Cardiff University has been told to change the way it sends out exam results after a student took her own life when she was wrongly told she had failed and could not progress to the third year of her course.
21-year-old Mared Foulkes from Anglesey was sent an email with the results on the morning of July 8 2020, but it did not include the mark for the re-sit she had taken and passed.
Later that night, Mared died after falling from Britannia Bridge.
An inquest in Caernarfon on 28 October, 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.
One email stated she had failed with a score of 39% when in fact she had passed the exam with 62%.
The 39% 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.
Her death was ruled as suicide.
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Katie Sutherland, the senior coroner for North West Wales, has since issued a prevention of future deaths report and written to the university demanding it re-thinks when, and with what wording, exam results are issued to students.
Ms Sutherland said Cardiff's system was "complex, confusing and at times capable of appearing misleading".
In her report she wrote: "Mared had failed one Professional Skills Assessment during the second year of her degree 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."
Ms Sutherland recommended that the university included ratifying examination results at the first available opportunity, including the word 'pending' where marks have not yet been ratified, providing staff with training on how to explain the assessment processes, and providing additional support to those who are going to receive a fail, particularly vulnerable students.
She said: "In my opinion there is a risk that future deaths will occur unless action is taken."
Cardiff University must now respond to the coroner by January 5 2022 explaining what action will be taken or else explaining why they will not be taking any action.
Professor Mark Gumbleton, Head of School, told the inquest in October there were "lessons always to be learned" following Miss Foulkes's death in relation to the "confusing" way students receive their results.
Her family described her as a “loving daughter” and an “amazing friend and sister”.