Mental health care failings exposed after Leicester university student, 18, dies by suicide

Lily was a student at the University of Leicester
-Credit: (Image: Leicester Mercury / Chris Gordon)


Lily Jahany was studying medical physiology in biological sciences when she died by suicide in 2022. An 18-year-old student at the University of Leicester, she had only been in the city for three months at the time of her death.

Lily had a "lengthy and complicated psychiatric history" that included a bipolar affective disorder diagnosis, as well as suffering from post-traumatic stress disorder, depression and anxiety. She took a number of overdoses, and tried to hang herself twice, before her death on Saturday, December 9, 2022.

Now, a prevention of future deaths report from Leicester coroner Fiona Butler has raised concerns about both her Student Roost accommodation service and the mental health care she received from the Leicestershire Partnership NHS Trust (LPT) during this time. 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.

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Ms Butler found that the Student Roost company did not require its staff to have first aid training at the time in question. All of Lily’s “extreme acts of self-harm took place at her student accommodation”, she added.

The coroner professed herself “surprised to learn” that no staff – or at least none in Leicester’s six Student Roost accommodation blocks – had first aid training and that training 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”.

She labelled the lack of suitable training “concerning”. She did, however, recognise Student Roost’s “Night Owl Service” which runs 24/7 and helps students “with everything from loosing their keys, broken taps, but also their wellbeing”. She said this was “an excellent idea”.

Student Roost told LeicestershireLive it was taking the findings “seriously” and intends to introduce emergency first aid training in all its properties. A spokeswoman for the company said: “We are aware of the coroner’s report from HM Coroner’s Office for Leicester City and South Leicestershire and our thoughts are with the family and friends of the student.

“We are taking the outlined concerns and suggested actions from the report seriously. Following the report, we have commenced a company-wide review with the intention of introducing emergency first aid training for team members in every Student Roost property, to further improve our services for the wellbeing of our residents.

“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.”

Further failings were found in the handling of Lily’s care by the Leicestershire Partnership Trust (LPT). Lily was being treated privately for her mental health difficulties, Ms Butler said. This meant her medical records were 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 ruled. 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. LPT procedures do set out the need for its staff to take “responsibility for referrals and liaising with other agencies involved”, Ms Butler continued.

This is a single line in their policy, however, and she ruled it “anything but clear”. Nor does it, in her view, “set out any expectation upon staff to proactively make contact with treating clinicians in the private sector to gain information”.

Moreover, Ms Butler said it “would not capture situations such as Lily’s, who was discharged from the Crisis Team after a one hour assessment and therefore was not under their care and treatment”.

A spokeswoman from LPT told LeicestershireLive: “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.”