Deceased
XRG
Demographics
22y, male
Coroner
Coroner Simon McGregor
Date of death
2020-07-15
Finding date
2023-10-02
Cause of death
Neck compression by ligature suspension (hanging)
AI-generated summary
A 22-year-old international student from India died by hanging at his home in Victoria. He was studying information technology at Monash University after experiencing academic difficulties, having failed multiple subjects and requiring re-enrollment. Prior to his death, he showed signs of depression and social withdrawal, particularly after returning from India in March 2020. He told his mother he felt stressed and depressed in late 2019, but received only brief counselling while in India. Upon returning to Australia, he became increasingly withdrawn, spending most time in his room playing computer games. Critically, he engaged minimally with university or community mental health services despite displaying clear warning signs. The coroner found the death was not foreseeable and no one bears responsibility, but identified a systemic issue: international students face unique barriers to help-seeking and commonly do not engage with available support services even when experiencing mental health crises. The coroner emphasised the need for universities to actively promote mental health engagement rather than assuming availability of services is sufficient.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
IN THE CORONERS COURT COR 2020 003788 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Simon McGregor Deceased: XRG Date of birth: 8 July 1998 Date of death: 15 July 2020 Cause of death: 1(a) NECK COMPRESSION BY LIGATURE
SUSPENSION (HANGING) Place of death: Berwick, Victoria, 3806 Keywords: Suicide, hanging, international university student
On 15 July 2020, XRG was 22 years old when he was found deceased by hanging in his bedroom. At the time of his death, XRG lived at Berwick, with his uncle, URG, and his uncle’s girlfriend and family.
XRG was born in Kerala, India, and was an only child. Whilst growing up, XRG and his family travelled extensively for his father’s work in Information Technology, including a period living in the United States between 2009 and 2014, which XRG enjoyed. Upon the family’s return to India, XRG attended an international school in Bangalore, completing high school there in 2016.1
In February 2017, XRG moved to Melbourne to commence a Bachelor of Information Technology degree at Monash University after being granted a TU-500 Student Visa for an initial three-year period.2 He initially resided with his uncle, before moving to share house accommodation in Clayton, where he appears to have resided through to December 2019, when he returned to India for a visit. When he returned to Melbourne in March 2020 to continue his studies, XRG stayed with his uncle, and continued residing there until his death.3
XRG was scheduled to complete his Bachelor’s degree in 2019, however, due to failing three subjects, he was required to re-enrol in 2020. In March 2020 he was granted a WA-010 Bridging Visa while his application for a further Student Visa was being processed.
The Student Visa was granted in May 2020.4 He enrolled in two subjects and passed one subject during semester 1 of 2020.5
The available evidence suggests that XRG was in good health during his time in Australia, attending a general practitioner on only one occasion on 30 March 2020 for respiratory symptoms. Health insurance records indicate that he made one claim, on 29 June 2017, though the reason for this claim is not given.
In relation to his mental health, XRG’s family believed he was coping well with university through to the end of 2019. His mother stated that in November 2019 he called her and “said 1 Coronial brief, Statement of pp.7-8.
2 Department of Home Affairs records.
3 Coronial brief, Statement of URG, pp.16-17.
4 Department of Home Affairs records.
5 His academic record from Monash University shows only the subject he passed in semester 1 of 2020. However, Peter John Barton, the Manager of Student and Academic Services in the Faculty of Information Technology at Monash University, explained that the unit he failed was removed from his academic record “due to COVID-19” (Coronial brief, Statement of Peter John Barton, p.27).
he was quite stressed and feeling very low and he cried a lot that day, telling [her] that he could not concentrate much on studies and feeling very depressed to be away from home and all”.6
When XRG visited India between December 2019 and March 2020, his family thought his behaviour was different to the past. His uncle stated that the family took him to see a psychologist or counsellor, but apparently no issues were identified.7 His mother stated that after three counselling sessions, “the doctor said he is perfectly all right and has given a few homeo medicines just to relax him and to get a proper sleep”.8
When XRG returned from India on 4 March 2020 and commenced residing at his uncle’s Berwick home, he was withdrawn and would stay in his room and only come out to eat or shower. His uncle thought XRG “seemed depressed” for “quite a long time”.9 XRG appeared to spend all of his time playing computer games.
The immediate precipitating factors or stressors for XRG’s decision to take his own life are not clear. His mother thought he may have been triggered by failing a further subject in semester 1 of 2020, “because he had hopes about his studies a lot and he did not want to disappoint us too in any way”.10
XRG’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury.
The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.
6 Coronial brief, Statement of p.9.
7 Coronial brief, Statement of URG , p.18.
8 Coronial brief, Statement of p.10.
9 Coronial brief, Statement of URG , p.17.
10 Coronial brief, Statement of p.10.
Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death under investigation.
Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of XRG’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.
This finding draws on the totality of the coronial investigation into the death of XRG including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.11
In considering the issues associated with this finding, I have been mindful of XRG’s human rights to dignity and wellbeing, as espoused in the Charter of Human Rights and Responsibilities Act 2006, in particular sections 8, 9 and 10.
MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred
Since the commencement of university in March 2020, XRG had been studying online and did not attend the university campus, due to COVID-19 restrictions.
On 14 July 2020, XRG followed his usual daily routine, eating breakfast and lunch when prompted by his uncle, but otherwise staying in the computer room. At around 10:10 pm XRG ate dinner that had been delivered to the house. At around 10:25pm, URG saw the computer room light turn off and heard XRG walk out of his room and retire to his bedroom.12
At approximately 11:05 am on 15 July 2020, XRG’s uncle URG realised that XRG had not emerged from his room, as he normally would have by that time. URG went to XRG’s 11 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.
12 Coronial brief, Statement of URG, p.19.
bedroom and found him suspended from his cupboard door with a brown belt around his neck.13
Emergency services were called and the 000 operator instructed URG to cut XRG down. URG did so, and commenced cardiopulmonary resuscitation.14 Ambulance Victoria paramedics arrived a short time later and commenced work on XRG, but sadly he was unable to be revived. He was formally declared deceased at 11:30 am.15 Identity of the deceased
On 15 July 2020, XRG , born 8 July 1998, was visually identified by his uncle, URG.
Medical cause of death
Forensic Pathologist Dr Heinrich Bouwer from the Victorian Institute of Forensic Medicine conducted an external examination on 16 July 2020 and provided a written report of his findings dated 21 July 2020.
The post-mortem examination revealed a ligature abrasion about the upper neck.
A computed tomography (CT) scan showed a fractured left horn of the hyoid cartilage.
Toxicological analysis of post-mortem blood samples did not identify the presence of any alcohol or any commons drugs or poisons.
Dr Bouwer provided an opinion that the medical cause of death was 1(a) neck compression by ligature suspension (hanging).
13 Ibid., p.20.
14 Ibid., p.21.
15 Coronial brief, statement of Senior Constable Bekki Morgan, p.37.
I directed that the Coroners Prevention Unit (CPU)16 conduct a review of the circumstances of XRG’s death with a view to identifying recurring themes and circumstances that might in turn point to opportunities to support international students better and thus reduce the risk of further suicides - which have a devastating impact on the student’s family, friends, and the wider university community - in future.
The investigation into XRG’s death was conducted in parallel with my investigations into four other suicides of international students which occurred during 2020. The five deaths related to students born in five different countries who attended four different universities across Victoria, who were studying diverse subjects (at both undergraduate and postgraduate level), and who had diverse living arrangements (including on-campus accommodation, share houses with other international students, and residing with family members).
To assist in this investigation, I requested information and policies from involved universities about how they support the wellbeing and health (including mental health) of international students. I was aided by the response I received from Monash University’s Executive Director of Campus Community Division, Vladimir Prpich, who provided an overview of the university’s mental health and wellbeing policies; suicide prevention policy and initiatives; and services and supports for international students in these areas. Vladimir Prpich also included copies of relevant policies, procedures and protocols. I thank Monash University and Vladimir Prpich for their efforts in this regard.
From my review of the material, the stand-out feature for me was how little engagement XRG had with Monash University in a health and wellbeing context. The only evidence in this regard was a statement from Peter John Barton, who was Manager of Student and Academic Services in the Faculty of Information Technology at Monash University. He wrote that he was unaware of any issues XRG experienced from a student services or academic point of view.
16 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 safety and in relation to the formulation of prevention recommendations. The CPU also reviews medical care and treatment in cases referred by the coroner. The CPU is comprised of health professionals with training in a range of areas including medicine, nursing, public health and mental health.
Further to this point, on the evidence before me, XRG also did not engage with health services external to the university: he made one claim on his Allianz health insurance (in June 2017), and there is a record of him seeing a general practitioner on only one occasion for a respiratory issue in March 2020. He told his mother he was feeling stressed and depressed towards the end of 2019, but his family were under the impression that he was successfully treated when he visited India over the 2019-2020 holiday season.
XRG’s lack of engagement with Monash University health and wellbeing services was echoed across the other four suicides I investigated. In each case the student had not contacted or been linked with relevant university services and was not engaged with any other health services in the community for mental health treatment and support.
In highlighting this lack of engagement, I make clear that I make no criticism of Monash University. As mentioned above, Monash University provided a range of information to me about supports for students in general and international students in particular; I was impressed by the thoroughness of this material, and I have no evidentiary basis for any concern with service design and delivery. Instead, through considering the material gathered across my five investigations, I have come to the conclusion that universities may be facing a different challenge: how to encourage international students to engage with and seek help from existing university services in the first place when they experience mental health crises and/or suicidality. Given that none of the five international students engaged with health services in the wider community or (to the best of my knowledge) disclosed suicidality to family or friends or clinicians, the challenge is even broader than this: how to encourage international students to seek help at all.
I am not the first Victorian coroner to identify this challenge. Coroner Audrey Jamieson of this Court previously investigated the suicides of Zhikai Liu and Nguyen Le, two international students who had not sought any health or wellbeing support either from the universities where they attended, or from health services in the broader community.17 Coroner Jamieson was also supported in her investigations by the CPU, whose case investigators undertook an analysis of Victorian suicides among adult students during the period 2009-2015, comparing between international students and Australia-born students. The CPU reported a number of differences, the most pertinent of which (for present purposes) were as follows: 17 Jamieson A, Finding into death of Zhikai Liu without inquest, Coroners Court of Victoria, reference COR 2016 001035, delivered 10 January 2019; Jamieson A, Finding into death of Nguyen Pham Dinh Le without inquest, Coroners Court of Victoria, reference COR 2018 00622, delivered 13 January 2021.
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 […]. 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.
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. 18
I 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 I do not have the evidence before me to make any specific recommendations about how to overcome these barriers.19 18 Jamieson A, Finding into death of Zhikai Liu without inquest, Coroners Court of Victoria, reference COR 2016 001035, delivered 10 January 2019, p16.
19 Jamieson A, Finding into death of Zhikai Liu without inquest, Coroners Court of Victoria, reference COR 2016 001035, delivered 10 January 2019, p6.
These comments resonate strongly with my own experience investigating the deaths of the five international students including XRG during 2020. In reflecting on the circumstances of the five deaths, I have not developed any clear insights into how help-seeking among international students might be promoted, and I suspect a coronial investigation may not be the most suitable mechanism to explore this.
At the early stage of my investigation into these five suicides, when I was still gathering evidence and considering how to approach the issues, I commissioned Orygen20 to prepare resources including a list of questions to ask universities about their health and wellbeing services, and an evidence-based Quality Evaluation Framework to assist me in understanding what types of policies and programs should be in place across universities to support international students. My initial intention was to use the Framework to assess the design and delivery of university services that the international students came into contact with prior to their deaths, so I could identify potential gaps to be addressed. As the investigations unfolded and the lack of engagement between the students and their respective universities’ services became clearer, I came to realise that this type of assessment would not generate the insights I was seeking. However, I believe the Quality Evaluation Framework may still have utility for international student prevention.
Orygen developed the Quality Evaluation Framework after a comprehensive review of research on university student and international student health and wellbeing, as well as suicide prevention and mental health promotion in tertiary education settings. The Quality Evaluation Framework identifies ten areas (five university-wide, five specific to international students) where universities are recommended to review their policies, guidelines and practices. The areas include mental health, suicide prevention and postvention, staff training in mental health and suicide awareness, initial orientation for international students, ongoing support for international students, and access to mental health services. In each area, the Quality Evaluation Framework describes minimum expectations that should be met, as well as best practice to aim towards.
I found the Quality Evaluation Framework to be an extremely helpful tool orienting me to elements and features I should be looking for when I reviewed the material that the universities provided to assist my investigations. I consider, therefore, that universities might also find the 20 Orygen is a not-for-profit mental health service and research institute dedicated to youth mental health.
Quality Evaluation Framework to be a useful tool for developing and reviewing how they support the health and wellbeing of international students.
Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was XRG, born 08 July 1998; b) the death occurred on 15 July 2020 at 130 Moondarra Drive, Berwick, Victoria, 3806, from neck compression by ligature suspension (hanging); and c) the death occurred in the circumstances described above.
Having considered all of the circumstances, I am satisfied that XRG intentionally took his own life. It is often difficult to determine what may have precipitated a person’s decision to end their own life. It is possible that XRG may have acted impulsively while upset about his difficulties with study, in the context of his generally depressed mood and social isolation. I find that XRG’s death could not have been reasonably foreseen, and no one bears responsibility for this tragedy.
(i) With the aim of promoting public health and safety and preventing like deaths, I recommend that the Victorian Department of Health and Human Services takes on the role of leading and coordinating efforts to support mental health and wellbeing of international students studying in Victoria, and to ensure international students can access mental health treatment.
Professor Euan Wallace, the Secretary for the Department of Health, indicated in his response dated 6 April 2021 that the Department would convene a taskforce to discuss the findings and consider the key themes raised by Coroner Jamieson’s investigation. Professor Wallace further noted that the Department was establishing a new Suicide Prevention and Response Office, and that international students would fall within the scope of the Office’s remit.
In this context, I intend to provide a copy of the Orygen Quality Evaluation Framework to the Suicide Prevention and Response Office at the Victorian Department of Health.
Pursuant to section 72(2) of the Act, I make the following recommendations:
(i) I recommend that the Suicide Prevention and Response Office review the Orygen Quality Evaluation Framework (attached as Appendix A) in the context of this finding and its other work relating to international students, and consider whether a resource such as the Quality Evaluation Framework would assist universities to assess and review how they support international student health and wellbeing.
(ii) I recommend that the Victorian Department of Health consider developing and maintaining a resource of this type to assist Victorian universities in implementing and reviewing their programs targeted at international student wellbeing. The resource could be regularly revised in collaboration with the universities to share new research, program design and ideas for monitoring international student wellbeing and encouraging help-seeking among those who may be experiencing mental health crises or suicidality.
I convey my sincere condolences to XRG’s family for their loss.
Pursuant to section 73(1B) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.
I direct that a copy of this finding be provided to the following: XRG’s Mother, Senior Next of Kin XRG’s Father, Senior Next of Kin URG, Applicant Senior Constable Bekki Morgan, Coroner’s Investigator Signature: ___________________________________ Coroner Simon McGregor Date : 02 October 2023 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.
Appendix A
RESPONSE TO THE VICTORIAN CORONER’S OFFICE INTERNATIONAL STUDENT SUICIDE PREVENTION OVERVIEW OF SUGGESTED AREAS FOR REVIEW UNIVERSITY WIDE
Mental health policy - Does the institution have a written policy addressing how mental health issues are managed?
Suicide prevention policy & postvention guidelines - Does the institution have policies or guidelines for suicide prevention and postvention?
Suicide prevention programs - Does the institution have any suicide prevention programs?
Staff training related to mental health and/or suicide - Does the university provide mental health or suicide awareness training to staff?
Clear and accessible pathway to mental health services for all students - Does the university provide mental health services that can be accessed easily and in a timely manner by all students who need support? Are university staff provided with information on community mental health services, including referral pathways, for students experiencing mental illhealth?
Orientation program for international students - Does the university provide an orientation program to support students upon arrival to Australia?
Ongoing support - Does the university provide ongoing support services to international students that address the stressors that may increase risk of suicide?
a. Key risk factors (e.g. acculturation/academic stress/discrimination etc) b. Mental health specifically
Risk screening and monitoring - Does the university have risk screening or monitoring processes in place?
Staff training policies relevant to international student mental health - Does the university provide staff training that addresses international student mental health?
Affordable Mental health service access - Does the university provide free mental health service access or financial aid to international students to access mental health services? Are these services culturally accessible (i.e. are staff trained in cultural awareness and/or are interpreting/liaison supports provided)?
UNIVERSITY WIDE POLICIES AND PROGRAMS There are a variety of institution wide policies and programs that are relevant to suicide prevention that can be implemented by universities. Although these approaches may not directly address international students, they are often foundational to high quality mental health promotion and the provision of services accessible to all students, including international students.
Rationale: Existing evidence shows that demand for university mental health services exceeds capacity, student mental health issues are increasingly complex, and that service delivery is variable across institutions (1). A mental health policy can be used to address such issues (2).
Best practice recommendations: Current best practice recommendations for a mental health policy are
Rationale: Policies and guidelines for suicide prevention and postvention are important tools that may reduce the risk of suicide occurring (3, 4). Prevention policies can shape institutional approaches and responses to suicide risk monitoring, prevention efforts, and support services. Postvention guidelines can cover similar elements, but also address the necessary steps after a suicide occurs to minimise distress (4). Postvention guidelines show promise for preventing suicide clusters where a number of individuals take their life after an initial suicide within their community (4, 5). The university should have suicide prevention and postvention policies and/or guidelines available to staff and students within the larger mental health policy or as a set of specific resources. Alternatively, the university may endorse appropriate guidelines provided by other relevant groups such as Universities Australia (6).
Best practice: Regardless of whether the guidelines are developed internally or by an external body, the university should have a clear documented communication strategy in place so that relevant staff and/or students are aware of the policy or guidelines and associated requirements (2, 6). For example, if using the Universities Australia Postvention guidelines, all staff should be made aware of Part A (e.g., the all staff section), while those responsible for responding to a suicide should be made aware of Part B (e.g., the suicide response team section) of the guidelines. If the institution has developed their own policies or guidelines, the document should ideally outline the development process. Key reported procedures in existing guidelines include how existing evidence, best practice approaches, and expert and lived experience consultation was used to inform guideline development (4).
Rationale: A small but growing body of evidence shows that universities can be an effective context for the implementation of suicide prevention interventions that can reduce suicidal ideation and risk of suicide (7).
Best practice: A common framework in suicide prevention classifies interventions as universal, selective or indicated on the basis of target groups (8, 9). Universal interventions target whole populations regardless of risk through increasing access to services, promoting student mental health, limiting means access for suicide, or promoting appropriate reporting through media (10). For example, mental health campaigns for all staff or students fall into this category. Selected interventions target subgroups who may be vulnerable to suicide due to specific or elevated risk factors such as LGBTQ+ individuals (11) and international students (12). For instance, gatekeeper programs are used to train those in contact with vulnerable populations (e.g., staff, student peers,
community leaders etc) to provide them with the skills necessary to assist at risk individuals and refer them to relevant support services. Gatekeeper training is currently the most widely used and researched suicide prevention strategy implemented within universities (7). Indicated interventions target those already displaying suicidal or self-harm behaviour through linking individuals into relevant support services such as mental health providers. For example, students identified as experiencing suicidal ideation can receive a clinical intervention such as cognitive behavioural therapy (3). This framework may be helpful when reviewing policies and programs at the university by allowing for a clear assessment of each of the different approaches: Assessing Universal approaches) does the university have any universal suicide prevention programs or policies? (E.g., Mental health promotion campaigns, suicide awareness programs, limitations of means access policy etc.) Assessing Selective approaches) Does the university have policies or programs to support at risk groups? (E.g., Gatekeeper training, specific support services for at risk groups etc.) Assessing Indicated approaches) Does the university have processes in place to identify those at risk and/or provide support pathways for individuals who indicate suicide risk or self-harm behaviours?
(E.g., Decreased class attendance monitoring, graduate supervisor training to identify suicide risk, etc.)
STAFF TRAINING RELATED TO MENTAL HEALTH AND/OR SUICIDE – DOES THE UNIVERSITY PROVIDE MENTAL HEALTH OR SUICIDE AWARENESS TRAINING TO STAFF?
Rationale: University staff regularly come into contact with students facing mental ill-health and are well placed to identify potential suicide risk in this group (13). However, staff often lack the skills and confidence to discuss mental health issues or suicide with students (13). Programs such as gatekeeper training or other mental health training can be used to improve staff confidence and skills relevant to supporting student mental health and suicide risk (7, 14, 15).
Best practice: It is important to consider the different staff groups who receive training and their specific needs. For example, academic staff may require training that clarifies their responsibilities related to student mental health, in combination with general capacity building related to identifying and referring on suicide (13). In contrast, staff employed in by the university counselling service may need more targeted training such as methods of safety planning that can be used with at risk individuals (15). Identifying the specific staff training and development pathways for different staff groups may facilitate a clearer picture of any existing gaps in the available training across the organisation.
CLEAR AND ACCESSIBLE PATHWAY TO MENTAL HEALTH SERVICES FOR ALL STUDENTS – DOES THE UNIVERSITY PROVIDE MENTAL HEALTH SERVICES THAT CAN BE ACCESSED EASILY AND IN A TIMELY MANNER BY STUDENTS?
Rationale: Accessible mental health services play a vital role in supporting student mental health by providing therapeutic care and referrals to other relevant health services (14). Existing evidence shows therapeutic care is an effective method for reducing suicidal ideation and suicide attempts (16).
However, university mental health services tend to face greater demand than they can effectively manage, which may lead to long wait times for access or service rationing (14, 17).
Best practice: Current Best Practice Guidelines for the Provision of Counselling Services in the PostSecondary Education Sectors of Australia and New Zealand recommend a student to staff ratio of 1
counsellor per 1000 students. Although current evidence suggests this is rarely the case across the sector with recent reported ratios of 1 staff member to anywhere between 3000-12000 students (17).
INTERNATIONAL STUDENT SPECIFIC POLICIES AND PROGRAMS International students face a unique set of stressors (e.g., financial, language, cultural, discrimination, etc.) (18-20) that can negatively impact mental health (20), increase suicidal ideation (12, 21, 22), and even lead to death by suicide (23, 24). Complicating matters, international students can face specific barriers such as lower mental health literacy and help-seeking intentions that can reduce engagement with support services, especially for suicidal ideation (25, 26). This combination of factors may increase the risk of death by suicide for those who could otherwise receive help (24). Prevention strategies and programs need to account for the unique stressors and barriers to reduce suicide risk in this group (12, 26). Only a small amount of research has directly addressed suicide prevention in international students (7). However, a variety of research, interventions and best practice recommendations have been developed that aim to support international students adapt and manage stressors associated with living and studying in another country (12, 19, 27-32). These strategies can be used to address the stressors and barriers that may increase the risk of suicide. Additionally, research addressing suicide prevention in other migrant communities has identified key areas that should be of focus including acculturation issues, stigma related to help-seeking, and the need for creating supportive communities (33). The combination of this research is used to guide the following suggestions.
ORIENTATION PROGRAM FOR INTERNATIONAL STUDENTS – DOES THE UNIVERSITY PROVIDE PRE-DEPARTURE TRAINING OR AN ORIENTATION PROGRAM TO SUPPORT STUDENTS UPON ARRIVAL TO AUSTRALIA?
Rationale: Orientation programs are important tools that can be used to help students understand the local culture, address early acculturation issues, and promote mental health services, while reducing stigma related to service access (34, 35). Pre-departure training on the host country culture and university systems can also be beneficial for addressing initial adjustment challenges (36). Such programs can decrease stress associated with adapting to a new country, increase awareness and engagement with health services, and help students form connections with their peers (32).
Best practice: Pre-departure programs should prepare students for life in Australia and the challenges that they may face while in country (37). Orientation programs should seek to address any potential misunderstandings (e.g., when to seek support, fear of repercussions, available services, etc.) and stigma related to mental health service access, as students can be reticent to access services due to mental health stigma and visa concerns (28, 37).
ONGOING SUPPORT – DOES THE UNIVERSITY PROVIDE ONGOING SUPPORT SERVICES ADAPTED TO INTERNATIONAL STUDENTS THAT ADDRESS THE STRESSORS THAT MAY INCREASE RISK OF SUICIDE?
Rationale: Students can face a variety of stressors throughout their time studying in Australia (28, 38).
Common stressors for international students include academic stress, financial hardship, experiences of discrimination, language issues, and feelings of loneliness (19, 20, 39). Such stressors can lead to poor mental health (39) and have been identified as risk and contributing factors to suicide deaths of international students (23, 24, 40). Universities can provide ongoing support services that can help students manage such stressors (34). For example, buddy programs are widely used to help international students build connections with local students (34). Similarly, academic support services can help students manage stress associated with academic work or language issues (34). Universities
are also well placed to monitor academic related stress. For example, an emerging field of research has demonstrated that digital technologies can be used to identify students who are potentially at risk of academic failure and notify relevant staff (41). Students who are at risk of failure can then be referred to appropriate academic support services.
Best practice: Culturally competent health services may improve outcomes for migrants accessing services (42). Current evidence indicates that providing written materials or services in the native language of migrants can improve outcomes (42). Additionally, training in symptom recognition for common mental health diagnoses may increase engagement with services, as evidence suggests that international students may not recognise they have a problem until they reach a crisis point (37).
Employment of dedicated international student support staff, and especially those who speak the native languages of common international groups, may facilitate the most culturally appropriate support services (34).
Rationale: Risk screening tools are important for identifying potential suicide risk that may otherwise be missed. This may be especially important for international students because evidence suggests that they are less likely to engage with services before a suicide attempt (43). A number of tools can be used by universities to identify potential risk and opportunities engage students with relevant support services. These include the reporting of mental health issues on intake, monitoring of class attendance, and ongoing check-in surveys (32).
Best practice: A comprehensive approach that involves both initial and ongoing screening for mental health issues and the regular monitoring of other relevant predictors such as class attendance will have the greatest potential to identify suicide risk.
STAFF TRAINING POLICIES RELEVANT TO INTERNATIONAL STUDENT MENTAL HEALTH CONCERNS – DOES THE UNIVERSITY PROVIDE STAFF TRAINING THAT ADDRESSES INTERNATIONAL STUDENT MENTAL HEALTH?
Rationale: Training that provides staff with an understanding of specific stressors and risk factors for international student mental health may help staff better support international student needs (32, 34).
Similar to the general staff training, clarifying staff roles related to international student mental health should be part of the training (32, 34).
Best practice: Training should seek to provide staff with the capacity to deliver culturally appropriate responses to international students (34). Ideally, training should be developed through co-design processes with international students (34).
AFFORDABLE MENTAL HEALTH SERVICE ACCESS – DOES THE UNIVERSITY PROVIDE FREE MENTAL HEALTH SERVICE ACCESS OR FINANCIAL AID TO INTERNATIONAL STUDENTS TO ACCESS MENTAL HEALTH SERVICES?
Rationale: International students are often under financial strain, which can reduce willingness to access fee paying mental health services (44). Providing free services or financial aid to international students for mental health services may reduce this barrier to access (44).
Best practice: Current best practice recommendations suggest that promotion of available mental health services for international students should occur on a regular basis, as this group report poor levels of awareness of available services (35). Ideally, students should also have a single point of contact that can help them navigate the available options and find the appropriate service to make sure they don’t slip through the cracks (37). Unfortunately, most university health services only provide short term support, and are ill-equipped to manage more complex cases (37). This means that students may need to seek help external to the university. However, few free or cheap external services provide long term support to international students, and this may increase the risk of suicide in this cohort due to the financial barriers.
LEVELS OF ACTION/RESPONSE USING A SUICIDE PREVENTION FRAMEWORK Universal: Whole of univeresity mental health and suicide prevention/postvention -policies/programs and services for all students domestic and international includes: awareness campaigns, .
Targeted programs and supports that address identified risk groups, e.g. training specific to identifying risk for international students, information delivered specifically to international students; peer-support programs for international students.
Indicated programs and supports that identify an international student at risk or in distress/crisis and connects them with support e.g. risk screening and monitoring and counselling supports delivered by culturally competent and accessible services.
QUALITY EVALUATION FRAMEWORK AREA FOR REVIEW MINIMUM EXPECTATION TOWARD BEST PRACTICE SUPPLEMENTARY QUESTIONS UNIVERSITY WIDE Mental health policy - Does the Policy describes aims, objectives, Policy PLUS implementation and action How is the policy communicated and institution have a written policy rationale and high level activities to plan to accompany policy with promoted to all members of the university addressing how mental health issues respond to mental health issues and timeframes, deliverables and community including staff, students, are managed? support wellbeing. responsibilities described. services?
The policy spans mental health Endorsed/approved and supported by Are there dedicated resources allocated promotion, prevention, early identification university leadership including VC. to delivering the policy?
of risk and responses for mental illHas the policy/will the policy be health.
evaluated?
How often is the policy reviewed? What type of stakeholders (internal/external) are involved in the review process?
Suicide prevention policy & Suicide Prevention Policy/Guidelines Policy PLUS implementation and action How is the policy communicated and postvention guidelines - Does the describes aims, objectives, rationale and plan to accompany policy with promoted to all members of the university institution have policies or guidelines high level activities to respond to: timeframes, deliverables and community including staff, students, for suicide prevention and responsibilities described. services?
preventing suicide and suicide postvention?
related behaviours (including Endorsed/approved and supported by Are there dedicated resources allocated addressing risk factors) university leadership including VC. to delivering the policy?
responding to suicide related Has the policy/will the policy be behaviours (including ideation and evaluated?
attempts) How often is the policy reviewed? What postvention responses to a type of stakeholders (internal/external) completed suicide. are involved in the review process?
Suicide prevention programs - Does Mental health promotion, campaigns and Provides activities and programs across How are these programs communicated the institution have any suicide suicide awareness programs to assist all of the following: and promoted to all members of the prevention programs? students and staff to: university community (for universal Universal approaches for entire approaches) and to specific cohorts look after their mental health and university community (mental health wellbeing promotion, limitations of means etc).
AREA FOR REVIEW MINIMUM EXPECTATION TOWARD BEST PRACTICE SUPPLEMENTARY QUESTIONS understand the signs if they/or Selective approaches targeted at (targeted) or individual students and staff someone else is at risk risk groups of students, e.g. specific (indicated)?
services for students with mental know about university and How are the programs delivered chosen?
health conditions.
community based Are they evidence-based?
services/supports that are Indicated approaches which How are they resourced and who is available. actively identify individual responsible for their delivery?
staff/students who might be at risk How often are the programs run?
either through drop in performance, drop in attendance, suicide related Have the programs been evaluated?
behaviours. Are student focused programs coproduced and/or delivered by students.
Staff training related to mental health Support services staff receive appropriate All staff and students are provided How is the training resourced and who is and/or suicide - Does the university and ongoing professional development mental health literacy or suicide responsible for their delivery?
provide mental health or suicide and training in relation to mental health awareness training as a core learning Is the training available to all staff (and awareness training to staff? conditions and suicide risk. module.
students) or only available to identified Training is made available to all staff who Training is tailored to specific groups, e.g. staff or only available if the faculty/staff are interested at no cost on: academic staff, different to student member agrees to pay cost?
support staff.
Communicating with students about How often is the training delivered during mental health issues or suicide risk. Specific training is provided to support an academic year?
staff on working with diverse student Responding to disclosure. Has the training been evaluated?
population groups, including CALD, Designing curriculum to mitigate Is the training delivered or co-delivered against unnecessary stress. Aboriginal and Torres Strait Islander by trainers with lived experience of Making adjustments for a student students, LGBTIQA+ and students with mental ill-health?
with a mental illness. disabilities.
Is the training flexible and/or adaptable to Responding to a mental health crisis.
suit a range of learning styles and audiences?
Clear and accessible pathway to Students are supported to navigate A coordinated approach to providing How are services promoted to students mental health services for all students mental health services: support both on and off campus and are they promoted more at certain
Services and supports (both on health services that can be accessed services in order to meet students’ and off campus) are promoted How does the university monitor service easily and in a timely manner by needs.
to students. use and evaluate service provision and students?
Services and supports respond to outcomes?
On campus services and complexities among specific supports are free and accessible
AREA FOR REVIEW MINIMUM EXPECTATION TOWARD BEST PRACTICE SUPPLEMENTARY QUESTIONS both face to face and digital cohorts of students at increased What is the counsellor to student ratio in services. risk of mental ill-health. the university student support services?
Targeted strategies and Clear relationships/agreements are What are the average wait times for outreach programs that support in place with community based student services provided directly by the early detection and intervention mental health services. university during the academic year?
for students experiencing mental Services and supports are cohealth issues.
designed with lived experience.
Clear processes and procedures for supporting a student in significant distress or crisis.
INTERNATIONAL STUDENT SPECIFIC Orientation program for international International students are required to Mental health and wellbeing information At what point in the prestudents - Does the university provide participate in an information session provided to students (as per minimum departure/orientation process does the an orientation program to support specifically on mental health and expectation) is also: university provide international students students upon arrival to Australia? wellbeing during orientation with specific with mental health related information?
Co-designed with other international focus on: students. In what format is that information Destigmatising mental health issues provided?
Available in languages other than and addressing reluctance in helpEnglish. Are all students provided this seeking behaviours.
information?
Followed up and re-provided at Information on what to do if you or other times across the course of someone you know is struggling.
their studies.
Service access and contact Clear guidelines on how mental information.
health disclosure is managed by Information on privacy and universities and health providers in confidentiality of sharing Australia.
personal/health information with education providers.
Ongoing support - Does the university Provision of support and services to Culturally competent services which Which area of the university is provide ongoing support services to international students which respond to includes cultural competency training and responsible for developing and delivering international students that address the stressors they may experience, including access to tools for student services and supports that respond to international stressors that may increase risk of (but not limited to): support staff. student stressors and/or needs?
suicide?
financial stress, Engagement of specific international Does the university maintain a working student support/wellbeing staff. list of interpreters; ethnic community discrimination, organisations and religious
AREA FOR REVIEW MINIMUM EXPECTATION TOWARD BEST PRACTICE SUPPLEMENTARY QUESTIONS Key risk factors (e.g. academic and Translators/translation of information into organisations/services to support acculturation/academic languages other than English are made culturally appropriate responses?
cultural stress.
stress/discrimination etc) available for international students.
Provision of peer supports and Mental health specifically Relationships with professionals and networking/social connection programs organisations that can assist with for international students (with each other complexities that are arising because of and with domestic student and other the diversity of linguistic, cultural or ethnic community members) background of International students.
Risk screening and monitoring - Does Standard process for university to provide A comprehensive approach that involves How are these processes monitored and the university have risk screening or opportunity to disclose any existing both initial and ongoing screening for reviewed?
monitoring processes in place? mental health issue(s) on Enrolment mental health issues (including an online How are these processes communicated Forms. Should be clear that this check-in survey) and the regular to staff and students?
information will only be used to connect monitoring of other relevant predictors Are online systems/data on academic students with appropriate support such as class attendance.
performance and attendance linked with services if need identified and no other Where education is delivered online, student services/supports to identify and purpose.
teaching and/or student support staff respond to emerging issues?
Standard process for staff who have proactive check-in with students How are staff supported to manage identified a drop in academic periodically during the semester.
disclosures of mental ill-health? Do they performance or class have adequate time and resourcing to attendance/engagement to connect to identify and respond to risk?
student services for follow up.
Simple reporting processes outside of staff including housemates, other students and friends. There should be clear and simple ways for these people to advise responsible staff of their concern.
Staff training policies relevant to All staff provided information, resources Training on culturally appropriate Which area of the university is international student mental health - and training (if resourced to deliver and responses to international students responsible for developing, contracting Does the university provide staff attend) which focuses on the specific related to suicide prevention, mental and/or delivering this training?
training that addresses international stressors for international students, health and wellbeing.
How is the training promoted?
student mental health? stigma relating to mental health issues Ideally, training should be developed How often is the training provided and at and communication strategies to discuss through co-design processes with what time of the year?
these issues with international students.
international students.
Is the training evaluated?
AREA FOR REVIEW MINIMUM EXPECTATION TOWARD BEST PRACTICE SUPPLEMENTARY QUESTIONS Affordable Mental health service Promotion and provision of financial Dedicated international student How are these services promoted to access - Does the university provide counselling and support services for wellbeing/support service or dedicated international students?
free mental health service access or international students on a regular basis. staff within student services that provides Is financial aid available to address financial aid to international students a single point of contact who can then Promotion and provision of free university financial barriers to accessing mental to access mental health services? assist with service navigation, referrals support services which deliver mental health care?
and advice on health cover service health supports.
Are students services staff trained in eligibility and costs.
Promotion of Overseas Student Health cultural awareness and/or are Information and promotion of free or lowCover (OSHC) entitlements and interpreting/liaison supports provided?
cost culturally sensitive counselling and information on how to pay for and access support services available in the treatment.
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