Dear Miss Knight,
1.1 We acknowledge receipt of your Report to Prevent Future Deaths ("your Report") dated 1st March 2019, issued under paragraph 7 , schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 following the Inquest which took place on 27th February 2019 into the death of Jack Jack" on 25th October 2018 ("the Inquest" ) .
1.2 We set out our response to paragraphs 5 and 6 of your Report, namely "Coroner's Concerns" and Action should be taken" below.
1.3 Firstly, by way of background, and to set a context for our response, we wish to provide an explanation of the support we offer students at Cardiff University ("the University" ) . We seek to explain and clarify the purpose of the services we provide, some of the operational context within which our Student Support and Wellbeing services work and the approach to personal tutoring at the University_ We also will set out here the University policy on personal tutoring; and local pastoral care in the School of Healthcare Sciences. We then address each of the specific points raised in your Report.
1.4 We are at all times very aware of the needs of Jack'$ family and friends: It is important to us that none of the information we present here in response to your Report takes away from our recognition of the fact that Jack'$ death was a tragedy. We wish to record here again the University' $ sympathies with and condolences to Jack'$ family and friends: RECEIED 0 9 APR 2019 QAA AnNTv Qu5rFrzes INVESTORS Athera Registered Charity; no. 1136855 UX Quxllty Arsund Hcet0 Kendahdea IN PEOPLE Elusen Gofrestredig, 1136855 10I7 Bronze Award skrd AnhrtdY OU May thif

2. Student Support at Cardiff University Context
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 Universities UK'$ Stepchange' 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 site for the Stepchange framework and later in 2019 we will launch a new strategy and action plan for mental health, founded o 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. This will enable them to work in increasingly more accessible and more innovative ways:
2.2 The University has a published Safeguarding Policy? which is overseen by the University Safeguarding Group: Those in the most senior roles within the University take an active interest in student mental health and presentations on the subject have been made in the last six months at University Senate, University Executive Board and the University Council, which is our governing body:
2.3 We provide a comprehensive range of Student Support and Wellbeing services to help students make the most of student life and remove barriers to them achieving their best possible outcome: This includes free, impartial, non- judgemental and confidential advice on a wide variety of matters? , including mental health and wellbeing: Our Counselling and Wellbeing services are offered to students experiencing personal, emotional or psychological difficulties (and) provide guidance , self-help materials, books and referrals for further specialist support "" Our Disability and Dyslexia Service also includes Mental Health Advisers who work primarily with students with managed, normally long term, mental health conditions to ensure adjustments are made under the terms of the Equalities Act 2010.
2.4 Alongside this we offer a wider range of services to support our students beyond direct mental health specific support. This includes the wider Disability and Dyslexia Service, Advice and Money Service, Student Occupational Health and services which help our students develop transferrable skills and prepare them for the work place. With the exception of mandatory health screening for biomedical and healthcare students, engagement with Student Support is not mandatory: WWW universitiesuk ac uklstepchange httpsLwww cardiff ac uklpublic-informationlpolicies-and-procedures/safeguarding (accessed 22 March
2019) https l Iwww cardiff ac uklstudylstudent-lifelstudent-support (accessed on 11 March 2019) https LLwwwcardilfac uklstudylstudent-lifelstudent-support/counselling-and wellbeing (accessed on 11 March 2019) pilot

Students are adults and can choose to use services if they feel would be helpful given their own personal circumstances. We use external measures and client and staff feedback to assure the quality of our student services: Counselling and Wellbeing provision and approach
2.5 Our Counselling Service is accredited by the British Association of Counselling and Psychotherapy ("BACP") . In common with most counselling delivery in University settings, the provision at the University exists to enable students to study effectively and achieve to the best of their ability. It is not there to provide therapy for self-development, as ongoing support throughout the student'$ university journey or as an emergency service. We seek to offer students access to prompt, reliable and equitable service. Our approach provides a forward-thinking stepped care service for students, offering student choice:
2.6 The counselling model our service uses follows the Talmons definition of counselling where the counsellor seeks to "help people to help themselves" _ To this end, in addition to one to one work, the service offers various self-help and guided self-help packages, psycho-educational material, online programmes, and iibrary of books and e-books: We offer courses and groups including mindfulness, emotional resilience and a therapeutic group on interpersonal relationships based on a programme developed by the World Health Organization and Columbia University: Accessible workshops are offered to address one off presentation on common difficulties. The different elements of the service can be accessed by the student as appropriate: they are not linear.
2.7 Starting from this approach, management seek to offer a greater Variety of therapeutic approaches, giving the client choices in their therapy: This provides scope for our Counselling Service to offer something immediate, but at the same time avoiding the false impression of the service as an emergency response operation:
2.8 The approach to one to one work we use is evidence based and well established. It comprises an initial 90-minute 'therapeutic consultation' _ This is a combination of assessment and a first counselling session. We offer ongoing 50 minute counselling sessions thereafter as appropriate: There is a service level approach to preferring solution-focussed Brief Therapy ("SFBT") techniques: During the initial 90 minute appointment our counsellors explore difficulties with the client, work together to identify strategies for making improvements. seek to draw on the client'$ inner strengths and resources; also provide self-help resources for clients to take away and use in their own time. These resources are emailed to the student. Discussion will normally take place which empowers the student to engage and request if want further sessions: Talmon, M,, Single-session therapy: Maximizing the effect of the first (and often only) therapeutic encounter; San Francisco USA: Jossey-Bass (1990) they they They they they.

2.9 There is much evidence that brief therapy is effective for most clientse. If further support is needed, further counselling sessions are available. Normally four sessions would be offered as standard, but these could increase to up to ten in some circumstances: The aim is to empower clients, moving them out of feeling stuck in problem or situation, into a direction of finding solutions, and using available resources in the most effective way possible.
2.10 Prior to accessing the support we have described above, students can attend widely promoted daily drop-in service, offering a brief 10 to 15 minute meeting with therapist. This may be to gain a coping mechanism, ask a question, take away self-help resource and/or begin to access the range of activities set out above_
2.11 We also offer Wellbeing appointments, which provide a practical approach to working through problems focused on information-giving, self-help strategies, action-planning and goal-setting: A Wellbeing Practitioner performs a different role to a counsellor, though they will often use counselling skills. will work with a student to identify specific strategies to try, and offer the opportunity for the student to return to review progress. This is normally a 30 minute appointment Access is flexible to suit the student'$ needs and can be face-to- face, via the telephone or online via webcam, email or instant messaging: Access to other services
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'$ Aid and 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: Targeted work
2.13 As part of our efforts to engage with the national discussion around student mental health; during Summer 2018 the Director of Student Support and Wellbeing contributed to a roundtable discussion and launch of a report by Student Minds UK? which set out a range of challenges to UK Universities specifically around supporting the Mental Health of LGBT+ students: At the University we recognised the potential for there to be barriers to some of our LGBT+ students achieving their best: Therefore, in September 2018, Student Support and Wellbeing initiated For example: 'The Cardiff Model of Short Term Engagement' , Short Term Counselling in Higher Education: Context Theory and Practice; Cowley, J, Groves, Vz Mair, D. (Ed:) (UK:2016); pp.109-126; also McKeel, 1996; http:/ /www.solutionsdoc co.uk/mckeel html [accessed 3/10/2014] https lLWww studentminds org_uk/lebtaresearch html (accessed 8 March 2019) They drug

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_
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 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:
2.15 This work was begun to Jack's death in October 2019. However, given the proximity in time between Jack'$ death and the suicide of two other students who identified as LGBT+ in the Spring of 2018 we proactively contacted Public Health Wales to consider whether there was more we could do. We have since taken a number of actions to enhance access to support for LGBT+ students: Suicide Safer
2.15 The University was identified in a practice case study in Suicide Safer Universities8 , 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. 3 . Personal Tutoring Arrangements at the University
3.1 The University' $ regulations state that our Academic Schools should clearly communicate to students at the beginning of each academic year the frequency of meetings they can expect and how the personal tutor system operates locally in that School. We state in our regulations: "As @ minimum, meetings with individual students should take place at least once per semester, although the expectation is that, for first year students in particular , may be significantly more frequent: Personal Tutors should initiate the contact with students and meet with their students within the first two weeks of the first semester. Meetings in the second semester should take place within the first five weeks In line with the University's Student Attendance and Engagement Procedures, Heads of School will ensure that records to confirm https llissuu comluniversitiesukldocslguidance-for-sector-practitioners-o/12ff8e315132110/64400960 (accessed 23 March 2019) prior good they P.21

or otherwise that a student has made contact with hisl her Personal Tutor a minimum of once each semester are maintained: "9
3.2 In addition, in the School of Healthcare Sciences, there is a mandatory meeting before and after each professional placement a student undertakes:
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.
3.4 The University is a very large and diverse organisation: As a consequence, the precise approach to Personal Tutor arrangements does differ depending on the Academic School and what is appropriate to the academic programme concerned.
3.5 The Code of Conduct sets out the Roles and Responsibilities of Personal Tutors: Personal Tutors are not there to provide professional mental health support; Your report rightly identifies that a personal tutor should signpost such cases to Student Support or a medical professional, which do. Indeed, the Code of Practice expressly states that: "Personal tutors will_ Listen to students experiencing difficulties and provide professional guidance that is within their competency and experience and direct them to the appropriate source of support in a timely and professional manner.
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 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 on the University's policy and approach to Personal Tutor support:
3.7 Current practice is that Personal Tutor meetings are managed and recorded through the University's Student Information Management System ("SIMS") which provides a means to monitor and track engagement in accordance with the policy: https Llintranet cardiff ac uklstaff teaching-and-supporting-students/supporting-study/personal-tutorskrole and-responsibilities/code-of-practice (accessed on 27 March 2019) they to,

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:
4. Response to specific points raised in your Report Matters of Concern 5 (1}: Provision f_sufficient services within Cordiff 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 @fter 4 gppointments students must reapply_This presents obvious difficulties for students with longer _term needs;
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 statutory care provider with the powers and resources that this affords:
4.2 Equally we understand that students do experience personal and mental health crises during their studies and may not know where to turn. Individuals may also present to University staff in unconventional ways due to the nature of the crisis face. We therefore work to ensure ur students are enabled to access services at these times and are safely supported to do this: At the University, as in many other higher education institutions, we are aware of a growing number of students who are coming forward indicating they are experiencing mental health crises. We are therefore evaluating how we approach management of these sorts of personal crises and anticipate making a series of changes during 2019. We therefore do not accept that provision is inadequate under the terms of what our services set out to do. We are content to express here our broad concerns about access for young people, especially transient higher education students, to NHS mental health resources: 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. 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.
4.3 We are not clear on what basis a conclusion has been drawn that there is "patchy provision of pastoral support by Personal Tutors" or what evidence is being relied upon to support the wide-ranging suggestions made under heading 5(2). No evidence was called from the University in relation to these issues at the Inquest and certainly, we do not accept what is being stated and respectfully refer you to the comments in paragraph 3 above in relation to the personal tutoring they . Also,

arrangements at the University and in particular the role and training of personal tutors.
4.4 Our staff work hard to promote the student support we offer through multiple channels to avoid students "slipping through the in the context of the support we provide and that which is provided by the NHS. In addition to the Personal Tutor system the many avenues we use to do this include professional service staff in Academic Schools, multi-media advertising and awareness campaigns, and other face to face staff such as Students' Union staff, trained student peer mentors and others: Many students who use our Student Support Services do so on a self- referral basis. Actions that should be_taken 6 (ai '(the_University may wish to consider) the resourcing_provision and aim of_ counselling and wellbeing services:
4.5 We have set out above the Student Support Services we offer to help students perform to the best of their ability, and as a result get the best possible outcome from their higher education experience. This is a common approach to the delivery of counselling and wellbeing services in a university, and we are very clear about the purpose of our services. As we have noted above we do not seek to operate an emergency response service. However, when a student is experiencing a crisis we will assist them in seeking appropriate help, prioritising their safety and that of those around them:
4.6 The nature of the academic year means there is far greater variance in demand through the calendar year for a student support service compared to provision in the NHS or workplace setting: Therefore, specifying a consistent position for waiting times can be complex
4.7 We allocate a budget of around E750,000 per year to student counselling and wellbeing specifically, and during both 17-18 and 18-19 we have increased the already high proportion of this allocation to staff time spent with students in these services. Demand continues to grow at a significant rate for this type of support in the University, as it does across the country: Around 95% of universities reported significant growth in demand in 2016-1710.This is broadly reflected in demand for our services, and we are our best to meet that demand: However, the demand on universities must be seen in the context of reductions in NHS mental health budgets over the past nine years and the consequences of this:
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 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: https:] Iwwwipprorg/publicationsInot-by-degrees (accessed 12 March 2019) net" doing goals

4.9 During September 2018 the waiting time for a 90 minute Therapeutic Consultation was 12 days, and up to 21 days for ongoing counselling. During October 2018 the maximum was 16 days for Therapeutic Consultation, and 20 for ongoing counselling: We have included an extract from the Student Intranet which explains to students what they can expect at Appendix B.
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 E150,000 additional investment for new posts to risk assess, triage and manage these situations: This in turn will release 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. Actions that should be taken 6 (b): '(the University may wish to consider) the training_of_Personal Tutors in relation to identifying real concerns with students:
4.11 We have noted this action in the University's ongoing review of our Code of Practice for Personal Tutors. We will also reflect on this issue as we address improvements to personal tutors training: In this context this is a helpful contribution to that process. As an action in response to this report our Centre for Education and Innovation have been made aware of the concern raised and this will be added to the review considerations.
4.12 However we would wish to emphasize the defined role, responsibilities and purpose of Personal Tutors in the University. The focus of the role is on the provision of academic advice and guidance, in an approachable and friendly manner as set out in our current Code of Practice. This prioritises accessibility, listening and awareness of where to refer situations outside the Personal Tutor'$ knowledge and experience_
4.13 In the case of the School of Healthcare Sciences most recently, and pertinent to the content of your Report, the role of the Personal Tutor was covered in a 'Supporting Assessment and Feedback Workshop' during July 2018. This was reiterated in the School'$ Assessment and Feedback Strategy for 2018/19. It is a requirement in the School that students are informed who their personal tutor is during induction week and contact is made with students within the first two weeks. This is communicated to students in person at induction at through the Student Handbook: Actions that should be taken 6 (c): (the_University may wish to consider) the gccountability of Personal Tutors for contacting students and vice versa and the frequency with which meetings take place: days - staff

4.14 We refer you to paragraph 3.7 above in relation to the way in which Personal Tutor Meetings are managed and recorded: As explained above the breadth and scope of the programmes we provide means that Personal Tutors do not operate in the same way from School to School; though we do set a minimum standard in our Code of Practice.
4.15 In the case of the School of Healthcare Sciences, within which Jack was a student, evidence in fact suggests that it goes much beyond the levels of contact indicated in your Report:
4.16 We hope you can appreciate from this response that we offer a comprehensive range of support services for our students, operating to an evidence based, clearly defined approach. We recognise that like other universities, our services are facing increased demand. We are not complacent, and we are putting in place resources, and working with partners, to help us to meet this demand We are also conscious of the need to always improve and develop our educational provision, including our approach to personal tutoring, and we have set out here some of the measures we are taking to do this We take our duty to prevent harm extremely seriously and will continue to prioritise work which helps us to this end:
4.17 Jack's death is a tragedy and a profound loss to his family, friends, the School of Healthcare Sciences, and the wider University and NHS communities in Cardiff.