On 29th March 2018 ! commenced an investigation into the death of Pamela Moran: The investigation concluded at the end of the inquest on 11th November 2019. The medical cause of death is 1a) acute on chronic intracranial bleed 2 anticoagulation for metallic mechanical heart valve, osteoporotic fracture of neck of femur and elbow (not operated on) ischaemic heart disease, dementia The conclusion of the inquest as how Mrs Moran came to her death was accidental death.

deceased was Pamela Moran and she was pronounced dead on the 17th of March 2017 at Morriston Hospital, Swansea: The cause of death was an acute on chronic intracranial bleed caused by a fall in the parking area of Tonna Hospital, where she suffered a fracture to her right hip, right elbow, and a head injury: Pamela was transferred to Morriston Hospital where the fractures to the hip and elbow were diagnosed. A request was made for a CT scan to assess the extent of the head injury however this was refused as a fractured hip and elbow do not fulfil the criteria for a CT head scan to be performed. It was not explained during that conversation however that Pamela was on warfarin, and had suffered a previous chronic subdural haematoma three months prior: This information would have brought Pamela within the criteria of a CT head scan The CT head scan was eventually performed on the 16th of March 2017 , To The some 40 hours after admission and after Pamela had begun to experience neurological signs. The CT scan showed an acute on chronic intracranial bleed, by which time the only treatment options being palliative care. It was found that there was a total of three missed opportunities (including the above) to ensure that the CT scan was done. It could not be stated whether an earlier CT scan in this case would have prevented death. The circumstances relating to Pamela's fall at Tonna Hospital has been the subject of a Serious Incident Review by the Health Board and steps have been in place to avoid a reoccurrence. Accordingly this report is not concerned with the circumstances surrounding_the fall but in respect of thematters that arose following_it:

In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation have the power to take such action.