South Wales Central

Coroner Area
Reports: 182 Earliest: Aug 2013 Latest: 27 Feb 2026

71% response rate (above 62% average).

Response Status
Responded 130 Historic 45 Pending 5
AI Classification
Action Taken 36%
Action Planned 18%
Noted 9%
Disputed 36%
Based on 11 classified responses
Top Categories
Wales prevention of future deaths … (90) Hospital Death (Clinical Procedure… (79) Road (Highways Safety) related dea… (23) Suicide (from 2015) (21) Mental Health related deaths (18)
Quarterly Trend
Category Breakdown
How does this area compare?
vs Wales average: +104 reports · +6pp response rate
vs national average: +99 reports · +9pp response rate
182 results
Summer Mant
Response Pending
2026-0118 27 Feb 2026
Cardiff & Vale University Health Board Department of Health and Social Care Velindre University NHS Trust +6 more
Child Death (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior doctors in a time-critical situation.
Helen Patching, Rachael Patching and Corey Longdon
Response Pending
2026-0081 9 Feb 2026
Natural Resources Wales Powys County Council Rhondda Cynon Taf County Bouorgh Council +2 more
Other related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency services' response times.
Ryan Harding Prevention of future deaths report
Response Pending
2026-0054 4 Feb 2026
Governor of HM Prison Parc
Alcohol, drug and medication related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due to staffing shortages.
Joan Read Prevention of future deaths report
Response Pending
2026-0055 4 Feb 2026
Chief Executive Cardiff & Vale Universi… [REDACTED}
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary A single consultant lacking cross-cover for geriatric perioperative care creates a risk of urgent test results being missed during periods of absence.
Lyn Maher
Response Pending
2026-0053 3 Feb 2026
London SE1 8UG NHS England [REDACTED] Chief Executive Officer (CEO) +1 more
Alcohol, drug and medication related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary Community pharmacists in Wales faced confusion regarding clinical checks and patient confidentiality, and had limited access to crucial drug history via the Welsh Clinical Portal, hindering safe prescribing.
Alexander Lewis
All Responded
2025-0539 24 Oct 2025
Home Office South Wales Police
Road (Highways Safety) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical information, and police training suggested a two-officer crew for safety.
Action taken summary The Department of Transport states there are no specific statutory regulations for the minimum distance single yellow lines must be from a junction, clarifying that it is for the local …
Theo Treharne-Jones
All Responded
2025-0521 16 Oct 2025
Association of British Travel Agents TUI UK
Child Death (from 2015) Other related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical barrier, allowing unsupervised access by a vulnerable child.
Action taken summary ABTA disputes the recommendation for additional security chains on hotel room doors, stating they could create fire safety risks and hinder evacuation, though their existing guidance allows for such m
Pamela Singh
All Responded
2025-0473 18 Sep 2025
Minister for Health and Social Care in …
Other related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary There is a lack of specific practice tools for family and care staff to recognise and escalate acute health deterioration in people with learning disabilities, despite national recommendations for such tools.
Brian Davies
All Responded
2025-0631 17 Sep 2025
South Wales Police HSE
Other related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary The investigation into a domestic explosion was compromised by police disposing of critical debris. There was no understanding of evidence preservation or protocol between police and HSE for such events.
Action taken summary The HSE will raise the coroner's concerns at the WRDP National Liaison Committee, recommend refresher communications to all signatory organisations, provide updates on national training material devel
Gareth Johnson
All Responded
2025-0464 12 Sep 2025
Chief Executive Cardiff & Vale Universi… Cabinet Secretary for Health and Social…
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary Deteriorating hospital infrastructure and critical care capacity issues pose a significant risk, as safeguards against moving critically ill patients may fail under pressure.
Peter Thomas
All Responded
2025-0450 3 Sep 2025
National Institution for Health and Car…
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of over-sedation due to clinicians applying it without adequate guidance.
Edward Funnell
All Responded
2025-0445 2 Sep 2025
Powys Teaching Hospital Board
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary Nursing staff demonstrated a lack of knowledge regarding podiatry referrals for pressure wounds and failed to follow a Tissue Viability Nurse's dressing recommendations, leading to unaddressed issues.
Lewis Petryszyn
Partially Responded
2025-0394 31 Jul 2025
G4S Cwn Taf Morgannwg University Health Boa…
State Custody related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary Policies lack specified timeframes for intervention and support for prisoners at risk of substance misuse, leading to delayed care and intervention from the Dyfodol service.
Gareth Tatchell
All Responded
2025-0384 28 Jul 2025
ABMU HEALTH BOARD
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Persistent delays in cancer diagnostic, staging, and treatment pathways, especially for staging scans, are adversely affecting patient survivability rates and prognoses, making treatable cancers irresectable.
Liliwen Thomas
All Responded
2025-0352 8 Jul 2025
NICE
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit detail on safe analgesia levels and supervision.
Valerie Hill
All Responded
2025-0301 13 Jun 2025
Merthyr Tydfil County Borough Council
Care Home Health related deaths Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing professional counter-signatures and a clear falls prevention policy.
Valerie Hill
All Responded
2025-0302 13 Jun 2025
First Minister of Wales
Emergency services related deaths (2019 onwards) Wales prevention of future deaths reports (2019 onwards)
Concerns summary Long-standing, systemic ambulance handover delays in Wales persist at intolerable levels, with risks remaining due to a disconnect between ambulance service rostering expectations and actual hospital capacity.
David Ejimofor
All Responded
2025-0273 4 Jun 2025
NEATH PORT TALBOT COUNCIL ROYAL NATIONAL LIFEBOAT INSTITUTION ASSOCIATED BRITISH PORTS
Child Death (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary The absence of lifeguards at a dangerous breakwater during high-risk periods, despite historical effectiveness, and insufficient evidence that new deterrence measures are working, poses an ongoing risk.
Robert Smith
All Responded
2025-0240 21 May 2025
Cardiff & Vale University Health Board
Mental Health related deaths Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary Mental health services lack clear guidance for clinicians on family information sharing and gathering, leading to inconsistent practices. Patient information leaflets also fail to adequately explain these processes.
Martin Saunders
Partially Responded
2025-01202 23 Apr 2025
Welsh Government Rhondda Cynon Taf County Borough Council
Road (Highways Safety) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary Reduced visibility, permissible right turns from a parking bay, and speed limits on a particular road create a high risk of collisions. Planned speed reductions may not fully mitigate this.
Colin Colley
All Responded
2025-0145 17 Mar 2025
Cardiff & Vale University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary Nursing staff and healthcare workers at St David’s hospital lack confidence and adequate training in falls risk assessments, enhanced supervision, and proper documentation, risking future deaths.
Rhiannon Williams
All Responded
2025-0139 12 Mar 2025
Innovation and Technology OFCOM Department for Science
Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary Online suicide forums and social media platforms provided information on self-harm and misleading professionals, raising concerns about the adequacy of The Online Safety Act 2023 in preventing access to such harmful content.
Jean Pike
All Responded
2025-0127 7 Mar 2025
Swansea Bay University Health Board
Mental Health related deaths Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary Discharge decisions were made without essential multi-disciplinary meetings or consulting care coordinators, despite clear warnings of high suicide risk, indicating a systemic failure in communication and risk management.
Annette Lewis
All Responded
2025-0126 6 Mar 2025
Cwm Taf Morgannwg University Health Boa…
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary Delays in implementing a "Failed Discharge" policy mean patients are not being appropriately referred for specialist review, increasing risks of re-attendance and errors in emergency departments.
Amy Padley
All Responded
2025-0105 24 Feb 2025
SWANSEA BAY UNIVERSITY HEALTH BOARD
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, and are reluctant to offer simultaneous support for addiction and mental health.