(1) Academic Advisor – Better use should be made of the person in this post for each school. There was a wasted opportunity for the academic advisor to be involved in face to face meetings with Daniel and help him when he was struggling to get his work in on time and to deal with his academic pressures. In the circumstances I heard that if work was late a penalty would be imposed. This seems ridiculous; why hit a man when he is already down?

(2) With regard to communication – this appeared to be deeply flawed amongst the huge number of University departments and units. The health clinic incorporating amongst other things a pharmacy and the counselling service, was excellent offering free access to students. The system failed – Daniel was not in the link between his GP/counsellor and the student support unit. If this link had been complete I do not believe Daniel would have died when he did.