Inquest Leads To University Suicide Prevention Report
With Libertas Barrister Chaynee Hodgetts
Libertas Member Chaynee Hodgetts has contributed to a Policy Report for members of the “For the 100” campaign, suggesting stronger strategic safeguards need to be implemented across Higher Education Institutions (HEIs), to seek to prevent avoidable University student deaths by suicide.
This work follows on from Ms Hodgetts representing the Foulkes family (who also contributed to the Report). The family lost their daughter, Mared Thomas Foulkes, by suicide, after she received an automatically generated issue of an inaccurate “degree fail” exam transcript on her Pharmacy degree course at Cardiff University.
Ms Hodgetts became involved with the case, having initially learned, in a Christmas card from a mutual contact, of the family’s struggle to persuade the Coroner that the University should be made an Interested Party (IP) at the inquest – and that the Coroner was not, at that early stage, persuaded as to the potential relevance of the University result received by Mared.
Upon becoming instructed on the case, through Mr Ian Winrow of Winrow Solicitors, Ms Hodgetts undertook a full review of the evidence, sought further disclosure, and made written representations in advance of the Pre-Inquest Review (PIR) that Cardiff University should be an Interested Party (IP) at the inquest, because the automatically computer-issued (and factually incorrect) fail result appeared to be directly linked to events involving Mared on the day she died. Tragically, she never knew that the computer-generated result was wrong, and that she had in fact passed.
Following Ms Hodgetts’ submissions at the Pre-Inquest Review (PIR), the Coroner ordered Cardiff University must become an Interested Party at the inquest, held in 2021. After several days of evidence at inquest, still represented by Ms Hodgetts, the family learned more – with the Coroner returning a Conclusion of suicide, and directed the University had to improve its exam results policy and provide better pastoral care. Ms Hodgetts’ further representations at inquest, that a Regulation 28 Preventing Future Deaths Report was necessary, were acted upon by the Coroner.
The Coroner, in the resultant Regulation 28 Preventing Future Deaths Report, ruled: “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)… 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… The sharing of examination results and how examinations are marked is complex, confusing, and at times capable of appearing misleading.” The Coroner ruled that Cardiff University were statutorily required to review their policies for the issuing and ratification of exam results, and the provision of proper pastoral support around the time of results day, and made specific recommendations. The University later provided a statutory response to the Coroner, and apologised publicly to the Foulkes family.
Mared’s family have since joined the “For the 100” campaign, along with other families seeking improved suicide prevention measures for students in UK Universities.
The latest media reporting on the new Policy Report [A. Griffiths, E. Roberts, M. Flynn and C. Hodgetts (with I. Foulkes and G. Foulkes), “The Case for Better Student Suicide Prevention in Higher Education: Some Observations from Wales” (August 2024, Policy Paper)] can be found here:
https://www.dailymail.co.uk/news/article-14068143/student-killed-failed-exam-university-tragedy.html
Selected previous media reports on the PIR and inquest can be found here:
https://www.bbc.co.uk/news/uk-wales-59080475
The Coroner’s Regulation 28 “Preventing Future Deaths” report, made in respect of Cardiff University, can be found here: https://www.judiciary.uk/wp-content/uploads/2021/11/Mared-Foulkes-Prevention-of-future-deaths-report-2021-0378_Published.pdf
The “For the 100’” campaign is a group of parents and families calling for better duty of care for students from Universities, with the “100” signifying the annual number of student deaths by suicide in Universities: https://www.forthe100.org.uk/
