10 Nov 2021 Mared Thomas Foulkes · Prevention of Future Deaths report North West Wales
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Concerns raised 3 Failure to distinguish pending assessment marks from failed marks View source Failure of examination results and marking processes to provide clear and non-misleading information View source Lack of a system for personal tutors to contact vulnerable students before release of failed examination results View source
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff University; that does not assign responsibility.
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’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff University; that does not assign responsibility.
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’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff University; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for personal tutors to contact vulnerable students before release of failed examination results
Wider context from the report “(2) There is no system in place for personal tutors to contact students ahead of the release of failed examination results, especially in vulnerable students. Students are not contacted directly by telephone by their personal tutors ahead of the release of the results in the event of failed modules or in the event of being informed that they had not successfully completed the year despite the complex and confusing assessment and results process and potentially misleading process around the sharing of examination results.
” Open source report
1 Mar 2019 Jack Liam May · Prevention of Future Deaths report South Wales Central
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Concerns raised 3 Inadequate provision of counselling and wellbeing services for students View source Insufficient training of Personal Tutors to identify and signpost students needing additional help View source Failure of Personal Tutors to initiate contact with tutees needing pastoral support View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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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. The report was sent to Cardiff University; that does not assign responsibility.
PFD Monitor interpretation Inadequate provision of counselling and wellbeing services for students
Wider context from the report “(1) Provision of sufficient services within Cardiff University to provide emergency help and support for students. Evidence suggested that there may be inadequate provision of counselling and wellbeing services , with long waits being experienced by attendees , also that after 4 appointments, students must reapply . This presents obvious difficulties for students with longer term needs;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff University; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff University; that does not assign responsibility.
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 .
” Open source report
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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
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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 Allocate additional investment for posts supporting risk assessment, triage and management of student crises.
Verbatim wording from the response “4.10 In recent years we have seen a substantial growth in students presenting to our services in crisis, and therefore not a state suitable for counselling. This is an issue we are currently seeking to alter our approach to in response to this presenting change. We are reviewing and improving a range of policies, including in particular our ‘Fitness to Study Procedure’, to make them more accessible and supportive; we are in the early stages of developing a new approach managing risk assessment and intervention where students are experiencing a crisis. We have recently allocated around £150,000 additional investment for new posts to risk assess, triage and manage these situations. This in turn will release staff time back to our counselling provision as the growth in this type of work has, to this point, been reactively managed by our counselling staff.” Source location 2019-0078-Response-by-Cardiff-University
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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 Increase staff time allocated to student counselling and wellbeing services.
Verbatim wording from the response “4.8 At the University Counselling Service management aims for a maximum wait of three working weeks for a combined assessment counselling session (90 minute Therapeutic Consultation); this is normally followed by a four week purposeful gap for the student to explore goals set at that consultation, and a date agreed for the student to re-engage with the service. The service aims for a maximum four week wait for ongoing counselling. Our Wellbeing Team aim for a maximum two weeks wait for assessment and four weeks for ongoing sessions.” Source location 2019-0078-Response-by-Cardiff-University
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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 Invest in and develop the Centre for Student Life as a future home for Student Support Services.
Verbatim wording from the response “2.1 The University has sought to take a lead nationally in debates around student mental health and the development of innovative approaches to supporting students. Our Director of Student Support and Wellbeing, ████████, was a member of the Universities UK Mental Health in HE Group which oversaw the initial development of the Universities UK’s Stepchange¹ strategic approach to mental health. Working with Student Minds UK, the University of the West of England, the University of York and Universities UK, the University is a pilot site for the Stepchange framework and later in 2019 we will launch a new strategy and action plan for mental health, founded on the Stepchange approach, which has been in development over the past 18 months. We are investing in a substantial new building, the Centre for Student Life, which from 2021 will be the home of our Student Support Services.” Source location 2019-0078-Response-by-Cardiff-University
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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
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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
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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
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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 that its counselling and wellbeing provision is inadequate for the purposes its services are intended to fulfil.
Verbatim wording from the response “Matters of Concern 5 (1): “Provision of sufficient services within Cardiff University to provide emergency help and support for students. Evidence suggested there may be inadequate provision of counselling and wellbeing services, with long waits being experienced by attendees, also that after 4 appointments students must reapply. This presents obvious difficulties for students with longer term needs;”” Source location 2019-0078-Response-by-Cardiff-University
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations