Recurring concern

Inadequate pastoral support systems for identifying and responding to welfare concerns

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First reported 28 Aug 2015•Latest report 10 Jul 2024

Definition

What this concern includes

Includes failures of an explicitly identified pastoral support system or function that affect its ability to identify, engage, assess, coordinate or provide appropriate support for welfare concerns, including dedicated role clarity, training, proactive contact and service coordination.

Not included

  • Excludes generic staff training deficiencies not explicitly tied to a pastoral support function.
  • Excludes failures belonging solely to clinical, emergency, safeguarding or mental-health services without a pastoral support-system component.
  • Excludes isolated communication, documentation, staffing or contact failures that are not dedicated to the pastoral support system.
  • Excludes neutral descriptions of pastoral care, education settings or student welfare without an unsafe-system assertion.
Reports
6

Distinct published reports

Individual concerns
9

A report can raise multiple concerns

Date range
2015–2024

First to latest report issue date

Stated actions
13

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Cardiff University1
Catholic Safeguarding Standards Agency1
Church of England1
Hewett Academy1
Universities UK1
University of Exeter1
University of Reading1
University of Southampton1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Berkshire

    AI-generated summary

    Benjamin Faux · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Benjamin Faux was a taught research Master's student at the University of Reading who had severe mental health difficulties, disengaged from his studies, and took his own life in his student accommodation on or around 5 August 2023. The concerns included inadequate pastoral support and monitoring, the absence of a process to ensure completion of study-suspension arrangements, unclear responsibility for resolving his academic situation, and a lack of University contact with him before his death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of named pastoral tutors for students on taught research courses

    Wider context from the report

    “(1) About 5 years ago, following concerns from academic staff that they were not equipped to support students with welfare issues, Reading University stripped out the pastoral care function from the academic supervisor role, leaving only ‘academic advisors/tutors’. There is alternative provision made for welfare but it is not part of the tutor role and students on taught research courses do not have named pastoral tutors; ”

    Source location

    Benjamin Faux · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide every Master’s by Research student with two academic points of contact and monthly meetings throughout the programme.

    Verbatim wording from the response

    “This change was an institutional decision made to reflect the view that it was more appropriate for academic staff to focus on providing academic and general pastoral support, with trained professionals providing more specialist welfare support where required. | 1. Strengthen support system for MbR programmes to ensure that all MbR students have monthly meetings with two academic points of contact.”

    Source location

    Response from Reading University
    Page 1 · response
    Published 29 July 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Professional welfare support from central teams, alongside academic pastoral support, is considered more appropriate than restoring specialist welfare duties to Academic Tutors.

    Verbatim wording from the response

    “1 | The Academic Tutor role was revised a number of years ago, with a stronger provision of professional welfare support made available within the central student services teams.”

    Source location

    Response from Reading University
    Page 1 · response
    Published 29 July 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The organisation lacks regulatory authority to mandate specific mental-health actions by member universities.

    Verbatim wording from the response

    “UUK represents 141 autonomous universities across the United Kingdom. However, it is important to note that our organisation does not represent all higher education providers nor possess the regulatory authority to mandate specific actions by our member institutions. Each university operates independently, with its own governance and procedures.”

    Source location

    Response from Universities UK
    Page 2 · response
    Published 29 July 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Individual universities are responsible for their own governance, procedures and decisions on specific mental-health actions.

    Verbatim wording from the response

    “UUK represents 141 autonomous universities across the United Kingdom. However, it is important to note that our organisation does not represent all higher education providers nor possess the regulatory authority to mandate specific actions by our member institutions. Each university operates independently, with its own governance and procedures.”

    Source location

    Response from Universities UK
    Page 2 · response
    Published 29 July 2024

    Open published response
  2. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Matthew George WICKES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Matthew George WICKES died in hospital on 30 June 2022 after jumping from a road bridge in Southampton during an acute anxiety crisis. Concerns included university staff awareness and training on student mental health and neurodiversity, gaps between academic assessment and pastoral support, difficulties in effectively reaching struggling students, and inadequate recording of academic meetings and agreed support.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Gap between academic assessment and pastoral support for students

    Wider context from the report

    “2. It was evident to the Court that very positive steps have already been undertaken in planning towards an early warning system for students in the academic year 2023/24. This will allow triggers to be identified and set for academic absence and changes in study or support behaviours (as is to be trialled in 2023/24). Such steps are to be commended and I hope will proceed at pace. However, I do have concerns that there is and remains an evident gap between the academic assessment of students and the pastoral support that they receive. I hope this will be addressed and filled – in part in the development of staff training and understanding around mental health and in what circumstances concerns should be raised (as above). Where academic absence or performance issues are identified, I am not convinced, on the evidence heard at this inquest, that enough has yet been done to also consider how ‘reaching out’ to such students can be most effectively achieved. It was evident that much of the group-focused approaches offered by the university or the initiatives where the onus is placed on the student to come forward, may not work. Practically, how best can students – especially those with neurodiverse needs – be compassionately and empathically approached and engaged with to ensure they receive the help and validation that they probably desperately require? ”

    Source location

    Matthew George WICKES · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  3. Cornwall and Isles of Scilly

    AI-generated summary

    HARRY JOSEPH PENGELLY ARMSTRONG EVANS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Harry Joseph Pengelly Armstrong Evans died by hanging on 24 June 2021 during an acute mental health crisis, following academic pressures and concerns about his wellbeing. The report identified concerns about the university’s lack of proactive personal engagement, failures in safeguarding alert follow-up, insufficient staff awareness of information-sharing policies, and reliance on email and online forms to access welfare support.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a policy enabling pastoral tutors to exchange mobile numbers with students

    Wider context from the report

    “4) Pastoral support The evidence indicated that if Harry’s pastoral tutor had known Harry’s mobile number, he may have called him. The court heard that there was no policy for pastoral tutors exchanging mobile numbers with students. The university is invited to review whether pastoral tutors should offer to exchange mobile numbers with their students, and to consider whether pastoral tutors should have a work mobile to facilitate a proactive approach in the event that there are concerns for wellbeing. ”

    Source location

    HARRY JOSEPH PENGELLY ARMSTRONG EVANS · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing out-of-hours support is considered sufficient, so staff will not exchange mobile numbers or receive work mobiles for student contact.

    Verbatim wording from the response

    “As was set out during the Inquest, concerns have been flagged by academic colleagues, professional services and sector representatives with regards to the proposed sharing of mobile numbers. The concerns include that this approach could have potential safeguarding implications, severe impacts on colleague wellbeing, and may mean students requiring urgent support do not use the appropriate Out Of Hours support service. With this in mind, the University is expanding its out of hours provision to ensure emergency support is available via phone for students in crisis twenty four hours a day across all our campuses. Advice is available to all staff out-of-hours (via our Estate Patrol team in the first instance) where there are serious student mental health concerns.”

    Source location

    Response from Vice-Chancellor's
    Page 4 · response
    Published 7 November 2022

    Open published response
  4. Inner North London

    AI-generated summary

    Alan Howard Foster Griffin · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Alan Howard Foster Griffin died by suicide at home on 8 November 2020 while under investigation by his former and current dioceses. The principal concerns were systemic and individual failings in the handling of unverified allegations, including inadequate verification, inaccurate and incomplete information-sharing, unclear responsibility, and failure to seek recommended legal advice.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficiently proactive pastoral support

    Wider context from the report

    “4. The Roman Catholic Diocese of Westminster was unaware of Father Griffin’s attempted suicide nine years earlier. However, it could still have been more proactive than it was in ensuring that he had maximum pastoral support. ”

    Source location

    Alan Howard Foster Griffin · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop and roll out mandatory safeguarding leadership training on professional curiosity, reflection and support for respondents.

    Verbatim wording from the response

    “Training The CSSA national training lead is developing a suite of training for those in leadership and management in safeguarding roles within Church bodies. Work has commenced and the training modules, which will include mandatory modules on reflection and professional curiosity and on the provision of support to those about whom allegations or concerns have been raised, and they will be rolled out over the course of 2022.”

    Source location

    2021-0243-Response-from-Catholic-Safeguarding-Standards-Agency_Published
    Page 2 · response
    Published 15 July 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Launch national Safeguarding Standards requiring information, pastoral, professional and legal support for respondents.

    Verbatim wording from the response

    “National Safeguarding Standards On 27th October 2021, the CSSA launched its new national Safeguarding Standards, which can be viewed at: https://www.catholicsafeguarding.org.uk/national-safeguarding-standards/the-standards/ Standard 5 relates specifically to the management and support of those who are the subject of allegations and concerns, and requires church bodies to:”

    Source location

    2021-0243-Response-from-Catholic-Safeguarding-Standards-Agency_Published
    Page 2 · response
    Published 15 July 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update practice guidance to emphasise prompt notification, timely investigations and ongoing support for respondents.

    Verbatim wording from the response

    “National Safeguarding Policy and Practice Guidance There is considerable existing practice guidance on Church bodies’ responsibilities towards clergy and religious against whom allegations have been made, including on conducting an initial meeting with an individual against whom allegations have been made. In view of this case, that guidance will be updated to emphasise the importance of promptly informing individuals of allegations made against them, of completing safeguarding investigations in a timely manner, and of ensuring that support needs are identified and met throughout.”

    Source location

    2021-0243-Response-from-Catholic-Safeguarding-Standards-Agency_Published
    Page 3 · response
    Published 15 July 2021

    Open published response
  5. South Wales Central

    AI-generated summary

    Jack Liam May · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jack May, a 20-year-old nursing student with a longstanding history of mental health problems, died in the River Taff on 25 October 2018; the inquest concluded that his death was suicide. The report raised concerns about the adequacy and accessibility of Cardiff University’s emergency, counselling, wellbeing and pastoral support services for students experiencing mental health or other personal difficulties.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient training of Personal Tutors to identify and signpost students needing additional help

    Wider context from the report

    “(2) Patchy provision of pastoral support by Personal Tutors. Evidence suggested that Personal Tutors receive only 3 hours of training (per annum) in relation to identifying and signposting students in need of additional help with mental health or other personal difficulties. Also, that some Personal Tutors do not contact their tutees to initiate contact, and some tutees do not respond. Therefore, students can, and do slip through the net. ”

    Source location

    Jack Liam May · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of Personal Tutors to initiate contact with tutees needing pastoral support

    Wider context from the report

    “(2) Patchy provision of pastoral support by Personal Tutors. Evidence suggested that Personal Tutors receive only 3 hours of training (per annum) in relation to identifying and signposting students in need of additional help with mental health or other personal difficulties. Also, that some Personal Tutors do not contact their tutees to initiate contact, and some tutees do not respond. Therefore, students can, and do slip through the net. ”

    Source location

    Jack Liam May · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review and improve Personal Tutor training, incorporating concerns about identifying students needing additional help.

    Verbatim wording from the response

    “3.6 The Code of Practice also states that Personal Tutors will undertake training. Personal Tutors are encouraged to attend in person training and we make them aware of the professional support we offer through training, the production and circulation of printed materials and other advertising. In addition, there is a substantial and growing range of resources on our Staff Intranet. An online training module is available to all those involved in personal tutor support. This includes guidance on, but not limited to, student services and resources to which students can be directed for emotional and mental health support, personal crises, incident and concern management. This is subject to ongoing development and enhancement. This improvement is informed by a range of stakeholders, and shaped by the parallel work of the University’s policy and approach to Personal Tutor support.”

    Source location

    2019-0078-Response-by-Cardiff-University
    Page 6 · response
    Published 9 June 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise the Code of Practice for Personal Tutors through the wider Policy Framework review.

    Verbatim wording from the response

    “3.3 The University has a Code of Practice for Personal Tutors, which is included as Appendix B. As outlined in the document it sets out the core standards for the provision of the personal tutor system and the responsibilities of the staff involved. This document has been in place in its current format since 2013. It is currently being revised in the context of a wider review of our Policy Framework. Its implementation as policy will involve [further] setting minimum expectations on matters such as the frequency of meetings and the roles and responsibilities of Personal Tutors. The Senior Personal Tutor Network, drawn from staff across the University, will also work together to investigate effective support and guidance that can appropriately be offered by Personal Tutors.”

    Source location

    2019-0078-Response-by-Cardiff-University
    Page 6 · response
    Published 9 June 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The University disputes the conclusion that personal tutor pastoral support is patchy and that students consequently slip through the net.

    Verbatim wording from the response

    “Matters of Concern 5 (2): patchy provision of pastoral support by Personal Tutors. Evidence suggested that Personal Tutors receive only three hours of training (per annum) in relation to identifying and signposting students in need of additional help with mental health or other personal difficulties. Also, some Personal Tutors do not contact their tutees to initiate contact, and some tutees do not respond. Therefore, students can do and do slip through the net.”

    Source location

    2019-0078-Response-by-Cardiff-University
    Page 7 · response
    Published 9 June 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing personal tutor arrangements, including recorded meetings and minimum standards, are relied on while allowing variation between academic Schools.

    Verbatim wording from the response

    “3.3 The University has a Code of Practice for Personal Tutors, which is included as Appendix B. As outlined in the document it sets out the core standards for the provision of the personal tutor system and the responsibilities of the staff involved. This document has been in place in its current format since 2013. It is currently being revised in the context of a wider review of our Policy Framework. Its implementation as policy will involve [further] setting minimum expectations on matters such as the frequency of meetings and the roles and responsibilities of Personal Tutors. The Senior Personal Tutor Network, drawn from staff across the University, will also work together to investigate effective support and guidance that can appropriately be offered by Personal Tutors.”

    Source location

    2019-0078-Response-by-Cardiff-University
    Page 6 · response
    Published 9 June 2019

    Open published response
  6. Norfolk

    AI-generated summary

    ISABEL ANN RICHARDSON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Isabel Richardson, aged 12, took her own life by hanging after a period of self-harm and indications on social media that she might kill herself. Concerns were raised about the purpose, operation and training of the school’s Pastoral Team and whether its pastoral system was sufficiently robust and structured to address Isabel’s difficulties.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the Pastoral system to provide sufficiently robust and structured support

    Wider context from the report

    “(1) A Pastoral Team were in place at the School but it was not clear from the evidence as to their purpose, how they worked or whether they were trained in the role they were expected to perform; (2) It was not clear that the Pastoral system was robust or structured enough to deal with the problems that Isabel presented. ”

    Source location

    ISABEL ANN RICHARDSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure Pastoral Team training for expected roles

    Wider context from the report

    “(1) A Pastoral Team were in place at the School but it was not clear from the evidence as to their purpose, how they worked or whether they were trained in the role they were expected to perform; (2) It was not clear that the Pastoral system was robust or structured enough to deal with the problems that Isabel presented. ”

    Source location

    ISABEL ANN RICHARDSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of clarity about the Pastoral Team’s purpose and operation

    Wider context from the report

    “(1) A Pastoral Team were in place at the School but it was not clear from the evidence as to their purpose, how they worked or whether they were trained in the role they were expected to perform; (2) It was not clear that the Pastoral system was robust or structured enough to deal with the problems that Isabel presented. ”

    Source location

    ISABEL ANN RICHARDSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement a new safeguarding team and structure.

    Verbatim wording from the response

    “On taking up post I carried out and urgent review of our approaches and within my first two days I implemented a new safeguarding team and structure. I also commissioned Kelly Waters, Senior Advisor for Safeguarding at Norfolk County Council, to audit our approach.”

    Source location

    Isabel-RichardsonR
    Page 1 · response
    Published 28 August 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish a fully trained safeguarding team.

    Verbatim wording from the response

    “I have now addressed these issues and have a fully trained safeguarding team in place. I have appointed an Assistant Principal to lead this team and provide feedback to the leadership team on a weekly basis. I have liaised with Norfolk County Council to provide a follow-up audit later this term to ensure the new structures are operating effectively.”

    Source location

    Isabel-RichardsonR
    Page 1 · response
    Published 28 August 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Appoint an Assistant Principal to lead safeguarding and provide weekly leadership feedback.

    Verbatim wording from the response

    “I have now addressed these issues and have a fully trained safeguarding team in place. I have appointed an Assistant Principal to lead this team and provide feedback to the leadership team on a weekly basis. I have liaised with Norfolk County Council to provide a follow-up audit later this term to ensure the new structures are operating effectively.”

    Source location

    Isabel-RichardsonR
    Page 1 · response
    Published 28 August 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Arrange a follow-up audit of the new safeguarding structures later in the term.

    Verbatim wording from the response

    “I have now addressed these issues and have a fully trained safeguarding team in place. I have appointed an Assistant Principal to lead this team and provide feedback to the leadership team on a weekly basis. I have liaised with Norfolk County Council to provide a follow-up audit later this term to ensure the new structures are operating effectively.”

    Source location

    Isabel-RichardsonR
    Page 1 · response
    Published 28 August 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Upskill key safeguarding team members and train all staff in safeguarding.

    Verbatim wording from the response

    “As well as restructuring the safeguarding team, seeking external support and guidance, appointing new staff members, and upskilling key team members we have also used our staff training days to train the whole staff team in safeguarding. We have made physical changes to the school site to improve security and allow for more structured interaction between staff and pupils.”

    Source location

    Isabel-RichardsonR
    Page 2 · response
    Published 28 August 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review safeguarding approaches to identify deficiencies and required improvements.

    Verbatim wording from the response

    “On taking up post I carried out and urgent review of our approaches and within my first two days I implemented a new safeguarding team and structure. I also commissioned Kelly Waters, Senior Advisor for Safeguarding at Norfolk County Council, to audit our approach.”

    Source location

    Isabel-RichardsonR
    Page 1 · response
    Published 28 August 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Commission an external audit of the safeguarding approach.

    Verbatim wording from the response

    “On taking up post I carried out and urgent review of our approaches and within my first two days I implemented a new safeguarding team and structure. I also commissioned Kelly Waters, Senior Advisor for Safeguarding at Norfolk County Council, to audit our approach.”

    Source location

    Isabel-RichardsonR
    Page 1 · response
    Published 28 August 2015

    Open published response
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Data last updated 7 September 2026