 2024).

Our aims were to:

• collate key findings identified within these serious incident reports;
• assess the quality of serious incident reports against sector-wide guidance (PDF, Universities UK) and NCISH guidance for investigating serious incidents;
• identify examples of good practice and areas needing improvement.

Key messages

Safety concerns

We found numerous factors that may have contributed to suicide and that should be the target of future prevention. Two stood out: mental ill-health and academic problems. Several other factors (e.g., neurodiversity, financial problems) point to the need for targeted support. Almost a quarter of incidents (where location was known) occurred within university-managed accommodation.

We suggest:

• mental health awareness and suicide prevention training should be available for all staff in student-facing roles;
• higher education (HE) institutions review the safety of university-managed accommodation, including physical safety, high-risk locations, and signposting for support;
• suicide prevention activities should be enhanced after a single death on the grounds that any suicide has the potential to lead to a cluster;
• postvention is available for anyone affected by a student’s death by suicide.

Suicide prevention within university systems

Most of the reports we reviewed identified points of learning, to improve internal processes. Many of these lessons are likely to be relevant nationally. Many of the reports noted that access to mental health and other support could be improved in terms of awareness, signposting, and reviewing the needs of specific groups. They also identified problems with information sharing and communication (both internally and with the student, the student’s family, and with other external agencies), risk recognition and management, improving information systems, pastoral support, training and guidance for staff, and confidentiality and access to information about students.

We recommend HE providers should review:

• access to mental health and other support, particularly for those at additional risk (e.g., students who have experienced violence or other adverse life events);
• system wide information sharing and best practice in the use of IT systems;
• how well confidentiality arrangements are working.

Universities UK/PAPYRUS/Samaritans guidance

We found most serious incident reports were broadly in line with the underlying principles of the guidance on carrying out a serious incident review, though not with all parts. Most included points of learning and plans for follow-up actions. A crucial omission was the absence of family involvement in the serious incident review process.

We suggest:

• input from bereaved families should be a key part of the serious incident investigation process;
• there be an early decision about the appropriate level of independence of reviewers;
• all serious incident reports have senior leadership sign-off, demonstrating institutional acceptance of the recommendations, and a commitment to implementation.

Safety messages for the wider system

Our national review has identified additional measures that reflect the wider context in which suicide prevention takes place – including policies, standards, and relevant data.

We suggest:

• a version of the duty of candour be introduced to the HE sector, setting out organisational responsibilities to be open and transparent with families after a suspected suicide. It would include a duty to provide information on what happened, at the earliest point. It should be developed and shaped by the sector itself to ensure it is appropriate to the higher education setting.
• a collaborative forum should be established for sharing of statistical data relevant to the prevention of student suicide nationally.
• this national review of higher education student suicide deaths should be established as a long-term initiative, across the UK.

Find out more