Gwent
Coroner Area
Reports: 53
Earliest: Jan 2014
Latest: 6 Mar 2026
83% response rate (above 63% average).
Gareth Williams
All Responded
2022-0270
31 Aug 2022
Aneurin Bevan University Heath Board
Mental Health related deaths
Suicide (from 2015)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
The deceased fell between two non-communicating care teams (mental health and ENT), leading to insufficient support and an inability to resolve his complex health problems.
Action Planned
(AI summary)
Aneurin Bevan University Health Board is expanding a service called 'Adferiad' to include people with other medical and long-term conditions, which will be delivered by a multi-disciplinary team including medical, nursing, and Allied Health Professionals to improve interdisciplinary working between physical and mental health specialties.
Gwynne Samuel
All Responded
2022-0181
17 Jun 2022
Wales Ambulance Service NHS Trust
Emergency services related deaths (2019 onwards)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
The ambulance categorization process failed to account for the clinical risks of a long lie for an elderly patient. A 12-hour delay in ambulance arrival for a serious condition contributed to the patient's death, highlighting systemic risks.
Noted
(AI summary)
The Welsh Ambulance Services NHS Trust acknowledges the coroner's concerns regarding the effect of long lies and systemic pressures. The Trust highlights collaborative work and limitations in insisting on discrete actions beyond lobbying and emphasizing patient safety concerns, while also recognizing the need for systemic change and support from the Welsh Government.
Marvin Rue
Historic (No Identified Response)
2022-0065
3 Mar 2022
Aneurin Bevan University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Repeated failures to conduct Multifactorial Risk Assessments for a known falls risk patient, despite multiple falls and transfers, were not addressed by previous action plans or staff accountability.
Barbara Young
All Responded
2022-0027
28 Jan 2022
Wales Ambulance Service NHS Trust
Emergency services related deaths (2019 onwards)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
A significant 3-hour delay in ambulance response for a severely injured elderly patient highlights ongoing issues in timely emergency medical care, potentially risking future deaths.
Action Planned
(AI summary)
The Welsh Ambulance Service NHS Trust details actions planned including improving utilisation of resources, supporting patients waiting for a response, reviewing the advice provided via 999 and a review of the response availability and capacity. The Trust has taken a review of the Medical Priority Dispatch System (MPDS) codes for Falls to determine if there were opportunities to improve the timeliness of response.
Brian Wareham
All Responded
2022-0010
14 Jan 2022
Aneurin Bevan University Health Board a…
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged without adequate information or support regarding complex medical conditions.
Action Taken
(AI summary)
The Richmond Clinic investigated the matter, met with the Health Board, explored communication options between primary and secondary care, and ensured all clinical staff are aware of them. They have explored obstacles to communication in this case and addressed them. The Health Board has established a single point of access Flow Centre for urgent referrals for admission, launched direct access telephone advice lines, and created a directory of "bypass numbers". The Medical Examiner Service is now operating in Gwent and GPs receive a weekly message from the Deputy Medical Director, highlighting key information and any changes to Secondary Care Services.
Ian Miller
Partially Responded
2022-0001
5 Jan 2022
HM Prison Usk
Ministry of Justice
State Custody related deaths
Suicide (from 2015)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading of prescribed medication, posing a significant risk to prisoner safety.
Action Taken
(AI summary)
The prison updated its prisoner induction process in January 2022 to include information on in-possession medication, the dangers of misusing prescription drugs, and instructions to report concerns. Guidance was issued to staff in January 2022 on identifying risks, amnesty bins have been added to wings, and random medication checks have increased to 10% of the prison population.
Mustafa Abdelkarim
All Responded
2021-0393
19 Nov 2021
Home Office
Other related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Immigration Officers receive an introduction to pursuit policy but lack specific training in pursuit procedures and decision-making during stressful pursuit situations.
Action Planned
(AI summary)
Immigration Enforcement will revise training to provide greater focus on dynamic decision making, with mandatory training for officers delivered from April 2022. Pursuit policy will be incorporated into the operational assurance framework.
Steven Evans
All Responded
2021-0372
3 Nov 2021
Civil Aviation Authority and British Gl…
Other related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
A lack of mandatory radio communication between ground crew and glider pilots meant observed glider problems before launch were not communicated. This ongoing absence of mandatory radio use poses a future risk to lives.
Action Taken
(AI summary)
The BGA reviewed launch signalling, clarified requirements with subject matter experts and gliding clubs, and revised rules and guidance on signalling. The AAIB confirmed the BGA's actions adequately addressed their recommendation. The BGA has clarified launch signalling requirements, including guidance on back-up signalling, through revised rules and guidance. All clubs required pilots and instructors to review safety information, and the AAIB confirmed the BGA's actions adequately addressed their recommendation.
Siwan Smith
All Responded
2021-0306
14 Sep 2021
Taff’s Well Medical Centre
Community health care and emergency services related deaths
Mental Health related deaths
Suicide (from 2015)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Medical centre reception staff failed to adequately assess a distressed patient's urgent mental health needs, not providing an emergency appointment or clinical callback, raising concerns about future risk to patients.
Action Taken
(AI summary)
The practice has implemented pop-up alerts for patients with mental health history, prioritizes appointments for patients with mental health concerns, and uses the e-consult platform to assess mental health risk.
Valmai West
All Responded
2021-0239
13 Jul 2021
Aneurin Bevan University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for patient observations, posing a risk to future patients due to insufficient monitoring.
Noted
(AI summary)
The Health Board reviewed nurse staffing levels which they state were adequate at the time of the incident. They have also commissioned an in-depth review of nurse staffing levels for the Emergency Department (ED) at the Grange University Hospital, and a similar review of medical staffing is also being undertaken.
Lynne Lawrence
All Responded
2021-0158
17 May 2021
Blaenau Gwent County Borough Council
Road (Highways Safety) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
An uneven pedestrian pavement creates a future fall risk, particularly for elderly individuals with reduced mobility.
Noted
(AI summary)
The council investigated the footway condition outside Alma Street and concluded that it does not meet the standard for intervention based on their inspection regime, which exceeds national minimum standards for safety and maintenance defects intervention.
Elizabeth Robinson
All Responded
2021-0072
12 Mar 2021
Aneurin Bevan University Health board
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess patient fall risk correctly, and were unaware of learning opportunities.
Action Taken
(AI summary)
Aneurin Bevan University Health Board has established a Ysbyty Ystrad Fawr (YYF) Health Care Support Worker (HCSW) pool in September 2020 to support enhanced care levels. The Corporate Serious Incident Team is implementing a training programme for Investigating Officers and trialling standardised template agendas for use at Serious Incident investigation meetings.
Alan Jones
All Responded
2021-0079
16 Feb 2021
Aneurin Bevan University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The patient's level of confusion and agitation increased without a multidisciplinary approach to management, and despite being in the highest falls risk category, there was a failure in falls prevention strategy; inadequate supervision contributed to multiple falls, and the ward caring for high-risk patients was staffed at a minimum level without accounting for fluctuations in acuity.
Action Taken
(AI summary)
The Health Board has reported the death to the Health & Safety Executive, developed a dashboard within the Datix Incident Reporting system for falls resulting in significant harm, and incorporated a new section on reporting patient falls into the Standard Operating Procedure for RIDDOR.
John Berrow
All Responded
2021-0080
7 Jan 2021
Specsavers UK
Other related deaths
Concerns summary (AI summary)
An optometrist failed to recognize a critical sign of intracranial pressure, lacked proper reference tools, and there was no system for disseminating clinical incident learning.
Action Planned
(AI summary)
Specsavers will commission a specialist optometrist or neuro-ophthalmologist to deliver training materials (concentrating on this topic) which will be recorded and disseminated via an online webinar available to all professional staff within the Company. They also hope to make the training available for the wider optical community.
Rory Attwood
All Responded
2021-0086
10 Dec 2020
Aneurin Bevan University Health Board
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Mental Health related deaths
Suicide (from 2015)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious incident reviews, which limits learning and partnership working for community-supervised patients.
Action Taken
(AI summary)
Aneurin Bevan University Health Board has reviewed its practices regarding GP involvement in Serious Incident Reviews and devised a process and pro forma to ensure GPs are invited to participate. The Mental Health and Learning Disabilities Division is also reviewing processes to ensure third sector and other organisations' involvement is recorded sooner.
John Tucker
Historic (No Identified Response)
2020-0266
19 Nov 2020
Gwent Police
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
There are concerns about the inadequate nature and extent of basic life support and first aid training provided to Gwent police staff, despite their regular contact with unwell or injured individuals.
Alyn Rees
Historic (No Identified Response)
2020-0190
9 Sep 2020
Aneurin Bevan University Health Board
Welsh Ambulance Services NHS Trust
Emergency services related deaths (2019 onwards)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Excessive ambulance waiting times (2 hours) without informing the family of estimated arrival, coupled with significant hospital patient transfer delays, prevented ambulances from being released for other emergencies.
Gareth Williams
Historic (No Identified Response)
2019-0464
25 Nov 2019
Newport County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Safety on a road known for speeding and overtaking would be improved by extending double white lines to restrict dangerous overtaking maneuvers.
Jamie Staley
All Responded
2019-0463
12 Nov 2019
Monmouth County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Lack of signage and relatively easy access points allow pedestrians to inadvertently stray onto the A40 near Gibraltar tunnels, posing a risk of future collisions.
Noted
(AI summary)
Monmouthshire County Council expresses condolences and explains the existing footpath infrastructure. They state that signage did not contribute to the accident, but will continue to work with SWTRA to identify any additional safety measures. Monmouthshire County Council confirms that the South Wales Trunk Road Agent (SWTRA) has installed Pedestrian Prohibition signs on existing signing infrastructure.
Diane Greenslade
All Responded
2018-0401
21 Dec 2018
Aneurin Bevan University Health Board
Welsh Ambulance Services
Community health care and emergency services related deaths
Concerns summary (AI summary)
Inadequate ambulance call categorisation without clinical assessment, failure to escalate after failed contact, and high demand compounded by hospital delays led to significant delays in medical intervention.
Action Planned
(AI summary)
The Health Board reports improvements in ambulance response times and highlights several initiatives to improve the timeliness of releasing crews at the hospital, including practitioners reviewing WAST calls and additional doctors in the Emergency Department. The Welsh Ambulance Services NHS Trust acknowledges concerns and has completed and continues to work on strategic and operational quality improvements in patient safety, including training of Clinical Contact Centre staff, recruitment of clinicians, and improvements to policies and collaborative working; the Trust will also undertake a concerns investigation to address whether the delay had any impact and would welcome an opportunity to meet with the family.
Ellie Clark
Partially Responded
2018-0066
6 Mar 2018
Aneurin University Health Board
Grange Clinic
Community health care and emergency services related deaths
Concerns summary (AI summary)
Failures in care planning, clinical oversight, and triage systems led to delayed and inadequate care. Critical medical information was not prominent, and staff felt unable to challenge decisions, impacting patient safety.
Action Taken
(AI summary)
The Health Board conducted a formal review of the action plan implemented in 2015 and shared lessons learned following the case with GP practices and paediatric consultants. Respiratory pharmacists developed a community pharmacy service to identify patients with outstanding reviews or overusing reliever medication and the ABUHB Medical Director issued further correspondence to all GP practices and paediatric consultants to ensure that lessons learned following this sad case are acknowledged and shared by the GP community
Georgina Lewis
Historic (No Identified Response)
2016-0460
22 Dec 2016
Aneurin Bevan University Hospital Board
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Concerns included the lack of family notification or consultation regarding discharge, absence of a discharge plan or follow-up support, and no contemporaneous GP notification. These failures left the patient without crucial support post-discharge.
Thomas Black
Historic (No Identified Response)
2015-0467
24 Nov 2015
HMP Usk
State Custody related deaths
Concerns summary (AI summary)
Prison staff failed to seek timely medical advice for a clearly unwell prisoner, indicating a critical lapse in duty of care and health monitoring.
Rachel Hollister
Historic (No Identified Response)
2015-0288
21 Jul 2015
Aneurin Bevan University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report identifies that medical staff and porters either did not follow or were unaware of the Health Board's Protocols.
Joanna Greensmith
All Responded
2014-0380
21 Aug 2014
South Wales Trunk Road Agent
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Road safety was compromised by a failure to treat the surface according to adverse weather plans and by the Route Steward not reporting hazardous running water across the carriageway.
1 response
from South Wales Trunk Road Agent