Recurring concern

Unreliable communication of significant academic decisions and support actions to students

First to latest report 5 Feb 2016 — 19 Jan 2024

Reports that mention this concern
5
Times this concern has been raised
6
Stated actions linked to this concern
4

What this concern includes

Includes failures in the student-facing process for communicating significant academic decisions, academic progress concerns, agreed guidance, required actions and related support arrangements, including failure to use an appropriately personal or accessible communication method and failure to provide or maintain a clear record for the student.

What is not included
  • Excludes routine academic correspondence and ordinary feedback that do not concern a consequential decision, significant progress concern or agreed support action.
  • Excludes failures in general student mental-health training, proactive outreach or pastoral-service capacity where communication of an academic decision or agreed support action is not the deficient control.
  • Excludes internal academic records that were not intended to inform or support the student, unless the failure also prevents the student from receiving the relevant decision or agreed action.
  • Excludes clinical, safeguarding and care-planning communications outside the academic-student support process.

Reports and published responses 5 reports

See individual reports that have raised this concern, and the actions taken in response

  1. 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

    Failure to maintain accurate and sufficiently frequent records of academic meetings and agreed actions

    Wider context from the report

    “3. The evidence at this inquest raised concerns over the existence, frequency and accuracy of the recording and minuting of academic meetings with students, especially those between the student and Personal Academic Tutor and the Project Supervisor in the third year of study. It was of concern to me that the University was unable to locate or provide clear minutes of supervisory catch ups, progress checks or agreed guidance or actions for Matthew. It was of further concern that the academic staff supporting and mentoring him in his third year had not provided written evidence of his progress or agreed minutes of actions etc to him. Whilst it is recognised, particularly in a third year of study, that there must be a balance between independence and appropriate support, it would in my view be important for any student and university academic team to have a clear record of achievement or progress. This must be able to be reflected back to the student and recorded in such a way as to ensure that both student and tutor are clear and agreed as to progress that has been achieved and as to what needs to be done to move forward. The absence of such information and appropriate support, which can lead to feelings of isolation and desperation, must be avoided at all costs. ”

    Source location

    Matthew George WICKES · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. North West Wales

    AI-generated summary

    Mared Thomas Foulkes · 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

    Mared Thomas Foulkes, aged 21, died beneath the Britannia Bridge on 8 July 2020; the inquest concluded that her death was suicide. Concerns included complex and potentially misleading examination-result communications, and the absence of a system for personal tutors to contact vulnerable students before failed results were released.

    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 to distinguish pending assessment marks from failed marks

    Wider context from the report

    “(1) The sharing of examination results and how examinations are marked is complex, confusing and at times capable of appearing misleading. Mared had failed one Professional Skills Assessment during the second year of her degree (2019/2020) and had undertaken a resit during the first semester for which she had received a ‘provisional pass’. This was not ratified in the June exam board; instead it was to be ratified in the September exam board round in accordance with the University’s policy (though that was not obviously clear at the time). The indication therefore to Mared in July 2020 was that she had not successfully completed the year. The result was later ratified in September. Furthermore, marks of 39% and 1% (fails) for assessments are given in situations where marks could be ‘pending’. ”

    Source location

    Mared Thomas Foulkes · 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 examination results and marking processes to provide clear and non-misleading information

    Wider context from the report

    “(1) The sharing of examination results and how examinations are marked is complex, confusing and at times capable of appearing misleading. Mared had failed one Professional Skills Assessment during the second year of her degree (2019/2020) and had undertaken a resit during the first semester for which she had received a ‘provisional pass’. This was not ratified in the June exam board; instead it was to be ratified in the September exam board round in accordance with the University’s policy (though that was not obviously clear at the time). The indication therefore to Mared in July 2020 was that she had not successfully completed the year. The result was later ratified in September. Furthermore, marks of 39% and 1% (fails) for assessments are given in situations where marks could be ‘pending’. ”

    Source location

    Mared Thomas Foulkes · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Coventry

    AI-generated summary

    Xuanze Piao · 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

    Xuanze Piao, a 17-year-old overseas student at Coventry University, was struck by a train near Coventry Railway station on 3 December 2018 and died from catastrophic injuries; the inquest concluded suicide. The principal concerns were that the university did not meet him face to face or contact his guardian or parents before emailing him about the risk of removal from his course, and that no relevant procedure or policy was in place.

    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 procedure for a face-to-face meeting with an overseas student under 18 before sending an email indicating risk of removal from the course

    Wider context from the report

    “(.1) The University did not have a face to face meeting with Xuanze, a student under the age of 18, prior to sending him the email dated 29/11/2018 indicating that he was at risk of being removed from the course and that he should attend a meeting to discuss this on 03/12/2018; (.2) In the absence of a face to face meeting with Xuanze, the University did not contact either Xuanze’s Guardian or Parents prior to sending Xuanze the email dated 29/11/2018 indicating that Xuanze was at risk of being removed from the course and that he should attend a meeting to discuss this on 03/12/2018; Evidence was given at the inquest that in the case of an overseas student under 18, notwithstanding both prolonged absence from academic commitments and a persistent omission to respond to email requests that the absentee student should make contact with the university, there was no procedure or policy in place either for a face to face meeting with the student or, in the absence of such a face to face meeting, for contacting that student’s Guardian or Parents, prior to the email being sent indicating that the U.18 student was at risk of being removed from the course and that he should attend a meeting to discuss this. ”

    Source location

    Xuanze Piao · 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

    Review policies and procedures for students under 18.

    Verbatim wording from the response

    “The University is undertaking a full review of its policy and procedures relating to students who are under the age of 18. This is expected to be complete by 31 January 2021. The University will provide a copy of the new policy to the Coroner when it has been finalised.”

    Source location

    2020-0230-Response-from-Coventry-University.pdf
    Page 2 · response
    Published 23 December 2020

    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

    Implement an additional process requiring welfare assessment meetings before withdrawing under-18 international students at visa-related engagement risk.

    Verbatim wording from the response

    “In relation to the concerns raised by the Coroner, the University refers to the chronology set out above. The University also confirms that it has already put in place an additional process for responding when international students who are under 18 fail to engage with their course where”

    Source location

    2020-0230-Response-from-Coventry-University.pdf
    Page 2 · response
    Published 23 December 2020

    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

    Provide the finalized new under-18 student policy to the Coroner.

    Verbatim wording from the response

    “The University is undertaking a full review of its policy and procedures relating to students who are under the age of 18. This is expected to be complete by 31 January 2021. The University will provide a copy of the new policy to the Coroner when it has been finalised.”

    Source location

    2020-0230-Response-from-Coventry-University.pdf
    Page 2 · response
    Published 23 December 2020

    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 attendance, engagement and welfare policies already provide face-to-face meetings and welfare checks and were followed.

    Verbatim wording from the response

    “The University’s attendance/engagement and welfare policies and procedures therefore already provide for face to face meetings and welfare checks and those policies and procedures were followed in this case. However, the University is committed to continuous evolution and welcomes any proposals, comments or suggestions about the development of its policies and procedures.”

    Source location

    2020-0230-Response-from-Coventry-University.pdf
    Page 2 · response
    Published 23 December 2020

    Open published response

  4. West Yorkshire (West)

    AI-generated summary

    Owen Arron Wynne Williams · 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

    Owen Williams was found unresponsive, suspended by a rope tied to a tree in a secluded wooded area, after accessing A level results that did not meet the grades required for his intended university course; his death was confirmed later that day. The report identified concerns about the lack of national consistency in how and when A level results are released, delays before support is available, UCAS opening later, and the absence of a national requirement to inform parents in advance about the results-release system and potential impact of unexpected results.

    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 national agreement on the timing and manner of A level results release

    Wider context from the report

    “I heard evidence from the Principal of the college that Owen attended that there is wide variance both locally and nationally of the timing and way in which colleges release A level results, some release results electronically as early as 6.00 am and later the same morning provide a facility within the school and college to provide support to students, some colleges / schools require the students to physically attend to obtain their results, when at the same time support by staff members is immediately on hand. I understand UCAS is available from 8.00 am onwards, once again some hours after some students have obtained their results. In particular, from the evidence presented to me it appears:- 1. That there is no national agreement across all educational institutions to the timing and manner in which A level results are released. 2. That there can be a significant time lag between results being released by some schools and colleges and the timing of when there is the availability of staff to provide support to those students that may have received unexpected results. 3. That UCAS is presently available some hours after some educational institutions have released student results. 4. That there is no national requirement for educational establishments to communicate directly to parents in advance of results day and explain the system in place for the release of the A level results at the educational establishment that their child is attending and to alert them to the potential that unexpected results can occur and to be alert to the impact that this may have upon their child. ”

    Source location

    Owen Arron Wynne Williams · 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

    Jointly host a roundtable with education-sector representatives to explore consistent school practice, embargo timing, student support and alternative higher-education choices.

    Verbatim wording from the response

    “On receipt of your letter, we contacted the Department for Education (DfE) and (JCQ) to discuss our own concerns about the time at which students can access their results without support from their school or college – and the inconsistency in approach. We believe improvements could be made to the process, and we are keen to work with DfE, JCQ, awarding organisations, schools, and colleges to improve the overall experience for students. In order to take this forward, we will jointly host a roundtable with DfE to explore how we can support students throughout the examination and results periods, particularly those who do not receive the grades they had hoped for.”

    Source location

    2019-0250-Response-by-UCAS
    Page 2 · response
    Published 9 September 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

    Exam-results release timing is determined by JCQ for GCSE, AS and A levels, and by individual awarding organisations for other qualifications.

    Verbatim wording from the response

    “The time at which GCSE, AS and A level results can be released by schools to pupils is a matter for the JCQ, a membership organisation representing independent awarding organisations including the four exam boards offering GCSE, AS and A level exams in England. The JCQ oversees exam processes”

    Source location

    2019-0250-Response-by-Department-for-Education
    Page 1 · response
    Published 9 September 2019

    Open published response

  5. Inner North London

    AI-generated summary

    Chentoоri Chanthirakumar · 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

    Chentoоri Chanthirakumar, a 24-year-old medical student, died by suicide after being discharged from a period of inpatient mental health treatment. The concerns included the university communicating by email about her examinations rather than arranging a personal meeting, and mental health staff not fully absorbing concerns raised by others because of confidentiality concerns.

    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 to consider personal meetings when communicating significant academic decisions

    Wider context from the report

    “The decision that Ms Chanthirakumar could re-take the fourth year of her medical degree was seen by the medical school as a helpful decision. The re-take was allowed on the basis of her ill health and was not a criticism of her academic achievement. That she would not be able to take her fourth year examinations in August 2015 came to be regarded as almost self evident, because she had not been able to attend the majority of her recent clinical placement and had been so recently so unwell. However, unbeknown to the university staff, Ms Chanthirakumar appears to have lacked some insight at this point, and was actually hoping not to have to re-take the year, but instead to take her fourth year exams in August 2015. Given the very particular course of very recent events leading up to the medical school’s decision, I wonder whether a personal meeting to discuss matters with her could have been arranged, rather than communicating this by email. A face to face meeting may not necessarily have had any impact on the outcome, but nevertheless I think would be a helpful consideration for the process in the future. ”

    Source location

    Chentoоri Chanthirakumar · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026