I.               Executive Summary

During the early hours of September 7, 2023, Koru Moss, a 17-year-old student at the Armand Hammer United World College of the American West (“UWC-USA” or the “School”) died by suicide in their residence hall at UWC-USA.  Following their death, at the request of Koru’s parents, Ivan and Grainne Moss (the “Mosses”), UWC-USA agreed to engage external counsel to conduct an independent investigation (the “Independent Investigation”) into Koru’s death and provide recommendations to the School as to any appropriate changes.

A draft report containing preliminary findings, conclusions, and recommendations—spanning more than 200 pages—was shared with UWC-USA and the Mosses in February 2025 (the “Report”).  Both the School and Mosses agree that the Report provides important information that should be shared not only with the School community, but made available to other boarding schools that are increasingly confronted by the risk of suicide among young people.  Because the Report has not been finalized and remains in draft, preliminary form and includes privileged, personal, and otherwise protected sensitive and confidential information, this document contains a summary of the key factual background, findings, and recommendations in the Report.

II.            Scope of Investigation

Shortly following Koru’s death, the Mosses contacted UWC-USA and UWC International to ascertain the circumstances surrounding Koru’s passing.  In April 2024, UWC-USA engaged Cozen O’Connor’s Institutional Response Group (“Cozen O’Connor” or the “Investigators”) to conduct the Independent Investigation.  Cozen O’Connor, in turn, engaged Dr. Susan Hunt, Psy.D.  UWC International did not respond and declined to participate in the Investigation and subsequent discussions concerning the preliminary findings of the Independent Investigation.

The Investigators were tasked with (1) determining the facts and circumstances of Koru’s death; (2) assessing whether there are any steps that could or should have been taken to reduce the possibility of or prevent Koru’s death; and (3) assessing what changes, if any, UWC-USA should make to its policies, practices, or personnel to protect the mental health of its students and assist in the prevention of student suicides.  The Independent Investigation included a review of available documents provided by UWC-USA, the Mosses, and relevant third parties; interviews with current and former UWC-USA employees and students and external professionals, and parents of UWC-USA students.

III.              Background

UWC-USA was founded in 1982 and is located in Montezuma, New Mexico.  It maintains a population of approximately 220 students per year, who attend UWC-USA for a two-year academic program.  Students, and many faculty and staff, live on campus.  Students live in one of UWC-USA’s five residence halls, each of which was staffed by a full-time Residential Coordinator who lives in an apartment within the residence hall.

UWC-USA maintains a Health Clinic, which was staffed by two nurses, a part-time Medical Director, and an Insurance Coordinator.  In addition to clinical care, the Health Clinic maintains a custodial license issued by the state of New Mexico, which allows the Health Clinic to fill prescriptions prescribed by a physician and administer physician-prescribed medication to students.  During the 2022-2023 and 2023-2024 academic years, UWC-USA also relied upon two independent contractors to provide mental health services at the Health Clinic, referred to herein as the UWC-USA counselors, and on an external provider to provide psychiatric services, including medication management for psychiatric medications.

Koru Moss—who identified as non-binary—elected to attend UWC-USA, after being advised by the New Zealand National Committee that UWC-USA was sensitive to issues impacting LGBTQ+ youth.  As part of the application process, UWC inquired about applicants’ mental health, but was not made aware that within the prior two years, Koru had received treatment related to suicidal ideation, which had resolved prior to Koru’s application.

Koru arrived at UWC-USA in fall 2022.  During their time at UWC-USA, they built many positive relationships and friendships that were important to them, including with certain UWC-USA staff. During their first year at UWC-USA, however, Koru experienced frequent misgendering by a teacher and experienced conflict with certain administrators related to Koru’s preference not to wear shoes around campus.

Shortly after arriving at UWC-USA, Koru experienced some mental health issues for which they obtained counseling and medication support from mental health professionals both on- and off-campus.  Specifically, in November 2022, Koru sought treatment from a UWC-USA counselor, requested an appointment with a psychiatrist so they could obtain medication, and was referred to a local internal medicine physician and psychiatrist in Las Vegas, New Mexico, who prescribed Zoloft.  No School personnel informed Koru’s parents that they had been referred to a psychiatrist or prescribed medication.

The external psychiatrist was not employed by UWC-USA, was not subject to oversight or supervision by the School, and there was no legal relationship between the external psychiatrist and the School.  Although the external psychiatrist was licensed to practice medicine during the periods treatment was provided to Koru, publicly available records show that in April 2012, the psychiatrist received a notice of contemplated action arising from prescribing practices, which were alleged to violate DEA rules.^[1]  The external psychiatrist’s license was later restricted by stipulation, from September to December 2022, including at the time of Koru’s first appointment, for non-compliant prescribing practices and inadequate record keeping.

In March 2023, after several appointments with the external psychiatrist, Koru emailed the Health Clinic, one of the UWC-USA counselors, and a UWC-USA administrator to request that their care be transferred to a gender-affirming provider because the external psychiatrist  was not respectful of Koru’s gender identity.  In response, the UWC-USA counselor offered to provide feedback to the external psychiatrist so that the psychiatrist could make corrections for future patients, and the Health Clinic directed Koru to fill out a packet to see another provider.  There is no documentation reflecting that Koru completed the packet, that the Health Clinic facilitated transfer of care, or that the Health Clinic followed up to ensure that Koru was continuing their therapy or medication.  In addition, the Health Clinic provided Koru with insufficient medication for their summer break without speaking to Koru’s family to ensure continuity of care during break.  No one from the Health Clinic communicated with Koru about whether they were still taking the medication or helped Koru navigate tapering off of the medication.  Following summer break, Koru returned to UWC-USA for their second year in August 2023.

On the morning of September 4, 2023, three days before Koru’s death, Koru emailed a UWC-USA administrator and disclosed that they were having “incredibly invasive and constant life-ending thoughts” that were “very disturbing and distressing” and “escalating with time.”  Within minutes, the administrator expressed sympathy, asked Koru if they wanted to talk, and directed Koru to go to the Health Clinic.  In their response, Koru stated that they were “capable of managing it.”  That morning, Koru met with three members of the School’s Health Team and disclosed their suicidal ideation to all three.  Although UWC-USA staff offered to speak with Koru further and, in one case, provided them with personal contact information, Koru was not monitored or supervised after their appointments.  Several School employees reported that Koru verbally denied having a plan or intent to harm themselves.  A member of the Health Clinic asked Koru whether they had spoken with their parents, and Koru responded that they had been in touch with their father that day.  But Koru had not told their parents that they were experiencing suicidal ideation, and the Health Team member took no steps to verify that they had done so.  No one on the Health Team or the UWC-USA administrator notified their parents or their Residential Coordinator that they had reported relentless thoughts of suicide.

The next day, September 5, 2023, Koru was offered a referral to the same external psychiatrist with whom they had met the previous year, despite having requested previously that their care be transferred, and Koru agreed to the referral.  Koru disclosed their suicidal ideation to this external psychiatrist.  The external psychiatrist prescribed Koru Prozac, which has been given a black box warning under FDA guidelines for potential increase in suicidal thoughts in adolescent populations.^[2]  The medication was dispensed to Koru by the School’s Health Clinic on the morning of September 6, 2023.  Again, between and after these appointments, no one supervised or monitored Koru, although that afternoon Koru attended dance class.  No one informed their parents about their suicidal ideation or the Prozac prescription.

On September 6, 2023, Koru attended all their classes and went on a walk with their friend.  That evening, at 9:30 p.m., Koru missed evening check at their dormitory.  Koru was located at approximately 10:27 p.m. and declared deceased at 12:59 a.m. on September 7, 2023.

IV.              Findings

The Independent Investigation into Koru’s death led to the following preliminary findings with respect to UWC-USA:

1. Self-Advocacy in Lieu of a Directive Approach

A review of Koru’s correspondence with UWC-USA employees in the Health Clinic, with the counseling team, and individuals within the administration reflects that Koru was required to exercise significant self-advocacy, both in their interactions with the school counselor during the 2022-2023 academic year, and between September 4 and 6, 2023.  Koru routinely had to drive the scheduling of appointments, engage in their own safety planning, make outreach to their faculty, and take steps to support their own self-care.

Moreover, beginning on September 4, 2023, UWC-USA’s response to Koru’s suicidal ideation was not directive, leaving the burden of forward momentum on a 17-year-old student in crisis.  There was inadequate coordination of information or health teaming, which had the effect of placing the burden on Koru.  No school administrator exercised ownership or developed a proactive plan for communication, intervention, and monitoring.  The School did not proactively direct or guide Koru’s care.  This was a critical aspect of assuming the responsibility for the safety and welfare of a child in the school’s custody, particularly when the School did not notify the Mosses (who would have been active participants in the decision-making about care and risk) of Koru’s escalating risk.  In the absence of parental involvement (occasioned by the failure to notify the Mosses), proactive direction and guidance by the School took on a heightened importance.

2. Continuous Observation and Supervision

Between September 4 and 6, 2023, UWC-USA employees missed critical opportunities to observe and supervise Koru to ensure their continued safety.  No call for observation was initiated in this case and multiple opportunities for increased monitoring were not engaged. UWC-USA should have escalated the level of care based on a more accurate risk assessment of known or knowable factors. That escalation could have included targeted check-ins with Koru, counseling check-ins, one-on-one observation, requiring the Mosses to come to campus, sending Koru home, or hospitalization.

Guidelines from a number of associations including the National Association for School Psychologists, the American Foundation for Suicide Prevention, and the American School Counselor Association, recommend that schools follow up with and continuously monitor students who have been identified as being at heightened risk for suicide.  Continuous monitoring and follow-up are vital to ensure student safety until a risk assessment and determination of care can be made.  Monitoring should continue until the assessment process is complete and a care plan is finalized.  Adults providing this vital monitoring and supervision should be informed of all relevant facts and understand the risk and protocols for supervision.

3. Evidence-Based Assessment and Intervention

UWC-USA should have conducted an evidence-based suicide screening assessment using a validated, structured tool and guided interview template, which would have allowed for a more nuanced assessment of risk.  The UWC-USA counselors and the lead nurse did not conduct such an assessment, nor did the external psychiatrist; instead, they all relied solely on their clinical impressions and judgment, which was not informed by current research surrounding suicidality risk assessment and reduction.  Although Koru’s description of their suicidal ideation included a number of features associated with higher risk for a suicide attempt, no one to whom Koru disclosed their suicidal ideation appear to have fully recognized the extent of the risk factors disclosed in Koru’s emails on the morning of September 4, 2023, which included several identifiable signs of elevated risk, including experiencing their ideations as acute, frequent, worsening and persistent, uncontrollable and strong, pervasive, intrusive, and active.  This failure to properly recognize and assess the nature and quality of Koru’s suicidal ideation inhibited the School’s ability to respond to Koru’s ongoing mental health crisis in an informed and evidence-based manner.

The mental health professionals also accepted and over-relied on Koru’s denial of intent and plan to attempt suicide as sufficient to dictate their risk level assessment without full consideration of a constellation of known or knowable factors which, if assessed consistent with evidence-based practices, may have informed a more nuanced assessment of risk and led the professionals to recognize an escalating crisis.  In addition to the risk factors, there were tangible and obvious warning signs that a suicide attempt may be imminent, most notably the acute, worsening, persistent ideation that felt uncontrollable and strong, communicated directly by Koru to an administrator, the lead nurse, and both mental health counselors.

Additionally, many witnesses, including healthcare and mental health professionals, noted that Koru’s presentation and affect did not match their stated concerns.  In resolving the dissonance between Koru’s reassuring presentation (including their demeanor, affect, and articulation of protective factors) during counseling sessions and their contrasting direct statements as to the severity and urgency of their suicidal ideation, counselors and mental health professionals did not employ objective, evidence-based assessment tools which would compensate for the deficiencies of subjective instinctual responses or confirmation biases.

Finally, although the counseling team and Health Clinic staff met basic standards of care for responsiveness and basic assessment, and the counseling team employed a rudimentary level of intervention during the appointment they had with Koru, no provider, including the external psychiatrist, applied an evidence-based intervention for suicide prevention. Koru’s level of expressed ideation was escalating, indicating additional strategies should also have been engaged. In addition, the counselors did not engage in education that may have been beneficial.  Specifically, the counselors should have educated Koru on the cycle of crisis.  In Koru’s case, providing this education would have been both an opportunity to engage cooperation for observation with Koru, by agreeing not to be alone until the crisis abates and creating a plan, as well as an opportunity to address lethal means reduction as a preventative measure.

4. Communication: Notification to Parents

Between September 4 and September 6, 2023, none of the personnel, healthcare or mental health professionals who spoke with Koru informed Ivan or Grainne Moss that Koru was experiencing relentless, ongoing suicidal ideation or that they had been prescribed psychotropic medication.  UWC-USA should have notified the Mosses to inform them of Koru’s expressed severe and urgent suicidal ideation, to seek their judgment in decision-making, and to obtain any relevant history that may have informed the course of care for Koru.  Outreach would have been critical to involve the Mosses in decision-making as to how to best care for Koru in light of their disclosures.  Such a conversation would also have informed UWC-USA’s response, and likely led to an increase in supervision and monitoring, additional interventions, and escalation of care.  The choice by UWC-USA employees to not inform Ivan and Grainne Moss of Koru’s suicidal ideation deprived them of the opportunity to intervene and support their child.  The School’s choice not to inform the Mosses does not conform to recommended practice by a number of sources, including the New Mexico Department of Health’s school health manual, that parents be informed any time a student is identified as having any level of risk for suicide.

5. Coordination of Information (Health Teaming)

Although Koru informed at least four members of the administration, Health Clinic, and counseling team about their suicidal ideation, those individuals did not communicate effectively to coordinate a response, ensure continuous observation and monitoring, inform need-to-know personnel and Koru’s family, escalate the concerns to senior leadership, or determine Koru’s need for elevated care.  Instead, responsibility for making decisions was diffuse, and members of the counseling team, administration, Health Clinic, and the external psychiatrist operated in a largely independent manner. UWC-USA should have coordinated information between the treating mental health professionals and UWC-USA administrators to develop an appropriate course of care.  That coordination should have included convening an ad hoc/crisis Health Team meeting; informing the Director of Residential Life, the Residential Coordinators, and notifying school leadership.  Because the counseling team, Health Clinic, the counseling team, and UWC-USA administration did not communicate and did not have suicide prevention policies establishing ownership for family notification and care determinations, Koru did not receive critical follow-up care, observation, intervention, and supervision between September 4 and 6, 2023 that may have been effective in preventing their death.

6. Documentation and Recordkeeping

Neither the Health Clinic nor counseling team implemented effective recordkeeping and documentation practices, including through the use of structured notes, clinical workflows, and an electronic health records system to maintain and share important information between them and with external providers.

Instead, the Health Clinic maintained handwritten records using standard template forms, which were maintained separately from the counseling team records.  The counselors maintained handwritten notes as well, and neither counselor used a structured note format. One counselor maintained deficient and inadequate notes, which were sparse and not in chronological order, appearing to have been created after the fact, rather than contemporaneously.  In Koru’s case, that counselor did not properly document his sessions to ensure the ability to share all relevant information with the external psychiatrist or with Koru’s residential coordinator.  In addition, the counselor did not document sufficient content to allow tracking of the evolution of presenting symptoms or the efficacy of treatment over time, which are important elements in evaluating risk.

Because all notes were handwritten and maintained separately, the counseling team and Health Clinic did not have immediate access to relevant information shared with the other office, nor could they quickly share information with external providers as needed.  In addition to the lack of EHR documentation, UWC-USA’s recordkeeping did not establish a clinical workflow using standard forms for consistency of assessment and care.

7. Referrals to the External Psychiatrist

Given its small size and remote location in rural, northern New Mexico, UWC-USA primarily relied on the services of an external provider to provide psychiatric services, including medication management for psychiatric medications.

Moreover, the external psychiatrist’s interactions with Koru were marked by gaps in assessment, intervention, monitoring, and communication.  The external psychiatrist primarily relied on Koru’s own description of their symptoms and was limited by not having all of the information along with other factors that would have contributed to a risk assessment. Additionally, the external psychiatrist did not conduct an appropriate intake given Koru’s extended hiatus from psychiatric appointments, failed to conduct an evidence-based assessment of Koru’s suicidal ideation, did not adequately implement any evidence-based interventions during or after the session with Koru, did not engage in any lethal means reduction counseling with Koru or coordinate lethal means reduction counseling with any UWC-USA personnel, did not communicate with the Mosses to develop and implement a treatment plan for Koru, or arrange for the school to do so, despite learning from Koru that their family did not know about the suicidal ideation, and did not verify any part of the follow up plan with the team at UWC-USA.  The external psychiatrist also did not create an observation plan for implementation at school.  Finally, the external psychiatrist’s practice with non-binary individuals was outside of the scope of the external psychiatrist’s cultural competency and training.

8. Health Clinic Structure, Policies, and Personnel

Throughout the relevant period, UWC-USA had an inadequate structure to support the effective functioning of the Health Clinic and the counseling team. Specifically, UWC-USA had no comprehensive policy manual for the Health Clinic.  During the 2022-2023 and 2023-2024 academic years, UWC-USA did not have written policies and procedures governing clinical practices, mental health, or suicide prevention and response.  There were no written policies and protocols related to medical recordkeeping and documentation, health teaming and communication, parental notification for emergent student needs such as suicidal ideation, identification and evidence-based assessment of suicidal ideation, intervention for suicidal students, monitoring and continuous observation, escalation of care, or postvention following a crisis event.

Although the Health Clinic maintains a custodial license issued by the state of New Mexico, which allows the Health Clinic to fill prescriptions and administer medication to students that were prescribed by a physician, UWC-USA had no policies, or procedures in place regarding parental notification of a student’s receipt of psychotropic medications, or for tracking non-compliance with medication or ensuring adequate medication supply or treatment over school breaks.  UWC-USA did not follow up with students who were non-compliant with their medication and did not inform parents as a matter of course when their children were prescribed psychotropic medication.

UWC-USA did not have policies regarding mandatory training on mental health for all staff, or protocols for what staff should do in the event of an on-campus suicide attempt.  UWC-USA did not, at that time, have any formal policies in place about how students should be located if they were missing at night check.  When students were not present at check, the Residential Coordinator generally completed their remaining checks and then asked the residential chat if anyone has seen the student before escalating the search further.

During the relevant period, UWC-USA also had no mechanism for visibility into the quality of their care for students.  Within the Health Clinic, there was no clinical director or properly credentialed supervisor.  The Health Clinic was staffed by two nurses and a Medical Director, who was an independent contractor who had no oversight responsibility for the Health Clinic and did not provide clinical supervision to the nurses or oversight or clinical supervision to members of the Counseling team.  The Health Clinic and the counseling team reported to the Dean of Students, who did not have medical or mental health expertise to guide informed oversight.  UWC-USA relied on independent contractors, rather than full-time employees, to provide counseling services. While this model may be appropriate with an appropriate supervisory structure, UWC-USA did not provide clinical supervision of the counselors, nor did the school take steps to ensure that the counselors were current in their training and following evidence-based practices.  No one from the school checked for compliance with continuing education requirements, ongoing licensure, or other professional development or compliance requirements.

In addition, there were systemic inadequacies that impeded the effective functioning of the Health Clinic and counseling team.  For example, while the School asked that information from a medical professional be provided during the application process, the Health Clinic and counselors did not conduct health screenings upon arrival, which may have helped identify students of concern.  Instead, after student arrival on campus, the School generally relied on student self-reporting, and the Health Clinic did not conduct repeat screenings (either annually or each semester).  Given the nature of the student body, and the high acuity issues presented by many students, this inhibited the ability to identify and provide effective support for students of concern.

9. Gaps in Training and Expertise of Counselors

Both UWC-USA counselors demonstrated significant gaps in training and understanding of evidence-based practices in assessment, intervention, and monitoring of suicide risk.  Of the two mental health counselors, one was not trained in current practices in suicide assessment, intervention, and monitoring of risk, either prior to joining UWC-USA or during onboarding.  The other counselor had significant relevant work history, but there is no evidence that this counselor remained current in effective practices or utilized evidence-based or current practices.  Critically, both counselors and the Health Clinic’s lead nurse lacked sufficient training and expertise to recognize the high-risk nature of Koru’s suicidal ideation.  And the absence of clinical supervision or the leadership of a clinical director left the school with limited visibility into those gaps and deficits.

V.              Recommendations

The Investigators have made the following recommendations:

• Admissions Recommendations: UWC-USA should modify its admissions policies and procedures to: provide feedback to National Committees regarding medical disclosures and gender-affirming care; require medical disclosures come from physicians directly; ensure that medical disclosures request all relevant information and are reviewed by appropriate personnel; evaluate the school’s ability to support clearly disclosed health needs; and require that the school meet with families as part of the admissions process.
• Health Screening Recommendations: UWC-USA should modify its Health Screening process to require a post-admission questionnaire and semesterly health screenings.
• Mental Health Staffing, Policies, and Procedures: UWC-USA should develop and implement mental health staffing, policies, and procedures, including a whole school policy, suicide prevention and response, and medication dispensing policies and procedures; strengthen the Health Clinic structure and supervision by designating a Medical Director and Clinical Director; and ensure personnel are qualified to perform their roles by experience or training. The school should also review the role of the SWEET team and its composition, develop a student health manual, create a Mental Health Screening Policy, and identify providers for diverse student needs.
• Mental Health Teaming and Coordination of Care: UWC-USA should enact policies and procedures related to mental health teaming and coordination of care, including the implementation of weekly and ad hoc Health Team meetings, creation of a Central Support Team for each student, documentation of all Health Team meetings, and creation of a clinical workflow for use by clinicians.
• Systems for Recordkeeping and Effective Documentation: UWC-USA should implement an Electronic Health Records system, case management software, and standardized forms and procedures to guide clinical workflow.
• Prevention, Education, and Training: A robust training protocol, including a New Student Orientation, staff training in key topics such as suicide prevention, gender identity, eating disorder recognition and response, neurodiversity, professional boundaries, and cultural competency.
• Culture and Climate: Take a number of steps to create a culture and climate of mental health, including launching a student well-being survey, reviewing its attendance policy, increasing free time for students, modifying its bed check and curfew policies; utilizing GPS enabled key cards for students, tracking meal attendance, maintaining regular contact with families when students need support, and locating external support for legal needs.
• Board Governance, Engagement, and Oversight: The school should report to the Board quarterly and in the event of any Mental Health Incidents, and designate an Implementation Working Group to implement these recommendations.
• Risk Management, Compliance, and Audit Program: UWC-USA should implement a risk management program including protocols for assessing student health care needs, establishing a Student Safety Committee, and placing AEDs in all dormitory buildings.
• Suicide Prevention Policies: UWC should implement school-wide plans for crisis response, suicide prevention, training and education, and elevated risk protocols. UWC-USA should also implement a postvention policy.

[1] After a hearing, the New Mexico Medical Board determined that there was insufficient evidence to impose discipline.  The external psychiatrist’s license was not suspended at that time or at any time during the period reviewed by the Investigators.

[2] The Investigators noted that any determination as to whether a single dose may have impacted Koru’s risk for suicide would require medical or pharmacological expertise.