Carmarthenshire & Pembrokeshire
Coroner Area
Reports: 23
Earliest: Sep 2013
Latest: 5 Jun 2025
70% response rate (above 62% average).
Richard Osman
All Responded
2025-0311
5 Jun 2025
Stewarts Law
Department for Transport
European Aviation Safety Agency
+1 more
Other related deaths
Concerns summary
Cockpit fire/smoke procedures need a full review for oxygen fire recognition and protective equipment. International civil aviation investigation protocols require amendment for state participation and final report timelines.
Action taken summary
The Department for Transport stated that ICAO has already amended Annex 13 (SARP 5.1.3) to allow states to request takeover of investigations if no report is produced within thirty days. …
Christopher Brazil
All Responded
2025-0198
23 Apr 2025
Department of Health and Social Care
Department for Culture, Media and Sport
Alcohol, drug and medication related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary
Unregulated online pharmacies easily sell prescription-only and controlled drugs, lacking patient verification, dosage guidance, and safeguards against misuse, exposing vulnerable individuals to unsafe medications.
Action taken summary
The Department for Science, Innovation and Technology states the Medicines and Healthcare products Regulatory Agency (MHRA) has already taken enforcement action against the referenced websites, with o
Susan Williams
All Responded
2024-0461
20 Jun 2024
NHS Wales
Hywel Dda University Local Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary
The In-Patient Medication Administration Record and A&E Record Card fail to document medication prescription times, only administration. This lack of recorded prescription times hinders checks for timely delivery and cross-referencing.
Action taken summary
The Welsh Government notes that the ongoing rollout of Electronic Prescribing and Medicines Administration (EPMA) systems to all Welsh hospitals by the end of 2025 will address both concerns by …
Roy Evans
All Responded
2021-0112
16 Apr 2021
Ceredigion County Council and Bucher Mu…
Accident at Work and Health and Safety related deaths
Other related deaths
Road (Highways Safety) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary
A vehicle should have been taken out of service due to multiple safety defects, including worn tyres and a fractured arm pivot, but remained in use after an inspection.
Michael Davies
All Responded
2019-0134
25 Apr 2019
Welsh Ambulance Trust
Emergency services related deaths (2019 onwards)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary
The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.
Gerwyn Thomas
All Responded
2018-0342
6 Nov 2018
West Wales General Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Insufficient dietetic staff, lack of mandatory training for nutritional assessment tools, and nursing staff's failure to act on doctor referrals to dietetics led to inadequate patient nutrition.
Herbert Francis
All Responded
2018-0242
26 Jul 2018
Department for Transport
Road (Highways Safety) related deaths
Concerns summary
The junction lacks adequate road markings, early warning signs, and properly positioned speed limit signs. Filter lanes are too short, and there's no westbound filter, increasing road safety risks.
Michaela Haines
All Responded
2017-0415
23 Nov 2017
Dyfed-Powys Police
Police related deaths
Concerns summary
The police STORM report was not consistently updated, leading to uncertainty about completed actions, potential loss of evidence, and duplicated work, highlighting a need for better training.
Cerith Pugh
All Responded
2016-0271
27 Jul 2016
Hywel Dda University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Referrals to consultants were inappropriately handled by middle-grade doctors, and essential liver function tests were declined due to a rigid demand management policy, lacking a mechanism for clinical override.
Mihangel ap Dafydd
All Responded
2016-0169
3 May 2016
West Wales General Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary
Windows in Morlais Ward service user areas are not ligature-free, posing a safety risk, and planned remedial work has not yet been completed.
Margaret Hions
All Responded
2016-0047
12 Feb 2016
West Wales General Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.
Efan James
All Responded
2015-0158
23 Apr 2015
Welsh Assembly Government
Child Death (from 2015)
Concerns summary
The Welsh Assembly Government's advice on reducing cot death is confusing, specifically regarding the ambiguous "very tired" criterion for parents considering bed-sharing.
Laura Hill
All Responded
2015-0092
20 Feb 2015
Hywel Dda University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
There was a breakdown in information transfer between child and adult mental health teams, coupled with ward understaffing and critical training needs regarding Section 136 procedures, absconding, and powers of detention.
John Shelley
All Responded
2014-0352
31 Jul 2014
Hywel Dda University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
The inquest revealed unstated circumstances that pose a continued risk of future deaths if action is not taken.
Robert Jones
All Responded
2014-0190
20 Mar 2014
West Wales General Hospital Glangwili C…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary
CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.
Lee Bonsall
All Responded
2014-0044
31 Jan 2014
Department of Health and Social Care
Service Personnel related deaths
Concerns summary
Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it an unviable treatment alternative.
Action taken summary
The Department of Health disputes that national guidelines restrict the repeat prescribing of citalopram, stating they are not rules and prescribing remains a clinical responsibility. They will, howev