Finding into death of Zhikai Liu

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2016 1035

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2)

Section 67 of the Ceroners Act 2008

I, AUDREY JAMIESON, Coroner having investigated the death of ZHIKAI LIU

without holding an inquest: find that the identity of the deceased was ZHIKAI LIU born 25 October 1991 and the death occurred on 6 March 2016 at 120 A’Beckett Street, Melbourne, Victoria 3000 from:

1 (a) MULTIPLE INJURIES

Pursuant to section 67(1) of the Coroners Act 2008, I make findings with respect to the following circumstances:

1. Zhikai Liu was 24 years of age at the time of his death. Mr Liu lived with his sister Zizhen Liu, at an apartment on the 21* floor of a building at 120 A’Beckett Street in Melbourne. He was a

Chinese national and was studying at Melbourne University.

2. At approximately 4.17 pm on Sunday 6 March 2016, Mr Liu fell from the balcony of his

apartment, landing on the courtyard below. Bystanders stopped to render assistance and

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contacted emergency services. Ambulance paramedics arrived shortly afterwards and declared

Mr Liu deceased. Police were also in attendance.

INVESTIGATIONS

Forensic pathology investigation

Associate Professor (A/Prof) David Ranson, Deputy Director — Head of Forensic Services at the Victorian Institute of Forensic Medicine, performed an external examination upon the body of Mr Liu, reviewed a post mortem computed tomography (CT) scan and referred to the Victoria Police Report of Death, Form 83. Anatomical findings were consistent with the known mechanism of injury. Toxicological analysis of post mortem blood did not identify any alcohol, common drugs or poisons. On the evidence available to him, A/Prof Ranson ascribed the cause

of Mr Liu’s death to multiple injuries.

Police investigation

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Upon attending the A’Beckett Street apartment, Victoria Police did not identify any signs of a disturbance, or third-party involvement in Mr Liu’s death. No ‘suicide note’ was located. There was no evidence of illicit drug usage within the apartment, nor prescription medication of any kind.

Senior Constable (S/C) Stephen Clark, the nominated coroner’s investigator,’ conducted an investigation of the circumstances surrounding Mr Liu’s death, at the coroner’s direction, including the preparation of the coronial brief. The coronial brief contained, inter alia,

statements made by Mr Liu’s sister Zizhen Liu, partner Tao Guo and five witnesses.

Zizhen Liu stated that her brother had moved to Australia to study in November 2015, and that his girlfriend Tao Guo was studying in Sydney. She observed that Mr Liu faced language barriers with local students and felt depressed and frustrated when he had difficulty

understanding what was happening in his university classes.

Ms Liu believed her brother suffered from depression due to a change of environment and

relationship issues with his girlfriend. Ms Liu stated that she had learnt from their mother that

' A coroner’s investigator is a police officer nominated by the Chief Commissioner of Police or any other person nominated by the coroner to them with his/her investigation into a reportable death. The coroner’s investigator takes direction from a coroner and carries out the role subject to the direction of a comer.

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in November 2015, her brother had referenced experiencing suicidal ideation whenever he was alone in the apartment. Ms Liu subsequently advised her brother to seek medical assistance, but said that he refused to do so, and insisted he was alright. S/C Clark confirmed that enquiries were made, but no doctor or psychologist was identified to have been treating

Mr Liu.

Tao Guo stated that she and Mr Liu maintained their relationship via telephone. She was aware that Mr Liu was suffering from insomnia, but he had never said anything to her about harming

himself in any way.

Ms Liu stated that on the evening of Saturday 5 March 2016, her brother expressed a desire to focus on the International English Language Testing System (IELTS), rather than spend time at Melbourne University. She added that their father had told Mr Liu to give the decision some thought.

Ms Guo communicated with Mr Liu at approximately 2.00 pm on Sunday 6 March 2016. She

stated that he was purchasing some items from China online and wanted to know if she needed

anything.

Ms Liu had a conversation with her brother at approximately 4.10 pm that afternoon, regarding his future. She stated that she told Mr Liu that he should change the way he dealt with his studies, and that he was spending too much time on the phone with Ms Guo and helping people with errands. Ms Liu stated that she could see her brother did not want to continue their conversation. She saw Mr Liu go to the kitchen and heard him say ‘[w]hy is life so difficult?

Why do we always have to make difficult decision?’ (sic). Ms Liu then saw her brother walk towards the apartment’s balcony, but a wall blocked her vision of him. She subsequently heard

a scream and rushed to the balcony, and saw her brother lying on the ground below.

Ms Liu stated that the balcony’s fence has a height of approximately 1.2 metres. She noted that Mr Liu’s phone indicated he had last sent a text message to his girlfriend at 4.12 pm that

afternoon.

The evidence of the circumstances of Mr Liu’s death indicate, on the balance of probabilities,

an intention to end his own life and therefore that his death was a suicide.”

2 A specific Finding will be made at the completion of this document.

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Coroners Prevention Unit Investigation

Mr Liu’s suicide as an international student struggling with English and with his studies is not a unique set of circumstances to the coronial jurisdiction. To provide context for my investigation into Zhikai Liu's death, I asked the Coroners Prevention Unit (CPU) to identify other Victorian deaths of international students in circumstances consistent with suicide. The CPU searched the Victorian Suicide Register (VSR) and identified 27 such deaths between 2009 and 2015 but acknowledged this was likely to be an under-estimate. The case identification process and analysis of the suicides are found in the attached memorandum titled

“Suicides of international students in Victoria, 2009 — 2015”.

The CPU compared the circumstances of the 27 international student suicides with a cohort of suicides among Australian-born students, to explore what might be distinctive about the

deaths. The findings included: a. Males comprised 22 (81.5%) of the 27 international student suicides.

b. The deceased's country of citizenship was in Asia for 24 (88.9%) of the suicides.

c. The international student suicide cohort had a lower prevalence of self-harm (11.1% versus 34.5%) and previous suicide attempts (11.1% versus 45.2%) than a comparison cohort of Australian-born student suicides; however more frequently experienced educational (66.7% versus 51.2%) and financial (37.0% versus 10.7%)

stressors.

d. There was a lower prevalence of diagnosed mental illness among international student suicides (14.8%) than Australian-born student suicides (66.7%), and a corresponding higher proportion of deceased with suspected mental illness (33.3%

versus 17.9%) or with no evidence of mental ill health (51.9% versus 15.5%).

e. Only 22.2% of the international student suicide cohort attended a health service for a

mental health related issue within six weeks of death. In contrast, 57.1% of the

3 The Coroners Prevention Unit (CPU) was established in 2008 to strengthen the prevention role of the coroner. The unit assists the coroner with research in matters related to public health and safcty and in relation to the formulation of prevention recommendations, as well as assisting in monitoring and evaluating the effectiveness of the recommendations. The CPU comprises a team with training in medicine, nursing, law, public heaith and the social scIcTICes.

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Australian-borm student suicide cohort had such an attendance within six weeks of

death.

16. Ina substantial number of the international student suicides, family and friends had expressed concern about the deceased’s deteriorating mental state proximal to the fatal incident.

Therefore, the CPU expressed a strong concern that the lower proportion of diagnosed mental illness among international students - and concomitant lower engagement with health services for mental health related issues - may reflect increased barriers to international students

accessing mental health treatment, rather than lower underlying prevalence of mental ill health.

Research into international student suicides in Australia

17. While the Australian media occasionally publishes stories regarding international student suicides,* the CPU was unable to locate any studies - either Australian or international -

addressing suicide among international students.

18. However, there was substantial literature on the health and particularly mental health of international students in Australia, which was clearly relevant to understanding the contexts within which suicide may occur. The literature highlighted that international students in Australia experience a range of stressors impacting on their mental health, and they are less likely than domestic students to seek assistance for mental health issues because of cultural, financial, linguistic and other hurdles.’ This information is consistent with international research® as well as the CPU's data, which indicated that the international student suicide cohort had far lower levels of service engagement for mental health than the Australian-born

student suicide cohort.

4 See, for example: Gilmore H and Johnston C, "More suicides uncovered among overseas students", Sydney Morning Herald, 2 July 2009; Baker E, “It's stressful being an other: The mental health woes of international students", Canberra Times, 2 Jone 2018.

5 See, for example: Forbes-Mewett H and Sawyer AM, "Mental Health Issues amongst International Students in Australia: Perspectives from Professionals at the Coal-face"; The Annual Conference of The Australian Sociological Association 2011 Conference Proceedings, pp.1-19; Pejic J, International Student Welfare in Australia, Melbourne: International Social Service Australia, 2012; Redfem K, " An empirical investigation of the incidence of negative psychological symptoms among Chinese international students at an Australian university" Australian Journal of Psychology, 2016, vol 68, pp.28 1-289; Forbes-Mewett H, Sawyer AM, "International students and mental health", Journai of International Students, 2016, vol 6, no 3, pp.661-677; Skromanis S, Cooling N, Rodgers B, Purton T, Fan F, Bridgman H, Harris K, Presser J and Mond J, "Health and well-being of international university students, and comparison with domestic students in Tasmania, Australia", International Journal of Environmental Research and Public Health, 2018, Vol 15, doi:10.3390/ ijerph15061147,

§ See, for example: Mori S, "Addressing the Mental Health Concerns of International Students", Journal of Counseling and Development, 2000, vol 78, pp.137-144; Onabule AI and Boes SR, "International students' likelihood to seek counselling while studying abroad", Journal of International Students, 2013, vol 3, no 1, pp.52-59.

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COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments connected with

the death:

1. The CPU's report on international: student suicides highlighted mental health related themes which strongly reflected the circumstances of Zhikai Liu's death. Specifically, Zhikai Liu's sister stated he had trouble with his studies and the English language, and consequently his mental state had deteriorated since he arrived in Australia to study. She encouraged him to seek assistance from a counsellor, but he did not do so, The CPU found that lack of help-

seeking for deteriorating mental state was a recurring theme in the international suicide cohort.

2. While I am unable to conclude that Zhikai Liu would still be alive if he had engaged with a health service to treat his deteriorating mental state, at the very least this would have created prevention opportunities that did not otherwise exist. Further to this point, the extant literature on international student mental health suggests that there is an underlying systemic issue with engaging international students in mental health treatment in Australia. Published studies have repeatedly found that international students in Australia experience a range of stressors impacting on their mental health, and they are less likely than domestic students to seek assistance for mental health issues because of cultural and financial and linguistic and other

hurdles.

3. J acknowledge that greater international student engagement with mental health services is a goal far easier articulated than achieved. Researchers have long identified cultural, linguistic, financial and other barriers to such engagement, and J do not have the evidence before me to make any specific recommendations about how to overcome these barriers. However, I

understand relevant experts and organisations exist who can consider this question.

4. The Australian Government Department of Education and Training is responsible for the National Code of Practice for Providers of Education and Training to Overseas Students (‘the National Code’), a legislative instrument with which all registered education providers to international students must comply. The National Code includes 11 standards, and Standard 6 - titled "Student Support Services" - sets out the support services that registered providers must provide "to ensure the mental and physical wellbeing of their overseas students". The Department of Education and Training is, in my view, therefore the most appropriate

_ government body to lead this work. A pertinent recommendation will follow.

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Under Standard 6 of the National Code, education providers to international students are required to have a critical incident policy which includes, inter alia, maintaining a "written record of any critical incident and remedial action taken by the registered provider". Critical incidents include deaths. Standard 6 does not appear to include any requirement beyond the education provider maintaining this written record, which is a major missed opportunity from a prevention perspective. A central public health principle is that health problems must be defined and understood before interventions are developed. A pertinent recommendation will

follow.

Further to the above, the written records of critical incidents would be highly useful to the Coroners who have a legal mandate to investigate international student deaths. They would assist the investigating Coroner to confirm a deceased person was an international student; the CPU noted that case identification was challenging because there was often a lack of evidence to confirm international student status. They would also provide the investigating Coroner with an outline of what if anything the institution has done in response to the death. There would be no legal or privacy barriers to providing a critical incident report to an investigating Coroner, as it is material to assist the Coroner in discharging the investigative function described in law.

A pertinent recommendation will follow.

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RECOMMENDATIONS Pursuant to section 72(2) of the Coroners Act 2008, [ make the following recommendations:

1. To promote public health and safety and to prevent like deaths, I recommend that the Australian Government Department of Education and Training undertake consultation, in whatever form it believes most appropriate, with Victorian international student education providers as well as other organisations involved in international student education and support ‘in Victoria, to identify strategies to engage vulnerable international students with mental health

support; AND

2. In undertaking its consultation, I recommend the Australian Government Department of Education and Training consider how critical incident reports maintained by education providers under Standard 6 of the National Code of Practice for Providers of Education and Training to Overseas Students, may be brought together to inform interventions to reduce

suicide among international students studying in Victoria; AND

3. LT recommend The Australian Government Department of Education and Training amend Standard 6 of the National Code of Practice for Providers of Education and Training to Overseas Students to include a requirement that, when a death of an international student occurs, within four weeks the education provider forward a copy of the written record of the

critical incident and remedial action taken to the Coroner in the jurisdiction where the death

occurred.

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FINDINGS

The evidence indicates that Mr Liu exhibited signs of undiagnosed and untreated mental ill-health,

after relocating to Australia to study in November 2015.

The investigation has identified that Mr Liu experienced suicidal ideation and demonstrated symptoms suggestive of depression, especially while adjusting to his new environment confronting language barriers and experiencing study difficulties at. university. Mr Liu was advised to seek

professional help for his mental ill-health but ultimately did not.

I accept and adopt the medical cause of death as identified by A/Prof Ranson and find that Zhikai

Liu died from multiple injuries, in circumstances where I find he intended to take his own life.

Pursuant to section 73(1A) of the Coroners Act 2008 (Vic), I order that this Finding be published on

the internet.

I direct that a copy of this finding be provided to the following:

Mr Jianshe Liu

The Office of the Chief Psychiatrist

The Department of Education and Training

Study Melbourne, Department of Economic Development, Jobs, Transport and Resources

Bijay Sapkota, National President, Council of International Students Australia

Pratik Ambani, President, Australian Federation of International Students

Manorani Guy, Victoria and Tasmania Branch President, International Education Association Inc Dr John Wellard, Policy Director - International, Universities Australia

Helen Kronberger, Director Victorian TAFE International

Senior Constable Stephen Clark

Signature:

. £

AUDREY JAMIESON CORONER

Date: 10 January 2019

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Coroners Court of Victoria

COR 2016 1035

CORONIAL INVESTIGATION INTO THE DEATH OF ZHIKAI LIU

Annexure 1:

Suicides of international students in

Victoria 2009-2015

Coroners Court of Victoria 65 Kavanagh Street

SOUTHBANK VIC 3006 Tel: (03) 8688 0700 Email: courtadmin@coronerscourt.vic.cov.au

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Memorandum

From: Jeremy Dwyer, Coroners Prevention Unit (CPU)

To: Coroner Audrey Jamieson

Date: 19 December 2018

Re: Suicides of international students, Victoria 2009-2015

1. Background

Coroner Jamieson requested that the Coroners Prevention Unit (CPU) provide advice on the incidence of suicide among international students who are studying in Victoria,

2. Method

This section describes the process by which the CPU identified suicide deaths relevant to Coroner Jamieson’s request.

2.1 Definitions

The CPU defined an international student to be a person who (a) usually resided outside Australia;

(b) held a student visa permitting temporary residence in Australia; and (c) was cnrolled to study in an Australian education institution.

2.2 Data source

The CPU used the Victorian Suicide Register (VSR) to identify suicides of international students.

The VSR is a database of suspected and Coroner-determined suicides maintained by the CPU. It includes basic demographic, method and location information for every suicide investigated by a Victorian Coroner between 1 January 2000 and the present. It also includes an enhanced dataset describing the circumstances in which suicides occurred, the medical and mental health background of the deceased, and relevant stressors and risk factors; this enhanced dataset is coded for all Victorian suicides between 2009 and 2015, with 2016 coding recently commenced.

Several fields in the VSR could potentially be used (either singly or in combination with other fields) to identify deaths of international students:

• "Current employment status" is a categorical variable with a number of coding options, one of which is "student".

• "Usual occupation” is a free-text field in which the coder records the deceased's occupation proximal to death; for students the occupation is "student".

• "Evidence that born overseas” is a binary variable that is coded as true if there is evidence the deceased was born outside Australia.

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• Free-text notes describe the deceased's socio-demographic profile including evidence of employment, belonging to a culturally and linguistically diverse community, and being a citizen of another country.

• Free-text notes describe the situational and contextual stressors that the deceased may have experienced in the lead-up to death. If the deceased was experiencing stressors relating to education, they would be described here.

• The text of the Victoria Police Initial Report of Death to the Coroner (‘Form 83') is stored in the VSR, and may include mention that the deceased was an international student.

These fields (with the exception of the Form 83 text) are all coded as part of the VSR's enhanced dataset but are not available within the core dataset.

2.3 Inclusion criteria

The VSR's enhanced dataset is fully coded only for the years 2009 to 2015. Therefore, the inclusion criteria were that the death: (a) was a suicide of an international student, which (b} was reported to a Victorian Coroner for investigation between 1 January 2009 and 31 December 2015.

2.4 Case identification

The CPU undertook five independent VSR searches using the following parameters:

• "Current employment status" = "Student" and "Evidence that born overseas" = true.

• "Usual occupation" contains "student" and "Evidence that born overseas" = true.

• Socio-demographic free-text notes contain "international student" or “overseas student" or "student visa".

• Situational and contextual stressors free-text notes contain "international student" or “overseas student" or "student visa".

• Form 83 text contains "international student" or "overseas student" or "student visa".

The results of the five searches were combined and the CPU reviewed all available material (including VSR coding and the Coroner’s finding) to determine whether each death met the inclusion criteria.

2.5 Information recorded For each relevant death the CPU recorded the following:

• Country of deceased person's citizenship, and geographical region where the country is located.”

• Amount of time the deceased had been studying in Australia.

7 Countries were mapped to regions using United Nations, "Standard Country or Area Codes for Statistical Use", Standard M49, https://unstats.un.org/unsd/methodology/m49/, accessed 5 December 2018.

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• Type of education institution where the deceased was enrolled to study (university, TAFE, secondary school or other).

• Age and sex of deceased.

Additionally, the available Coronial material for each death was reviewed to identify any evidence regarding education-related stressors the deceased may have been experiencing.

2.6 Limitations

The identification of relevant cases was dependent on there being sufficient information recorded in the VSR and other Coronial material regarding the deceased's status as an international student. A particular issue the CPU encountered in this respect was being unable to confirm that the deceased was in Australia on a student visa (as opposed to another type of visa such as a prospective marriage visa or partner visa, which would also enable a non-citizen to study in Australia).

The results of the CPU case identification process — while as thorough as could be achieved given this limitation — are likely to represent an under-estimate of the true frequency of suicide among international students in Victoria.

3. Suicides of international students

Between 2009 and 2015 (inclusive) the CPU identified 27 Victorian deaths that were confirmed to be suicides of international students. A further 16 deaths were identified that could potentially be classified as international student suicides:

• Five suicides where the deceased was born overseas and was studying in Australia and was not an Australian citizen, however was in Australia as a recently arrived (within five years) migrant rather than holding a student visa. The majority of these deceased migrated as children with their families.

• Five suicides where the deceased was born overseas and was studying in Australia, but there was insufficient evidence to establish that the deceased held a student visa.

• Three suicides where the deceased was born overseas and was studying in Australia, but held a partner visa or refugee visa rather than a student visa.

• Three suicides where the deceased was born overseas and entered Australia on a student visa, but had ceased study before their death. (In two of these three deaths the deceased was in Australia holding an expired student visa.)

The CPU determined not to include these further 16 deaths in the following analysis, while noting

they could potentially be of relevance in any broader consideration of how students from culturally and linguistically diverse communities are supported.

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3.1 Sex and ave group

Table 1 shows that the frequency of international student suicides by sex and age group. The majority of the deceased (15 of 27, 55.6%) were males aged 18 to 24 years. Males comprised 22

(81.5%) of the 27 suicides.

Table 1: Frequency of international student suicides by sex and age group, Victoria 2009-2015.

Age group Male Under 18 years - 18 to 24 years 15 25 to 29 years 5 30 to 34 years

35 to 39 years - AO years and older 1 Total 22

Female Total 1 16 3 8 1 2 5 27

3.2 Institution and time in Australia

Table 2 shows that the frequency of international student suicides by the institution where the student was studying and the length of time the student had been in Australia. Most students (20 of

27, 74.1%) were studying at university.

Table 2: Frequency of international student suicides by study institution and length of time studying in

Australia, Victoria 2009-2015.

eee University TAFE See Unknown Total Less than | year 4 2 - 1 7 Between | and 2 years 5 - “ 1 6 Between 2 and 3 years 5 - - 1 6 Between 3 and 5 years 3 - ” - 3 Unknown 3 1 “ 1 5 Total 20 3 - 4 27

3.3 Country of citizenship

Among the 27 deceased, their country of citizenship was located:

• In Asia for 24 deaths.

• In the Americas for two deaths.

• In Europe for one death.

The specific countries of citizenship that occurred most frequently were Hong Kong (four deaths), China (three deaths), India (three deaths), Indonesia (three deaths), Korea (three deaths) and

Malaysia.(three deaths).

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4, International students and Australian-born students

To explore the distinctive features of international student suicides in Victoria, the CPU selected the following comparison group: all suicides in Victoria between 2009 and 2015 of students aged 18 ycars or over® who were born in Australia. A VSR search yielded 84 suicides that met these criteria.

4.1 Comparison across stressors

The CPU compared the international student and Australian-born student suicide cohorts across several areas relating to contextual, situational and interpersonal stressors, to identify any substantial differences that might suggest targeted suicide prevention opportunities for ‘international students. In summary, the main areas of similarity were:

Proximal to death, 63.1% of the Australian-born students and 59.3% of the international students gave an indication that they intended to take their lives.

Similar proportions of deceased in the two cohorts experienced the following interpersonal stressors: separation from partner (29.6% of Australian-bom student suicides versus 29.7% of international student suicides), conflict with partner (19.0% versus 25.9%), and family violence involving partner (8.3% versus 3.7%).

Similar proportions of deceased in the two cohorts experienced the following contextual and situational stressors: work-related stressors (15.5% of Australian-born student suicides versus 22.2% of international student suicides), social isolation (20.2% versus 25.9%), and substance misuse (39.3% versus 33.3%).

Areas of difference included:

&

34.5% of the Australian-born student cohort had a known history of self-harm, compared to 11.1% of the international student cohort.

45.2% of the Australian-born cohort had previously attempted suicide, whereas the proportion was 11.1% for the international student cohort.

A higher proportion of the Australian-born student cohort than the international student cohort experienced death of a family member (25.0% versus 0.0%), conflict with family members other than partner (35.7% versus 22.2%), exposure to family violence other than involving partner (14.3% versus 0.0%), and conflict with non-family acquaintances (25.0% versus 14.8%).

A higher proportion of the Australian-born student cohort than the international student cohort experienced the following contextual and situational stressors: legal issues (16.7% versus 3.7%), gender and sexuality (10.7% versus 0.0%), exposure to abuse (28.6% versus 7.4%) and exposure to suicide of another (20.2% versus 0.0%).

The youngest person in the international student suicide cohort was aged 18 years. The CPU was concermmed therefore that if the Australian-born student suicide cohort included students aged under 18 years, this could reduce its utility as an appropriate comparison group.

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• A lower proportion of the Australian-born student cohort than the international student cohort experienced the following contextual and situational stressors: educational issues (51.2% versus 66.7%) and financial issues (10.7% versus 37.0%).

4.2 Themes in the international student suicides

Educational and financial stressors featured more prominently among the international student suicide cohort than the Australian-born cohort. Therefore, the CPU reviewed the available Coronial material regarding the experience of these stressors among the international student cohort, to identify any common themes.

The most prevalent theme in education was that the student had either failed or was in the process of failing the course; this was present in 10 of the 27 deaths. In five of these 10 deaths, the deceased feared parents discovering the failure. In three of the deaths, the failure appeared to have implications for the student's visa eligibility. The other main educational stressor, in three suicides, was that the deceased was not enjoying his or her course and wanted to either cease study or change courses.

Among financial stressors, inability to pay tuition fees was evident in five deaths and was directly linked to gambling losses in two of these deaths.

4,3 Mental ill health and related treatment

Table 3: Frequency and proportion of suicides by mental ill health diagnosis, international students and Australian-born students, Victoria 2009-2015.

• International students Australian-born students Mental ill health n % n % Diagnosed mental illness 4 14.8 56 66.7 Suspected mental illness 9 33.3 15 17.9 No evidence of mental ill health 14 51.9 13 15.5 Total 27 100.0 84 100.0

Table 3 shows the frequency and proportion of international student suicides where there was evidence the deceased had a diagnosed mental illness, a suspected mental illness without diagnosis, or there was no evidence of mental ill health. Table 3 also includes comparison data drawn from the Ausiralian-born student suicide cohort. The data shows a far lower prevalence of diagnosed mental illness among international student suicides (14.8%) than Australian-born student suicides (66.7%), and a corresponding higher proportion of deceased with suspected mental illness (33.3% versus 17.9%) or with no evidence of mental ill health (51.9% versus 15.5%).

These differences were reflected in the CPU analysis of most recent health service contacts for reasons relating to mental health, which is shown in Table 4. Among the international student suicide cohort, 22.2% attended a health service for mental health related issues within six weeks of death. In contrast, 57.1% of the Australian-born student suicide cohort had attended a health service for reasons relating to mental health within six weeks of death.

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Table 4: Frequency and proportion of suicides by most recent health service contact for mental health related reasons, international students and all Victoria residents 2009-2015.

Most recent health service contact for International students Australian-born students mental health n % n A Within six weeks of death 6 22,2 48. 57.1 Between six weeks and 12 months 2 TA 14 16.7 No contact in 12 months _ 19 70.4 22 26.2 Total 27 100.0 84 100.0

The CPU further reviewed the available Coronial material and noted that among international students who did not have a formal diagnosis of mental ill health, there was often evidence that friends and/or family members were concerned about the student’s behaviour and deteriorating mental state in the period leading up to suicide. This suggests that the lower incidence of diagnosed mental illness in the international student cohort may be due to lack of engagement with the Australian health system (a diagnosis must be given by a health practitioner) rather than reflecting a lower incidence of mental illness as such.

5. Implications

A potential implication of the data presented here is that international students, their friends and family members should be educated about health referral pathways so they know how to engage appropriate services when they have a concern about apparent deterioration in a student's mental health. Another potential implication is that education institutions may need to provide financial counselling and review how they engage with students who are failing or otherwise disengaging from courses.

However, the provision of services to international students in Victoria - including for example health and wellbeing services, housing services, financial counselling and educational guidance - is a highly complex area and mostly delivered at an institution (rather than state or national) level.

Therefore, the CPU believes the most crucial next step is to disseminate this data through the education sector, so that the institutions themselves - as well as the organisations representing international students - can consider its implications for how international students are supported in

Victoria.

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