Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0378, written 10 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Nov 2021 |
|---|---|
| Reference | 2021-0378 |
| Deceased | Mared Foulkes |
| Coroner | Katie Sutherland |
| Coroner area | North West Wales |
| Category | Suicide (from 2015) · Other related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Katie Sutherland Acting Senior Coroner
Senior Coroner for North West Wales
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
President and Vice-Chancellor, Cardiff University
1
CORONER
I am Katie Sutherland Acting Senior Coroner for North West Wales
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
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.
4
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).
5
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In my
opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it
is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
(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.
Coroner's Office, Shirehall Street, CAERNARFON, Gwynedd, LL55 1SH
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you, Cardiff
University, have the power to take such action.
(a) Ratifying examination results at the first available opportunity, i.e. June, where a student
has a provisional pass following successful resit for an initial failed Professional Skill
Assessment (or equivalent in other schools or colleges)
(b) Amending wording on exam notification correspondence to students (transcripts, emails,
etc) to include ‘pending’ results, clarifying which exam board round (June or September)
will ratify the results and clarity on assessment and ratification processes.
(c) Provide additional and ongoing training to school staff on the clarity of explanation to
students of assessment processes.
(d) Provide further additional support to students where they are to receive a ‘fail'
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
5th January 2022. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
1. Family
2.
3. The Chief Coroner
Head of School of Pharmacy and Pharmaceutical Sciences
who may find it useful or of interest.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He
may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the
release or the publication of your response by the Chief Coroner.
9
Dated 10 November 2021
Signature_________________________
Acting Senior Coroner for North West Wales
Coroner's Office, Shirehall Street, CAERNARFON, Gwynedd, LL55 1SH
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
CAR.DIFF
UNIVERSITY
PRl FYSGOL
CAER_DY@
Vice-Chancellor's Office
Swyddfa'r ls-Ganghellor
Katie Sutherland
Acting Coroner for North West Wales
Coroner's Office
Shirehall Street,
CAERNARFON
Gwynedd LL55 1SH
31 January 2022
Dear Coroner Sutherland,
Cardiff University
Main Building
Park Place
Cardiff
CF10 3AT, Wales, UK
www cardiffac.uk
Prifysgol Caerdydd
Prif Adeilad
Plas y Pare
Caerdydd
CF10 3AT, Cymru, DU
www caerdydd ac.uk
Re: Mared Thomas Foulkes - Prevent Future Deaths ("your Report") dated
1 Oth November 2021
We acknowledge receipt of your Report to Prevent Future Deaths ("your Report")
dated 10th November 2021, issued under paragraph 7, schedule 5 of the Coroners
and Justice Act 2009 and regulations 28 and 29 of the Coroner's (investigations)
Regulations 2013, following the Inquest which took place on 28th October 2021
into the death of Mared Thomas Foulkes ("Mared") on 8th July 2020 ("the
Inquest").
We set out our response to paragraph 5 and 6 of your Report, namely "Coroner's
Concerns" and "Action should be taken", below.
We are, at all times, very aware of the needs of Mared's family and friends. It is
important to us that none of the information we present here, in response to your
Report, takes away from the recognition of the fact that Mared's death was a
tragedy. We wish to record here again the University's sympathies with, and
condolences to Mared's family and friends.
The University takes seriously the Coroner's concern that the process for the
ratification and release of in-year resit results is complex and confusing. We seek
to explain the position both in general terms, and as it applied to Mared in 2020 in
response to the Matters of Concern detailed below. We then detail the actions we
are taking in response to each of the Coroner's recommended actions.
We are committed to ensuring the process for the release and ratification of in
year resit results is simplified and removes the potential for confusion. The actions
are set out, in detail, in sections 3-5 below and include:
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•
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The removal of potential confusion about the results of in-year resits. The process
for the release of in-year resit results has been reviewed to ensure that all
available results are ratified at the Main Examining Board in June. This means that
students will know the outcome of all assessments they have taken, including in
year resits, and will not have provisional results that are subject to later
ratification at the Resit Examining Board in September.
The custom and practice of using notional mark (e.g. 1% to record an academic
fail) where the student has not met a competency standard has been stopped with
immediate effect.
A review of the published results transcripts is underway which will provide results
for all component parts of a module, clarify the assessment date and attempt
number and confirm any progression, resit requirement or academic award. It will
also seek to improve tone, language and make explicit reference to where students
can access help and support if they are concerned about their results.
These actions will be taken before the release of transcripts in July 2022.
We will ensure our Academic Schools are briefed on these changes and the expectation
that they ensure academic staff are available to students at the time of examination
results to respond to questions, queries and concerns.
I would like to finish by saying that Mared was a valued member of the School of
Pharmacy and Pharmaceutical Sciences and the wider University, and we would like to
again express our sincere condolences to her family and friends at this time.
Yours sincerely,
Vice-Chancellor
Cardiff University
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