Deficiencies in mental health care exposed after 18-year-old Leicester university student took his own life

Lily Jahany was studying to become a doctor when she committed 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 “long and complicated psychiatric history” that included a diagnosis of bipolar affective disorder, as well as suffering from post-traumatic stress disorder, depression and anxiety. She took a series of overdoses and tried to hang herself twice before she died on Saturday, December 9, 2022.

Now a Preventing Future Deaths report from Leicester coroner Fiona Butler has raised concerns about both the Student Roost accommodation service and the mental health care she received from Leicestershire Partnership NHS Trust ( LPT) during this time. While Ms Butler could not rule that the failings “contributed more than minimally, trivially or negligibly to Lily’s death”, she said lessons had to be learned.

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

The coroner said he was “surprised” to learn that no staff – or at least none of the six Student Roost accommodation blocks in Leicester – had first aid training and that training was not mandatory. Accommodation staff “could be the first people on the scene of a situation (in their apartments) that requires first aid and then emergency services.”

She labeled the lack of proper training “looking”. She did, however, acknowledge Student Roost’s “Night Owl Service,” which operates 24/7 and helps students “with everything from lost keys, broken faucets, and their well-being.” She said this was “an excellent idea”.

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

“We take seriously the concerns outlined and the actions suggested in the report. Following the report, we have begun a company-wide review with the intention of introducing emergency first aid training for team members at each Student Roost property to further improve our services for the well-being of our residents.

“Furthermore, we are aware of the mental health concerns felt by students across the UK and have invested in mental health first aid training. We currently have over 50 team members across our head office and property teams who are qualified in mental health first aid, which we are building every year to further support residents and team members. Our dedicated Resident Wellbeing team also provides 24/7 on-site support for residents.”

Further failings were found in Leicestershire Partnership Trust’s (LPT) handling of Lily’s care. Lily was treated privately for her mental health difficulties, Ms Butler said. This meant her medical records were kept privately rather than in the national system.

This had the effect of misleading those treating her in Leicester about the degree of risk to her welfare, Ms Butler ruled. However, she added that it also put a “greater onus 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 “get the full extent of Lily’s mental health challenges”, she added. LPT procedures set out the need for its staff to take “responsibility for referrals and liaison with other agencies involved”, Ms Butler continued.

However, this is one line in their policy and she ruled that “anything but clear”. In her view, it also does not “suggest any expectation that staff will proactively contact private sector clinicians to obtain information”.

Furthermore, Ms Butler said she would “not capture situations such as Lily’s, who was released from the crisis team after an hour’s assessment and was therefore not under their care and treatment”.

A spokeswoman for LPT told LeicestershireLive: “Sincere condolences to Lily’s family and loved ones. We are committed to providing our patients with the best quality care and will ensure we learn from Lily’s death.”