A CORONER has called for ‘urgent action’ to tighten of procedures by health and university professionals following the death of an Exminster student.

Richard Middleton, assistant coroner for Dorset, warned there were ‘missed opportunities’ by officials which contributed to the death of 18-year-old Alexander Kieran Channing, known as Alec.

He was found hanging in his halls of residence in January 2022.

Mr Middleton has issued a Prevention of Future Deaths report to the Vice Chancellor of Arts University Bournemouth, Dorset Healthcare NHS Foundation Trust and Devon Partnership NHS Trust following an inquest into Alec’s death.

The coroner recorded a Alec died by suicide but added opportunities had been missed to assess the risk of suicide, the last being two days before his death.

In 2021 Alec was diagnosed with Emotionally Unstable Personality Disorder and spent some time detained in hospital under the Mental Health Act.

Following his discharge, he was seen by the Home Treatment Team and then transferred to the Community Mental Health Team at his home in Exminster, but a delay followed in transferring his care to the CMH Team in Bournemouth when he went to university.

The inquest heard it had been wrongly believed this transfer of care could not take place until he had registered with a GP surgery in his university town.

On January 25, 2022, two days before he died, Alec contracted Covid so a face-to-face mental health assessment was postponed.

On January 27, Alec was found hanging in his room.

Paramedics attended and pronounced him dead at the scene.

Dorset Police investigated and found no suspicious circumstances.

In his report Mr Middleton said there had been a lack of liaison and raised concern about four issues, including the lack of training for the wellbeing services at the Arts University for students diagnosed with Emotionally Unstable Personality Disorder.

He also said: ‘There appears to be a failure amongst staff at the Exeter CMHT to appreciate that there can be a direct transfer of a patient’s care to another CMHT Trust without the need for a patient to have to first register with a GP surgery.

‘There was a lack of involvement of a responsible clinician in the process of discharge planning from the district hospital in Exeter to the care of Bournemouth CMHT at Dorset Healthcare NHS Foundation Trust.’

Mr Middleton also said there was no policy in place at

Devon Partnership NHS Trust which ‘encourages a repeated proactive approach in seeking consent from a patient to share information at relevant times’.

He concluded: ‘In my opinion urgent action should be taken to prevent future deaths.’

Following Alec’s death, a fundraising campaign was launched in Exminster, where he had been well know, to buy a bench in his memory with donations reaching £3,000.

Contact Samaritans for free at any time on 116 123 or visit www.samaritans.org.