PFD report

Jack Liam May · Prevention of Future Deaths report

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Issued 1 Mar 2019•South Wales Central

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
13

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Inadequate provision of counselling and wellbeing services for students
    Part of recurring concern: Inadequate university mental-health support systems for studentsPart of recurring concern: Insufficient student mental-health support capacity
  2. Insufficient training of Personal Tutors to identify and signpost students needing additional help
    Part of recurring concern: Inadequate pastoral support systems for identifying and responding to welfare concerns
  3. Failure of Personal Tutors to initiate contact with tutees needing pastoral support
    Part of recurring concern: Inadequate pastoral support systems for identifying and responding to welfare concerns
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

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

    Stated by Cardiff UniversityStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2019.
  2. Action

    Allocate additional investment for posts supporting risk assessment, triage and management of student crises.

    Stated by Cardiff UniversityStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  3. Action

    Increase staff time allocated to student counselling and wellbeing services.

    Stated by Cardiff UniversityStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

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

    Stated by Cardiff UniversityExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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; ”

Is this part of a recurring concern?

Yes — Inadequate university mental-health support systems for students; Insufficient student mental-health support capacity.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Inadequate pastoral support systems for identifying and responding to welfare 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. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Inadequate pastoral support systems for identifying and responding to welfare 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

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
Page 9 · 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

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
Page 8 · 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

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
Page 2 · 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

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

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

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
Page 7 · response
Published 9 June 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.8

  1. 1

    Evaluate and refine the newly introduced LGBT+ student support measures with the student community.

    Stated by Cardiff UniversityStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2019.
  2. 2

    Develop a new approach to risk assessment and intervention for students experiencing mental-health crises.

    Stated by Cardiff UniversityStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2019.
  3. 3

    Review and improve policies, including the Fitness to Study Procedure, to make crisis support more accessible and supportive.

    Stated by Cardiff UniversityStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2019.
  4. 4

    Deliver and extend suicide-prevention workshops for staff and students under the Suicide Safer Strategy.

    Stated by Cardiff UniversityStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2019.
  5. 5

    Progress a formal Memorandum of Understanding with Cardiff Samaritans to embed postvention support.

    Stated by Cardiff UniversityStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2019.
  6. 6

    Provide enhanced LGBT+ student support through dedicated accommodation, trained peer support, a gender-transition pathway and enhanced trans-issues training.

    Stated by Cardiff UniversityStated completedThe respondent said that this action was complete when they made their response on 9 June 2019.
  7. 7

    Launch a new student mental-health strategy and action plan based on the Stepchange framework.

    Stated by Cardiff UniversityStated plannedThe respondent said that this action was planned when they made their response on 9 June 2019.
  8. 8

    Participate in the JISC-coordinated all-Wales project to develop learning analytics for identifying at-risk students.

    Stated by Cardiff UniversityStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Responsibility for assessing and responding to students’ physical or mental health crises rests with the NHS and other appropriate statutory services.

    Stated by Cardiff UniversityRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Evaluate and refine the newly introduced LGBT+ student support measures with the student community.

Verbatim wording from the response

“2.14 We launched a range of new student support measures in February 2019. This included dedicated accommodation options for first year students, trained LGBT+ peer to peer support, a new pathway for students transitioning gender and enhanced training for student support professionals on trans issues. This exercise is a trial, which we will evaluate in due course. We will work with the student community over the coming months and years to assess its success and modify it accordingly.”

Source location

2019-0078-Response-by-Cardiff-University
Page 5 · 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

Develop a new approach to risk assessment and intervention for students experiencing mental-health 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
Page 9 · 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

Review and improve policies, including the Fitness to Study Procedure, to make crisis support more accessible and supportive.

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
Page 9 · 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

Deliver and extend suicide-prevention workshops for staff and students under the Suicide Safer Strategy.

Verbatim wording from the response

“2.15 The University was identified in a good practice case study in Suicide Safer Universities⁸, a framework developed by Universities UK and Papyrus in 2018. We have used this framework to develop a Suicide Safer Strategy. This is used in Student Support and Wellbeing but relates to the wider University. As part of this work we undertake to prioritise suicide prevention. To this end we have delivered 22 workshops to 469 staff and students so far during the 2018-19 academic year, with a further 16 workshops scheduled before the end of academic year. We are committed to continuing and enhancing this work going forward.”

Source location

2019-0078-Response-by-Cardiff-University
Page 5 · 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

Progress a formal Memorandum of Understanding with Cardiff Samaritans to embed postvention support.

Verbatim wording from the response

“2.12 In addition to the specific Counselling and Wellbeing services which are the focus of your Report (para. 6(a)) we also offer drop-in services at times throughout the week for our other support services, alongside other methods of access such as e-mail counselling and advice and support over the telephone. We work in partnerships with external agencies to offer enhanced access to students for their services. These include Women’s Aid and drug and alcohol specialists. We have invited the Samaritans onto campus during University closure to assist with postvention after a suicide. We are currently progressing the development of a formal Memorandum of Understanding with the Cardiff Samaritans to better embed this important work.”

Source location

2019-0078-Response-by-Cardiff-University
Page 4 · 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

Provide enhanced LGBT+ student support through dedicated accommodation, trained peer support, a gender-transition pathway and enhanced trans-issues training.

Verbatim wording from the response

“a project to work with our LGBT+ students to develop a range of measures that would ensure our support services area was as accessible as possible. To our knowledge, we were the first University in the UK to use this research, and the recommendations from it, in this way.”

Source location

2019-0078-Response-by-Cardiff-University
Page 5 · 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

Launch a new student mental-health strategy and action plan based on the Stepchange framework.

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
Page 2 · 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

Participate in the JISC-coordinated all-Wales project to develop learning analytics for identifying at-risk students.

Verbatim wording from the response

“We are part of an all-Wales project, coordinated by JISC, to establish a learning analytics system, this will explore how enhanced information on engagement and progress can help staff identify at-risk students in the future.”

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

Responsibility for assessing and responding to students’ physical or mental health crises rests with the NHS and other appropriate statutory services.

Verbatim wording from the response

“4.1 As we have set out above student support services are primarily provided by universities to help students get the best possible academic outcome. Universities do not provide student support specifically to address physical or mental health crises. This remains the purview of the NHS, and other statutory services appropriate to the individual circumstances at the time of crisis. The NHS is best placed to assess and respond to psychiatric illness and mental ill health presentations because it is a statutory care provider with the powers and resources that this affords.”

Source location

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

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026