Mared Foulkes

PFD Report All Responded Ref: 2021-0378
Date of Report 10 November 2021
Coroner Katie Sutherland
Coroner Area North West Wales
Response Deadline ✓ from report 5 January 2022
All 1 response received · Deadline: 5 Jan 2022
Response Status
Responses 1 of 1
56-Day Deadline 5 Jan 2022
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

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.

Coroner's Office, Shirehall Street, CAERNARFON, Gwynedd, LL55 1SH
Responses
Cardiff University
31 Jan 2022
Response received
View full response
Dear Coroner Sutherland, 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: = THE QUEEN'S Athena ANNIVERSARY PRIZES 0, INVESTORS ' SWAN UK Quality Assured Registered Charity No. 1136855 IN PEOPLE 20]5 Silver Award Skrwydd Ansawdd y DU Elusen Gofrestredig Rt1if. 1136855

• 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.
Action Should Be Taken
(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'
Report Sections
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).
Copies Sent To
2. Head of School of Pharmacy and Pharmaceutical Sciences
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.