A coroner has demanded a university changes its exam results policy and provides more pastoral care after a student killed herself because she was wrongly told she had failed her exams.
Mared Foulkes, 21, from Anglesey, north Wales, died on July 8 after falling from the nearby Britannia Bridge over the Menai Strait.
The Cardiff University student was in her second year studying pharmaceuticals, having worked part-time in a pharmacy for several years.
An inquest in Caernarfon last month was told Miss Foulkes had received an automated email from the university hours before her death saying that she had failed her re-sit exam and would not be moving on to third year.
One email stated that she had failed with a score of 39 per cent when in fact she had passed the exam with 62 per cent.
The 39 per cent related to a previous exam she had failed on March 26 and not the re-sit exam she had taken – and passed – on April 24.
Now, Katie Sutherland, the acting senior coroner in North West Wales, has issued a Prevention of Future Deaths report, urging changes from the university.
A senior coroner has demanded Cardiff University changes its exam results policy and provides more pastoral care after dedicated pharmacy student Mared Foulkes (pictured) killed herself because she was wrongly told she had failed her exams and could not finish her degree
Witnesses described how Mared ‘disappeared’ from the bridge where she took her own life
In the report, the coroner described the results process as ‘complex, confusing and at times capable of appearing misleading’.
Calling for this process to be simplified, Ms Sutherland also urged the university to ensure personal tutors were available to students who had potentially failed exams so they could help them through the ‘complex and confusing assessment and results process’.
Cardiff University must legally respond to the report within 56 days detailing action taken or proposed to be taken and setting out the timetable for any changes.
If they fail to make any changes in response to the report, the university is duty-bound to explain why no action is proposed.
The report came after an inquest found Mared had taken her own life under the belief she would not be able to progress to her third year of university.
At the inquest, held last month, her mother, Iona Foulkes, said that she felt it was ‘plain and simple’ that her daughter’s actions that day were a ‘direct result’ of receiving a misleading email from Cardiff University.
Mared Foulkes was described as a dedicated student who would have believed ‘her dreams and aspirations were finished’ when she received the email telling her she could not progress
Mrs Foulkes said: ‘She received an automatic email – there was nothing personal – no phone call, nothing.
‘She believed she had failed and the email said she could not progress with her degree.
‘She was devoted to her course and to her work in the pharmacy, she would have been horrified.
‘She would have felt like all her dreams and aspirations had finished with that sentence – for a 21-year-old it’s unbelievable.’
The mother-of-two said she felt that the course tutor should have been in contact with Miss Foulkes directly regarding the results and believes parents of students should be made aware of exam results dates.
‘Parents should not have to drive by their daughter’s grave on the way to and from work’
In a statement shared after Mared’s inquest, her parents Iona and Glyngwn Foulkes described the way the university communicated its exam results as ‘wanting’ and ‘barely understandable’.
They added: ‘ It has added an extra weight to our sadness.
‘We are sad that the outcome could and should have been so different.
‘Now we are left with memories in photograph albums, memories of her kindness and other fine qualities.’
‘Parents should not have to drive by their daughter’s grave on the way to and from work.
‘We are learning to live without Mared but the task is heartbreaking and we remain very poor students.
‘We are not the first parents to express disbelief at the poor communications of universities with students and we are sorrowful that we won’t be the last.
‘Our hopes for Mared matched her own ambitions. We entrusted her learning and well-being to the university.
‘Since Mared’s sudden death we have lived through a harrowing time of grief and mourning. The shock and aftershocks of her death remain with us.
‘We never imagined that we would outlive our much-loved daughter and first-born or that her brother would become our only child.’
They said they hoped the coroner’s report would prevent the deaths of other students.
When the Covid-19 pandemic started Miss Foulkes had been forced to complete her studies online.
The inquest heard how Miss Foulkes had gone to work at Rowlands Pharmacy in Caernarfon that morning having been for a run and had returned home to have dinner with her parents and brother at around 6pm.
She then told her mother she was going to Tesco in Bangor to get ingredients to make a cheesecake the following day.
Shortly after leaving the house Miss Foulkes drove to Britannia Bridge, which links Anglesey with Bangor.
She was seen leaving her vehicle and walking to the side of the bridge and ‘disappearing’.
Mrs Foulkes said that her daughter made no mention of the fact that she was due to receive results that day or that she had received an email saying that she had not been successful.
She also said that Miss Foulkes showed no signs of feeling down in the lead up to her death but had been upset by the recent death of her grandmother.
Anwen Jones, who witnessed the incident while she was driving onto Anglesey with her 10-year-old son, said Miss Foulkes appeared to show ‘no hesitation’ in her actions.
Ms Jones said: ‘She just went up and over in a split second – there was no stopping and thinking.
‘She just disappeared.’
The emergency services were called by members of the public but sadly Miss Foulkes was pronounced dead at the scene.
A post-mortem examination later revealed that she sustained a lethal head injury in the fall.
Prior to taking her own life, Miss Foulkes had texted one of her housemates about the results saying: ‘I did c**p.’
The inquest also heard how Miss Foulkes had sought help from student support services prior to her death but at that time it was not believed that she posed a risk to herself or others.
Acting senior coroner Katie Sutherland concluded that Miss Foulkes had intended death to be the outcome of her actions.
Recording a conclusion of suicide, Ms Sutherland said: ‘Mared had not sought any help from a GP regarding low mood and there were no suicide notes.
‘She did not report suicidal thoughts when she sought assistance from student support in 2019 but did appear distressed and admitted that she was engaging in self harm.
‘Evidence suggests that she put herself on the ledge and walked with determination from her car to the ledge.
‘There is no clear evidence whether she jumped but I do feel she took herself off the bridge by stepping off. I don’t consider this to be a cry for help.
‘I do consider that she had the intent to end her life and will return a conclusion of suicide.’
Parents Glyngwyn and Iona Foulkes, speaking after an inquest in Caernarfon into the death of their daughter, said they hoped the coroner’s report would prevent other student’s deaths
In the Prevention of Future Deaths report, the coroner wrote: ‘Mared had failed one Professional Skills Assessment during the second year of her degree (2019/2020) and had undertaken a re-sit 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.’
Calling for action by Cardiff University to prevent further tragedies, the coroner urged the ratifying of examination results at the first available opportunity, in June, where a student has a provisional pass following a successful re-sit of an initial failed Professional Skill Assessment (or equivalent in other schools or colleges).
She suggested amending wording on exam notification correspondence to students to include ‘pending’ results, clarifying which exam board round (June or September) would confirm the results and clarity on assessment and ratification processes.
In addition, the acting senior coroner said there should be additional and ongoing training to school staff on the clarity of explanation to students of assessment processes and extra support to students where they are to receive a ‘fail’.