Investigation and inquest
On 14/07/2020 I commenced an investigation into the death of Mared Thomas Foulkes, 21 . The investigation concluded at the end of the inquest on 28 October 2021. The conclusion of the inquest was Suicide.
Circumstances of the death
Mared Thomas Foulkes, aged 21, died beneath the Britannia Bridge on 8 July 2020. Mared was a student at the School of Pharmacy and Pharmaceutical Sciences at Cardiff University studying for a M Pharm. She had received examination results the morning she died indicating that she had ‘not successfully completed this year/stage of her programme of study’. It was revealed after her death that she had successfully completed the year (once the ratification process had occurred).
Coroner’s concerns
(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’.
(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.