In a statement dated 6 October 2022 the University said:

“After carefully considering the judgement [sic] and its implications for the higher education sector, we will be seeking leave from the High Court to appeal the judge's finding that the University was in breach of the Equality Act. We would like to make it clear that this appeal is not against the Abrahart family, nor are we disputing the specific circumstances of Natasha's death. We remain deeply sorry for their loss and we are not contesting the damages awarded by the judge. In appealing, we are seeking absolute clarity for the higher education sector around the application of the Equality Act when staff do not know a student has a disability, or when it has yet to be diagnosed.”

In response to media enquiries we said: 

“We are disappointed that the University of Bristol has said it intends to seek permission to appeal from the High Court after this was refused by the trial judge. We are also unclear why the University needs any further clarity on the application of the Equality Act. The judge in Natasha’s case simply applied a law that has been in place for over a decade, and which the University of Bristol has had plenty of time to understand. The fact that they still don’t understand, for example, that a medical diagnosis isn’t a prerequisite to complying with the Equality Act is worrying to say the least, especially as Natasha’s Senior Tutor wrote over a month before her death “This does seem to be a genuine case of some form of social anxiety”. The University of Bristol should be focussing its attention on improving support for vulnerable students, not dragging this painful legal process out by petitioning the High Court.”

University’s application to the High Court

On 12 October 2022 the University filed an “Appellant’s Notice” with the District Registry of the High Court in Bristol, seeking permission to appeal the outcome of the trial. This is the University’s second attempt at getting the original ruling overturned. Seven grounds for wanting an appeal are listed, each questioning different rulings under the Equality Act. They have until 28^th October to supply any additional supporting arguments, considered necessary to assist the court. Everything in their submission is case specific, so contrary to their recent announcement, no absolute clarity could ever be provided for the Higher Education sector.

Evelyn Welch 

We had hoped that Professor Welch, appointed as Vice Chancellor in September 2022, would be ‘a new broom’. We hoped she would want to sit down with us to discuss what we think the University could do, right now, to improve the safety of its students. It is therefore very disappointing that Professor Welch has signed off on the continued attempts by the University to overturn the findings of the trial judge in Natasha’s case, rather than committing to learning lessons from the way she was treated. To this day no one within the University of Bristol has apologised for the obvious failings in Natasha’s case.

Professor Welch claims to be acting for the sector, but the judgment in Natasha’s case hasn’t imposed any new duties on providers of Higher Education. It simply applied legal principles that have been in place for over a decade, and which the University of Bristol should have complied with in its interactions with Natasha. Does Professor Welch think the Equality Act 2010 grants disabled students too many protections, and if so which protections would she like to see removed? Does she think University’s should be less accountable? Does she really think that dragging out this process is the best way to spend the University’s considerable resources? The University has said that “this appeal is not against the Abrahart family”. Does that mean that Professor Welch won’t ask us to pay the University’s legal costs, which are likely to be over £100,000, if she succeeds in getting the trial judge’s ruling overturned?

Is it just us – or is this how all other parents, especially ones who have lost a child, can expect to be treated by Bristol?

Professor Welch should be doing what is best for her students, instead of washing her hands of any responsibility, and leaving the job of protecting disabled students to parents. She should be rising to the challenges of adjusting the University’s processes to comply with the law, rather than seeking to change the law to match what they do. It is hard to understand why a supposedly caring institution would want to question the rights of disabled students.

Please sign and share our petition calling on the Government to establish a statutory duty of care owed by universities to their students.

Robert & Margaret

His Honour Judge Ralton, in the County Court at Bristol, has refused to grant permission for the University of Bristol to appeal his landmark judgment of 20^th May 2022. HHJ Ralton gave the following reasons:

“The Defendant's grounds of appeal essentially repeat the Defendant's arguments made at the trial which have been fully addressed in the reserved judgment. I am not satisfied that the Defendant has a real prospect of a successful appeal or that there is some other compelling reason why the appeal should be heard.”

Do not be mistaken into thinking that in seeking ‘Permission to Appeal’ the University has all along been simply attempting to establish exactly what its legal obligations are under the Equality Act.

Their parallel objective of driving down any liability payment has never stopped:

• The University’s barrister, in open court, on the last day of the trail, had suggested an award of £25,000. Natasha, in their view, had not suffered enough, or for a long enough period, to be entitled to a greater payment. It was also argued that their suggested amount should be viewed as nothing other than an uppermost starting point, and that any such award for damages should also be apportioned over other stressors, which were not of their making, despite clear expert evidence that but for the conduct complained of, Natasha would not have experienced the deterioration in her mental health that led to her suicide.
• The University has repeatedly quibbled over having to pay for specific parts of our funeral expenses; in particular, for the cost of a headstone, and for a few light refreshments at the reception. They were wrong in law yet refused to accept it.

What next? The University is now required to pay the previously ordered damages of £50,518 — for pain, suffering, loss of amenity and injury to feelings — unless they file an application with the High Court for permission to appeal to that court no later than 14^th October 2022. That application would usually be considered ‘on the papers’ i.e. without an oral hearing. If ‘Permission to Appeal’ is refused by the High Court, the University would then have another seven days in which to request that the decision be reconsidered at an oral hearing.

So, will they or won’t they, at long last do the right thing? Or will intransigent and unrepentant decision-makers, with bruised egos, continue along their chosen path of reputational self-destruct?

If senior university management had any integrity, somebody should by now have resigned. Instead, everybody at the top continues to hide behind a wall of anonymity — the so-called “spokesperson”.

Brady left Bristol on 31st July 2022. But this all happened on his watch!

Robert & Margaret

It took four years to get to trial and, after a lot of pain and effort, we finally received a judgment which confirmed what Natasha’s family and friends have known since August 2018. The University of Bristol is responsible for the death of our daughter on 30th April 2018.  Like most other grieving parents, at the start of our journey, we simply wanted to find out what had happened in Bristol. Early on, we sought to work collaboratively with the University on any internal inquiry into what had occurred. Surely it was important to establish if Natasha’s death could have been prevented, and if so, what urgent action was required by the institution to help keep other students safe? The University responded, saying that it “does not carry out investigations into the deaths of students registered at the University.”

Our primary goal, however, remained unchanged, yet despite our best endeavours to help protect and save other students, we continue to be frustrated at every step. In Coroner’s Court, the University argued that there was no “legal or factual basis for intensive scrutiny” of its role in Natasha’s death — and so it escaped any proper examination or accountability. In our subsequent civil action, the judge fully agreed with us and our lawyers, that the University had discriminated against our daughter, and that it was their stubborn refusal to adjust an assessment process, which ultimately resulted in her death. 

That chain of events is not disputed. It is only the legal necessity to make any such adjustments that is still being argued over. The University of Bristol, moreover, is still not prepared to admit anything or make any necessary changes to the way things are done at that institution. They are presumably just keeping their fingers crossed and hoping that no other student dies under similar circumstances!

They actually disagree with most aspects of the judgment and have now sought permission for an appeal to the High Court. Their legal documentation was submitted on Friday 17th June. There are no fresh developments. It is essentially a fifteen-point re-run of their original arguments, which previously failed at trial. Further court action will of course push up our legal costs and, regrettably, the can is once again being kicked down what might be a long and winding road. Their submissions, by the way, include arguing for a lower award of damages; £25,000 was originally proposed during the trial. How insulting is that!

The University has also stated that it is seeking to obtain a proper understanding of its obligations under the Equality Act (2010); which is quite an amazing admission for a self-acclaimed ‘sector leader’. Perhaps they should consider listening to our lawyers who are experts in the field.

Importantly, permission to appeal will only be granted where the court considers that the appeal would have a real prospect of success, or there is some other compelling reason for the appeal to be heard.

The University has recently:

• Commented on the significant impact that this case could have on how all higher education providers support their students. So they accept that BIG changes are needed; and
• Said that it is committed to working with partners …. "to improve services and ensure we are collectively providing the best possible support for students". So anybody but us?

The moral case for making changes has never been stronger. And, as parents, we remain determined to do everything we can, but surely the most important thing at this point is for the University to implement an action plan to ensure that other students are not subjected to similar levels of unnecessary distress. Instead of responding in an adversarial manner, it is now time for the University to start cooperating with us, so that we are all working together, to achieve a shared goal that will help protect many other students.

Today we have submitted lengthy legal representations opposing the University’s application for permission to appeal.

So once again we must wait for a decision from the court.

Robert & Margaret

1. Full Judgment [ here ]

2. Statement read outside Bristol County Court on 20 May 2022:

His Honour Judge Ralton, a senior circuit judge, has today found that the University of Bristol was liable for multiple and repeated breaches of the duties it owed to our wonderful daughter, Natasha Abrahart, under the Equality Act 2010. These breaches amounted to disability discrimination. In particular he found: that the University breached its duties to make reasonable adjustments to the way it assessed Natasha; the University engaged in indirect disability discrimination against Natasha; and the University treated Natasha unfavourably because of the consequences of her disability.  He found that these breaches led to her death on the 30th of April 2018, noting that “it was accepted by the medical experts that the primary stressor and cause of Natasha’s depressive illness was oral assessment.”

Today, 1481 days after Natasha took her own life on the day of an assessment she simply couldn’t do, after years of protestations from the University that it did all it could to support her, after having battled our way through an inquest and a civil trial, we finally have the truth: The University of Bristol broke the law and exposed our daughter to months of wholly unnecessary psychological trauma, as she watched her grades plummet, and her hopes for the future crumble before her eyes.  

Natasha came to Bristol to study physics, the subject she loved.  She was bright, she was diligent, and she was hardworking.  In a document we found on her computer after her death she said: “I am planning to pursue physics because I love the idea of being able to understand (or at least notice) the rules that nature follows.  It's amazing that we are able to make accurate predictions based on mathematics, but it's even more incredible when nature behaves in unusual, counterintuitive ways, such that we can't immediately understand what's going on.”  Natasha would have made an excellent physicist if only the University of Bristol hadn’t discriminated against her.

Natasha had always been a shy girl but by the time of her second year at Bristol this had developed into severe Social Anxiety Disorder, a condition which the court found rendered her disabled for the purposes of the Equality Act.  Social Anxiety Disorder is one of the most common anxiety disorders.  In Natasha’s case it meant that she struggled to speak with people she didn’t know, particularly people in positions of authority, and in situations where she thought she would be judged on what she said.  It was only after Natasha’s death that we fully appreciated just how bad this issue had become and how poorly the University had responded to her needs.

Although Natasha did very well in her written work, and passed her first year with flying colours, she hit a brick wall when it came to the University’s inflexible policy of oral assessments in the second year.  Expecting Natasha to take part in oral assessments was like expecting a student in a wheelchair to take an exam in a room at the top of a long flight of stairs.  To use the legal jargon that we’ve had to become familiar with, the University’s insistence on oral assessments put Natasha at a ‘substantial disadvantage’ in comparison to other students who did not share her disability.  Natasha’s disability meant that she ran out of post-laboratory interviews, or did poorly in them, or failed to attend them at all. And for that, she was, in effect, punished.  The University awarded her zero marks for many of these assessments and in some instances issued her with penalties.  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 having told the university, in February 2018, that she was feeling suicidal and “to a certain degree have attempted it”.  Instead of attending that session, she took her own life.

The adjustments that Natasha needed to succeed on her course were so simple, so obvious, it beggars belief that the University has spent the last four years arguing that they were not required to make them.  The adjustments which the court has found the University should have made included: removing the need for oral assessments altogether or, in relation to the conference on the 30th of April 2018, assessing Natasha in the absence of her peers or using a smaller venue.  The University put forward many reasons why it was not required to make these adjustments: they said that Natasha needed to go and speak with the right department; they said they needed a form completed; they said they needed a doctor’s letter; and they said that, in essence, it isn’t possible to be a physicist without giving oral presentations.  Each of these defences failed at trial.

Today, it must again be emphasised, that we do not seek to blame any individual member of staff.  It is clear that some of them have been deeply affected by Natasha’s death and obviously no member of staff wanted her to come to harm.  We do however blame the University as an institution.  We blame the University for not training its staff properly in its duties towards disabled students and on when they could and should share information internally about students who are at risk of suicide.  We blame the University for maintaining a system, which was so inflexible, that it exposed our daughter to suffering which the judge described as “serious and, from what I have seen in the evidence, continuous”.  We blame the University for arguing that there was no “legal or factual basis for intensive scrutiny” of its role in Natasha’s death at the inquest and for accusing us of pursuing “spurious claims”.  And we blame the University for the role it played in our daughter’s death.

There has been lots of discussion during this case about the duty of care which universities owe to their students.  The concept of a duty of care relates specifically to the law of negligence and not the Equality Act.  During the trial the university agreed with the judge’s characterisation of its defence that, whilst it cares for its students, it is not legally required to care.  Ultimately the judge found, because Natasha was protected by the Equality Act, he was not minded to impose a duty of care in negligence in Natasha’s case, although he found that if such a duty did apply then “there can be no doubt that the University would have been in breach”.  So the University was wrong.  It was legally required to care, and the source of that requirement in Natasha’s case was the Equality Act.

We have been asked whether we think the University of Bristol has changed since Natasha died.  How can it have changed when it doesn’t accept it did anything wrong?  Even during the trial the head of the University’s Disability Services said that they would only “reluctantly” support a disabled student where their disability meant that they had to communicate via an intermediary.  The only even vaguely relevant change that the University has been able to point to is that its Disability Services will now send a student two emails, rather than one, before giving up on a referral.  That is not a meaningful change.  We are deeply concerned that the University still does not understand the issue of disability, let alone its duties to disabled students, including those students disabled by way of mental illness, and the potential for causing harm to those students as a result.

What does this judgment mean for the world of Higher Education? It is a wake-up call.  It is a clear statement that universities must carefully consider whether their existing policies and practices will put any disabled students at a substantial disadvantage.  They need to consider how their methods of assessment will impact on each and every student including those with non-physical disabilities and or mental ill-health. Policies and practices that fail this test should be changed unless there is a very good reason for not doing so.  If those changes aren’t made then universities should expect to be held liable for the consequences which, as our case sadly shows, can be utterly devastating.

Now is the time for change.  The University of Bristol has recently announced the appointment of its 14th Vice-Chancellor — Professor Evelyn Welch — who is due to start on the 1st of September 2022.  Will she do what no one in the University has done for four years?  Will she commit to learning the lessons from Natasha’s case?  Will she meet with us so we can help her change the system within the University which still risks failing students so badly?  And will she, or anyone else at the University, apologise for the part it played in Natasha’s death?

Michelle Donelan, Minister of State for Higher and Further Education, declined to meet with us until our court case was over.  I wonder if she will now listen to what we have to say?

We are one family in a network of bereaved families who want to learn from deaths and help universities identify safer practices and put them in place, but sadly, to date we are hardly ever consulted.  There is no group of people more determined to prevent such tragedies happening to anybody else.  Between us we have a wealth of knowledge about how and why distressed students slip through the net.  We can help identify small low-cost changes that could and should be implemented, right now, to save lives and protect student mental health.  

Finally, we would like to thank our family and friends who have supported us over the last four years, the brave former students who gave evidence to the court despite still living with the trauma of Natasha’s death, the 900 people who contributed to our crowdfunding campaign for legal costs, the charity INQUEST who support families through that very difficult process, and to the journalists who have covered Natasha’s case over the years. Special mention should also be made of our hugely supportive and strongly committed lawyers: Gus Silverman, Bethany Parr, Sarah Steinhardt, Tom Stoate, Heather Williams QC and Jamie Burton QC.  They were outstanding. 

We loved Natasha dearly.  We will always love her.  And it is heart-breaking that our exceptional daughter, who gave us so much joy, and had so much more to offer the world, was failed so badly and suffered such unnecessary torment.  

Robert & Margaret

Bristol County Court is due to deliver its judgment at 2pm on Friday, 20 May 2022.

Irwin Mitchell have issued a pre-judgment [press release].

It will be 1481 days after Natasha died.

Robert & Margaret

The trial started on Tuesday morning, 1^st March 2022, and finished on Tuesday afternoon, 8th March 2022. On the first morning Jamie Burton QC provided an extended summary of our case against the University. The court heard live evidence from Natasha’s mother [Margaret Abrahart] and university friend [Rajan Palan]. Live evidence was subsequently given by three university support staff [Barbara Perks, Karen Harvey-Lindon, Karen Hocking], two university academics [Dr Adrian Barnes, Dr Chris Bell] and two independent consultant psychiatrists instructed by each party respectively [Dr Braithwaite, Professor Burns]. Five of our seven witnesses were not cross-examined in court after the University accepted what most of them had to say in their statements. There were 14 lever arch files of documents.  Press were present most days e.g. The Bristol Cable.  In its closing submissions the university repeated its claim that it does not owe its students any relevant legally enforceable duty of care.

His Honour Judge Ralton, presiding over the case, said it would take some time for him to draw up his judgment. He will obviously need to give full and careful consideration to the complex legal issues that were argued in court. It is right and proper that this important decision is given due diligence and not rushed. No specific date was given for when the judgment would be ‘handed down’, but we will of course keep you posted on any developments.

It has taken four years of detailed preparation, for us to get this far, and during that period we have had to get used to a lot of delays. But, gratifyingly, we have now at long last had an opportunity for all relevant evidence to be heard and considered - something which was denied in coroner's court.

Thank you for your support. It has helped keep us going financially and emotionally.

For now, we must simply sit tight and wait patiently.

Robert & Margaret

With the trial due to start on 1 March everything is pretty hectic right now.  However, we thought we would just take a moment to reflect on what has now been nearly four years of detailed investigation and analysis.  Sadly, instead of enjoying our retirement, we have both needed to become detectives.

The first year was primarily focused on an investigation of the Mental Health Trust and in preparing for a lengthy inquest. The NHS, after a bit of persuasion, eventually engaged with us. The University of Bristol, in contrast, bluntly told us that they do not investigate student deaths. The Coroner in a similar vein ruled that her inquest would not consider the adequacy of support provided to Natasha by the University. This was all extremely disappointing.  And none of it made any sense to us, given that we believed our initial probing had identified a number of obvious problems at the University which urgently needed fixing.

Angry and bewildered, that only limited scrutiny had been applied to the University, we were left with no other option but to initiate a costly civil action. At that point we had no real idea about how long this legal process might take, or how demanding this fight for justice would be on us, but we were determined to help put matters right for all subsequent students. There were periods of searching, periods of gathering evidence and putting it together, and long periods of waiting for something to arrive. During this time of uncertainty, we experienced a variety of emotions. We have been stressed. We have been angry. We have cried. But throughout this period we have always been enormously grateful for support: from family, friends, our amazing legal team, and you, our supporters. Every donation has been hugely appreciated. Every comment is cherished.

This part of our journey is coming to an end. We are nearly there, nearly at the point where all of the evidence that has been assembled will be put before a judge for a ruling.  Natasha will at long last have her day court, but whatever the outcome, she will never get to hear it.

Thank you. Thank you. Thank you.

Robert & Margaret

Trial listed for 1^st - 9^th March 2022

In September 2021, our lawyers were told by email that:

• the University’s barrister had limited availability to attend a trial at the start of 2022; and, if required;
• a suitable alternative counsel could be instructed to cover March 2022.

Thereafter, on 3^rd November 2021, a court official proposed that the seven-day trial be listed for 1-9 March 2022. Both parties were at that point simply asked to confirm that such dates remained acceptable to everybody involved. However, despite chasers from our solicitor, six weeks later the Defendant’s lawyers had still not responded to the court. This is frustrating and unhelpful. The trial was accordingly assigned to that slot on 14^th December 2021; with a Pre-Trial Review scheduled for 21^st January 2022.

In February 2021, the University was given permission to obtain and rely upon evidence from an expert in psychiatry regarding issues of disability and causation. The associated report originally needed to be disclosed no later than 30^th July 2021. That period was subsequently extended to 17^th December 2021, but no report was supplied. Instead, the Defendant has once again applied to vary the timetable for bringing this case to trial.

It has taken three and a half years to get this far, and the end of our legal fight to establish the full truth about Natasha’s death is rapidly approaching, which is of course wonderful news, although we are now obviously wondering who will turn up in court to argue on behalf of the University of Bristol. This case, importantly, is also not just about what happened to our daughter. It involves novel and untested law as regards the common law duty of care a university has towards a student.

This will be our fourth Christmas with an empty seat at the dinner table.  We wonder, what would Natasha be doing now aged 24. She loved physics. She wanted to do physics research, and we had always believed that she would be good at it. Most of her friends have now graduated and obtained good jobs. Sadly, she didn’t even get to the end of her second year, as an undergraduate student in the School of Physics at the University of Bristol.

There is still a huge amount of work to get through in the next ten weeks, but we remain confident that all of our outstanding questions will eventually be answered in Bristol County Court. Your continuing support strengthens our resolve to maintain momentum, until the bitter end, despite the emotional drain of having to constantly revisit the heart-breaking events that occurred in Bristol at the start of 2018.

Thank you again.

Robert and Margaret

The University’s application to vary the timetable for bringing this case to trial was due to be heard in chambers by His Honour Judge Ralton on 23^rd September 2021. Having originally submitted no actual dates, whatsoever, and with only four working days left before the hearing, the University agreed to our own suggested set of dates for a revised scheduling of all remaining pre-trial exchanges. The University also agreed to the inclusion in any ensuing order of our proposals for: 

• the immediate delivery of certain outstanding documents; and
• that any further requests for specific disclosure “shall be responded to promptly” and in any event “within 14 days of receipt” of a request.

So no more chasing. No more ignored emails. No more three month waits!

Everything was duly ordered on 21^st September, without the need for anybody to attend a hearing, and witness statements were finally exchanged on Friday 19^th November 2021. The University, surprisingly, has only provided five witness statements. Seven witness statements were provided from Natasha’s family and friends. Two ancillary statements were also provided from Irwin Mitchell.

Thank you so much for your ongoing generosity and support.  It means such a lot to us, knowing that this fight for justice is being supported by so many people, most of who never even knew Natasha, but still believe that what we are doing is necessary for the protection of university students everywhere. 

Recently we have received some exceedingly generous donations, that will be used to help fund our QC, and for which a special public thank you is overdue.

The court is currently waiting to hear from the University regarding a potential trial date in March 2022. Hopefully we will not have to wait much longer.

Robert & Margaret    

New evidence is gradually being secured, as we continue to unravel what actually happened to our daughter at Bristol, and prepare ourselves for the lengthy ordeal of a seven-day trial in Bristol County Court. Amazingly, key evidence is only now just starting to come to light, as the legal procedures for obtaining relevant information are applied. This is a long and tortuous journey with each step in the disclosure process providing only small additional snippets of the information sought.

The University has applied to vary the timetable and to extend the time for exchange of witness statements, and psychiatric evidence. Their application to the court was submitted on 28^th July and will be heard on Thursday 23^rd September. They have not so far supplied any specific details on exactly what length of delay they will be asking for. The trial window has also been extended to March-May 2022; but we are told that the University’s lawyers and staff are not collectively available for any seven-day trial during that period.

In a civil action, both parties are expected to cooperate with each other, enabling the court to deal with cases justly and at proportionate cost. However:

• District Judge Woodburn, during the preliminary hearing on 23^rd February, had at our request ordered the Defendant to answer certain outstanding questions requesting greater clarity about a rescheduled oral assessment, that had apparently occurred on ‘Practical Physics 203’. These questions had originally been formerly and appropriately served on the Defendant on 23^rd November 2020. The University responded as ordered, miraculously, the very next day on 24^th February 2021. Their answer, however, was quite astonishing: three months after our original request, it appears they had only approached two of the four members of staff who were most likely to have been involved, and both individuals were “presently unable to recall” whether that additional assessment had occurred.
• The Defendant, in response to our request for specific disclosure of certain items, eventually supplied seventy-nine additional documents on 26^th July 2021, making a grand total of 218. Having now separated ‘wheat from chaff’, such disclosure nevertheless failed to include many of the documents which our solicitor had asked for three months previously. Others have still not yet been delivered.

Both matters will obviously need to be revisited.

No parent should have to bury a child. No family should have to take legal action against a university, to establish if, and to what extent, any of its acts or omissions might have caused or contributed to the death of their child. I wonder – should parents expect candour, transparency, openness and a commitment to learn from any sudden death?

Robert & Margaret

On 6 April 2021 both sides were due to exchange lists of the relevant documents in their possession so that the other side could request copies.

We provided the University with a list of 255 documents before the deadline. At the last minute a partner at the University’s solicitors (DAC Beachcroft) told us he wouldn’t be able to meet the deadline. Two days later they sent us a list of 139 documents, the majority of which were just what we already had from the inquest, with a few additional documents that we could have downloaded from the internet ourselves. None of these documents increased our understanding of what happened to Natasha. 

We strongly suspect that the University holds a significant number of documents which it has not yet listed for disclosure. Therefore, on 28 April 2021, our solicitor sent the Defendant’s solicitor a letter listing 32 documents or classes of document which we believe are in the University’s possession and ought to be disclosed. We are now waiting for their response and are disappointed that once again we have had to push the University for answers to our reasonable questions.

We remain so very grateful for your continuing support, and encouraging comments, which have helped keep us motivated throughout this agonising journey. It is now three years since Natasha died, and we still have unanswered questions about what actually happened at the University. That is about to change!

Thank you for your patience in sticking by us, and sharing our journey in pursuit of the full truth, and getting justice for Natasha. It is with your help that we have got this far.

Robert & Margaret

On 23 February 2021 we had a ‘Costs and Case Management Hearing’ before District Judge Woodburn at Bristol County Court. As with so many things these days, the hearing was by telephone. We were represented by our junior barrister, Sarah Steinhardt, of Doughty Street Chambers and the University was represented by a senior barrister, Paul Stagg, of 1 Chancery Lane.

The purpose of the hearing was for the Court to:

• Set ‘directions’; basically a list of steps which both sides are required to take in the run up to the trial. 
• Decide how much each side should be allowed to incur in legal costs.

There was a lot to get sorted out in the weeks and days before the hearing, so it was an unpleasant surprise when, on 17 February, the University notified us that they intended to ask the Court to order us to “use reasonable endeavours to obtain and disclose communications involving Natasha by e-mail or any form of social media or any form of messaging service from October 1st 2017 onwards.” It was quite a shock to be told this so shortly before the hearing, particularly because the University’s lawyers had been sent our proposed directions back in October 2020 and hadn’t said anything about this before. They now seemed to want us to hand over a potentially vast quantity of electronic messages sent by Natasha in the months leading up to her death. We couldn’t understand how all these messages could be relevant to the case. Why did the University want to see private messages between Natasha and her boyfriend? What were they hoping to gain by going on such an invasive and insensitive fishing expedition? Any party to a legal case is already under an obligation to hand over relevant material, so we couldn’t understand why the University wanted to place this additional emotional, practical and financial burden on us. Thankfully at the hearing itself the Court decided that we won’t be required to do anything more than is required by the normal disclosure rules.

The University’s barrister then objected to various parts of our ‘costs budget’, mainly arguing that if we win our case the University shouldn’t have to pay the costs of us instructing a Queen’s Counsel in addition to a junior barrister. In response to these arguments Sarah explained that this is essentially a ‘test case’ on two important points:

1. Whether universities owe a duty of care to exercise reasonable care and skill in relation to student welfare. 
2. When universities are required to make reasonable adjustments to the way in which they assess students who are disabled by mental illness.

The University’s barrister disagreed that this is a test case, and instead characterised it as a “private dispute between two parties”. He said it wasn’t as if there were other cases “lining up” to see what the Court decides in our case. Sadly, we know that mental illness among students is a real and growing problem. The university sector as a whole is almost certainly keeping a very close eye on the outcome of this case, as well they should.

Ultimately, the judge agreed that the importance of this case goes beyond simply our family and Bristol University, and allowed us to include the significant majority of the costs we had claimed in our budget. 

The Defendant was also ordered to answer our outstanding questions regarding an additional oral assessment that had apparently occurred on ‘Practical Physics 203’.

The next stage in our case is for both parties to provide each other with a list of the relevant documents they hold by 6 April 2021. Various further steps will then have to take place, including exchanging witness statements, and the trial itself will take place during the first available seven day window after 1 October 2021.

We remain very grateful to all of you who have sent us words of support and encouragement, as well as providing financial support to cover some of the substantial legal costs we have incurred and will continue incurring in order to give our legal team the best chance of preparing for this hugely important trial. If the court agrees with us and finds that universities do have a legally enforceable duty of care in respect of students’ welfare then we think this will make a big difference to students and young people all across the country. We really hope we can make Natasha proud.

Robert & Margaret

We are continuing our fight for justice through the civil courts.

On 17 September 2020 we served the University’s lawyers with a ‘Reply’ to their Defence.  This challenged various aspects of the University’s interpretation of the facts leading up to Natasha’s death and the underlying legal principles.  Copies of the Particulars of Claim, the Defence and the Reply can be obtained from Bristol County Court, where Natasha’s case was transferred on 19 October 2020.

Natasha’s case has to be heard in the county court as opposed to the High Court as it includes a claim for breaches of the Equality Act 2010.  We hope that the trial will take place in 2021. 

On 23 November 2020 we served the University’s lawyers with a ‘Request for Further Information’, essentially asking them to clarify their Defence relating to one of the oral assessments Natasha took.  If the University doesn’t clarify this point voluntarily then we may have to ask the court to order them to do so.

On 23 February 2021 there will be a ‘Costs and Case Management Conference’ at Bristol County Court, at which a judge will decide the level of legal costs that both sides are allowed to incur and will set a timetable for bringing the case to trial. 

In the ‘costs budget’ that was served on us, the University’s lawyers said that they planned to incur costs of over £100,000 in defending the claim.  In other words, this is how much they want to charge us if we lose.  This is a daunting prospect, but we will not be deterred from seeking justice for Natasha.

In the aftermath of Natasha’s death the University of Bristol said 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”.  They also confirmed that Natasha’s death “… did not trigger any additional review of the operation of the University’s services or procedures …”.  To us, this response was totally unacceptable, as it would be to any other parent who had just lost a child, and so we proceeded on our own, as best we could, and without their help, to find out what had transpired.

They now have to defend their various acts and omissions in the county court, including by instructing a psychiatrist to assess the extent to which those acts and omissions contributed to Natasha’s death.  In our view this is something that could and should have happened in 2018, without exposing us to the risk of a £100,000 legal bill from the University’s lawyers.

We remain so very grateful for your support.

Robert & Margaret

Lawyers acting for the University of Bristol have served their Defence today, confirming that all parts of our case will be contested in court.

We now expect the case will be transferred to Bristol County Court, where there will be a ‘Costs and Case Management Conference’.  This is where the court will set a timetable for bringing the case to trial and will decide how much each side can incur in legal costs.  We will know then how much the University may try to recover from Robert if we lose the case.

To be clear, as parents, we still want what we have always wanted, but have so far been denied by a system in which the odds are heavily stacked against us:

• accountability for our daughter’s death;
• a clear understanding of the events leading up to Natasha’s death and whether the University of Bristol breached its legal duties; and
• to ensure that the University of Bristol, and universities across the country, improve the way they safeguard vulnerable students.

Fundamental differences exist in how the two major organisations involved have reacted:

• The Avon and Wiltshire Mental Health Partnership NHS Trust has established an ‘action plan’ “… to minimise the possibility of this sort of tragedy happening again”. [post-inquest statement]
• The University of Bristol is still in denial. Consequently, it is now the subject of our civil action for breaches of the Equality Act and negligence. This was our last resort after the Coroner at Natasha’s inquest ruled that any failures by the University in supporting Natasha were outside the scope of her inquiry. 

It is a public disgrace that the only way a bereaved family can try to establish exactly how and why their child died, is by instigating a costly legal process, and/or by going to court in an adversarial manner. Litigation is unpleasant, and should not be necessary, since openness and honesty are purported to be the essential underpinnings of our university system.

The bigger picture cannot be overemphasised. If we can discover why our daughter died, and how her death might have been avoided, a similar tragedy could be prevented. History must not be allowed to repeat itself.

Two years have now elapsed, and as far as we can tell, no changes arising from Natasha’s death have been made at the University of Bristol. What are they waiting for?

Each life saved is what counts.

Robert & Margaret

Today, twenty-six months after Natasha’s death, we have taken the next major step in our fight for truth, justice and accountability. Civil proceedings have now been served on lawyers acting for the University of Bristol.

Bringing these proceedings is not a step we have undertaken lightly.  Although our lawyers are still working at substantially reduced rates, the costs of bringing a case to trial are significant. We also face the risk of having to pay the University’s legal costs if we lose. Nonetheless we feel we’ve been left with no other option but to take our fight to the civil courts.

The inquest in May 2019 concluded that Natasha’s death was contributed to by neglect on the part of the Avon and Wiltshire Mental Health Partnership NHS Trust. However, the Coroner ruled that looking into whether the University had complied with its legal duties was outside the scope of the inquest. This was hugely disappointing because we believed, and still believe, that the evidence indicates a series of failures by the University to comply with its duties under the Equality Act 2010 and its general duty of care to Natasha.

While the mental health trust engaged with us and confirmed that changes would be made as a result of Natasha’s death, the University of Bristol took a very different approach. After arguing that there was no “legal or factual basis for intensive scrutiny of the University” at the inquest and that “further investigation of Miss Abrahart’s problems [with her course] … will add nothing that is not already extensively documented” the University issued a press release following the inquest saying they did everything they could to help Natasha. We believe the evidence clearly shows this wasn’t the case, which is why we have taken this step.

Our case argues that the University of Bristol:

• Breached its duties under the Equality Act to make reasonable adjustments to its standard practice of orally assessing students on Natasha’s course, despite this practice placing her at a substantial disadvantage when compared with students who didn’t share her disability (Social Anxiety Disorder).
• Indirectly discriminated against Natasha, for the same reasons.
• Discriminated against Natasha for reasons arising from her disability when they docked her marks, awarded her no marks, or awarded her low marks in relation to the oral assessments.
• Breached their duty of care to Natasha by failing to provide her with adequate support when it became aware that she was suicidal and suffering from social anxiety.

Our case relies in part upon the evidence of a consultant psychiatrist experienced in the treatment of Social Anxiety Disorder, who has concluded that Natasha’s treatment by the University made a material contribution to her deteriorating mental health in the months before her death, and to her eventual suicide.

The overriding need for a costly civil action is fourfold:

• To hold the university to account.
• To establish the truth about what happened.
• To bring about changes in the way in which vulnerable students are supported at the University of Bristol and beyond.
• To send a clear message to the entire higher education sector.

We are so grateful for the support we received in our preparations for the inquest, both in terms of messages and donations. If you feel able to support this next stage of our fight for Natasha and for all vulnerable students then that would be a huge help.

Robert & Margaret

Natasha’s inquest lasted eight days (7^th-16^th 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 2^nd 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 23^rd 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 5^th 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 9^th 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.

Legislators

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.

Numerous post-inquest articles were published in the national press [e.g. The Guardian (16^th May, available to everyone) and The Telegraph (30^th May, subscription required)].

We will not go quietly into the night!

THANK YOU FOR SUPPORTING US

Robert and Margaret

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 30^th 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 

Many thanks to everyone for your generous support.

On 12^th 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 7^th - 17^th  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

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 (20^th January, subscription required); The Guardian (22^nd January, available to everyone)]. This generated a short burst of significant additional contributions to our crowdfunding campaign.
• BBC East Midlands Today (26^th 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 3^rd and final pre-inquest review hearing has been confirmed. This will now take place at 1 pm on Friday 12^th April.
• The full 3-week inquest is still scheduled for 7^th-24^th 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

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.

Background

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 3^rd 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.

 Meetings

On 21^st 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 17^th December 2018 we met with senior management from AWP to hear their response to the concerns we raised at the first meeting.

Progress

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.

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

Particular aspects of this hearing were reported in the press [e.g.  Bristol Post, Huffington Post.] Further details included:

• 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.

Next steps

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