South Wales Central
Coroner Area
Reports: 181
Earliest: Aug 2013
Latest: 27 Feb 2026
73% response rate (above 63% average).
Summer Mant
No Identified Response
2026-0118
27 Feb 2026
Aneurin Bevan University Health Board
Betsi Cadwaladr University Health Board
Cabinet Secretary for Health and Social…
+7 more
Child Death (from 2015)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI 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
No Identified Response
2026-0081
9 Feb 2026
Bannau Brycheiniog National Park
Natural Resources Wales
Neath Port Talbot County Borough Council
+2 more
Other related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency services' response times.
Joan Read Prevention of future deaths report
All Responded
2026-0055
4 Feb 2026
[REDACTED}, Chief Executive Cardiff & V…
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
A single consultant lacking cross-cover for geriatric perioperative care creates a risk of urgent test results being missed during periods of absence.
Action Taken
(AI summary)
• The Health Board has undertaken a detailed internal Patient Safety Review and enacted several improvements.
• Further actions are planned to reduce risk and strengthen system resilience.
Ryan Harding Prevention of future deaths report
All Responded
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 (AI summary)
Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due to staffing shortages.
1 response
from HM Prison Parc
Lyn Maher
Partially Responded
2026-0053
3 Feb 2026
Digital Health and Care, Wales
General Pharmaceutical Council
Health and Social Care for Wales
+1 more
Alcohol, drug and medication related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI 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.
1 response
from General Pharmaceutical Council
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 (AI 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.
Noted
(AI summary)
The Department of Transport notes that there are no specific statutory guidance or mandatory distance regulations for yellow lines near junctions. The decision rests with the local authority, and traffic signing is devolved to the Welsh Government. The Minister explains police driver training standards, noting that decisions on crewing are operational matters for Chief Constables. Pursuits resulting in a fatality are referred to the Independent Office for Police Conduct. South Wales Police acknowledges the concerns about crewing of Road Policing Unit officers during pursuits, but states its training and operational model are designed to ensure public safety and officer competence. They highlight national standards, training, and post-pursuit review processes, while also emphasizing the need to balance operational effectiveness and resource availability, deeming single crewing the most practical option.
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 (AI 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.
Disputed
(AI summary)
ABTA outlines its role as a trade association, describes guidance provided to members on health and safety, and states that security chains could create fire safety risks; it offers condolences but does not comment on specific safety provisions at the accommodation. TUI expresses sympathy but declines to take further action, arguing that the suggested measures would create unacceptable fire risks and that their existing practices align with industry guidance. They emphasize compliance with local standards and offer customer support through their website and resort representatives.
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 (AI 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.
Action Planned
(AI summary)
The Welsh Government is adapting the Paul Ridd to roll it out to the social care workforce and the wider public sector, developing tier 2 and tier 3 training for health and social care professionals, and incorporating learning disability annual health checks into the GP Wales core contract.
Brian Davies
All Responded
2025-0631
17 Sep 2025
HSE
South Wales Police
Other related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI 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 Planned
(AI summary)
The HSE will raise the coroner's concerns at an upcoming WRDP National Liaison Committee (NLC) meeting, recommending refresher communications to signatory organizations, providing an update on national training material for work-related elements of investigations, and providing an update on a proposed 'Suspected Gas Explosion checklist'. They will also provide the Senior Coroner with HSE guidance related to gas safety investigations. South Wales Police will raise the coroner's concerns with the National Liaison Committee regarding the Work Related Death Protocol and collaborate with the HSE and other signatories to ensure any appropriate amendments are made to the protocol. They also noted that they will work with the HSE to ensure the service is able to gather evidence and information needed to identify the cause of explosion.
Gareth Johnson
All Responded
2025-0464
12 Sep 2025
Cabinet Secretary for Health and Social…
Chief Executive Cardiff & Vale Universi…
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Deteriorating hospital infrastructure and critical care capacity issues pose a significant risk, as safeguards against moving critically ill patients may fail under pressure.
Action Planned
(AI summary)
The Health Board has developed an Electrical Failure Emergency Action Card outlining actions to respond to power failures, developed an updated Critical Care Escalation Plan, and integrated key elements into the Major Incident Plan. They are also undertaking regular review and simulation of escalation and major incident plans and ongoing staff training. Welsh Government officials met with Cardiff and Vale UHB to discuss infrastructure issues at the ITU, critical care and theatres departments and a business case is being developed to refurbish the ITU. The Welsh Government will also write to Cardiff and Vale UHB to confirm what clinical governance is in place to approve changes in the location of critical care and to ensure the appropriate clinical cover is in place and write to selected health boards to request them to respond to the NHS Performance and Improvement critical care network census.
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 (AI 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.
Action Planned
(AI summary)
NICE will reconsider its guideline on alcohol-use disorders, with the prioritisation board looking at the topic again in approximately February-March 2026 to determine if any changes are needed, including pharmacological treatment for acute alcohol withdrawal.
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 (AI 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.
Action Taken
(AI summary)
Powys Teaching Health Board has provided podiatry awareness training to ward teams, shared Regulation 28 learning, and will ensure all staff attend training provided by Tissue Viability Specialist Nurses. The Lead podiatrist will attend all wards to ensure the teams are aware of the scope and breadth of the role of the podiatrist.
Lewis Petryszyn
Partially Responded
2025-0394
31 Jul 2025
Cwn Taf Morgannwg University Health Boa…
G4S
State Custody related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI 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.
Noted
(AI summary)
G4S states that timeframes are already contained within policies and procedures as required nationally and pursuant to the service level agreement with CTMUHB, and those timeframes are complied with, therefore no action is proposed.
Gareth Tatchell
All Responded
2025-0384
28 Jul 2025
ABMU HEALTH BOARD
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned
(AI summary)
The Health Board has secured locum cover for radiology for 12 months commencing in October 2025 and the data issue has been remedied with the information now captured on our data insights visualisation platform. A recent review of the head & neck single cancer pathway has confirmed positive compliance against key indicators. Although current monitoring requirements for clozapine remain unchanged, the Trust will circulate emerging scientific literature regarding less frequent blood count monitoring to all prescribers and pharmacists to increase scrutiny of abnormal blood count results in established treatment.
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 (AI 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.
Action Planned
(AI summary)
NICE will consider updating the recommendations in its guidelines on inducing labour (NG207) and intrapartum care (NG235) regarding the frequency of clinical assessments before active labour, and the use of combination therapies for pain relief.
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 (AI 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.
Noted
(AI summary)
The First Minister for Wales acknowledges concerns about ambulance patient handover delays at Cwm Taf Morgannwg University Health Board and outlines the Welsh Government's governance and escalation processes for NHS organisations, noting that all health boards are in escalation for urgent and emergency care.
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 (AI 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.
Action Taken
(AI summary)
The council's Health and Safety team reviews incident reports for environmental factors contributing to falls, contacts care homes to investigate and make recommendations, and reports trends to the Adult Social Care Management Team. They also ensure that environmental risks are addressed alongside individual care plans.
David Ejimofor
All Responded
2025-0273
4 Jun 2025
ASSOCIATED BRITISH PORTS
NEATH PORT TALBOT COUNCIL
ROYAL NATIONAL LIFEBOAT INSTITUTION
Child Death (from 2015)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI 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.
Action Planned
(AI summary)
The RNLI is undertaking daily monitoring of people using Aberavon beach, Little Beach, and the breakwater between 10:00 and 19:30 to understand usage and water entry points. A report will be prepared with recommendations following the 2025 Lifeguarding Season, and the RNLI will work collaboratively with Neath Port Talbot Council and Association British Ports given the Coroner’s concerns. Associated British Ports will undertake a signage, fencing and barrier review and implement any necessary actions identified by such review. The initial review is anticipated to be concluded by the end of July 2025. NPTCBC will continue dialogue with RNLI and ABP, and will be led by RNLI’s recommendations. NPTCBC awaits the outcome of RNLI’s current monitoring and risk assessment period following which changes in service along the beachfront area will be implemented if recommended.
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 (AI 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.
Action Planned
(AI summary)
Cardiff and Vale University Health Board has worked to co-produce guidance on information sharing with families, revised a patient information leaflet, and commissioned a co-produced family engagement project to enhance family involvement.
Martin Saunders
Partially Responded
2025-01202
23 Apr 2025
Rhondda Cynon Taf County Borough Council
Welsh Government
Road (Highways Safety) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI 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.
Noted
(AI summary)
The Welsh Government states that the A4059 is a local road and the responsibility of Rhondda Cynon Taf County Borough Council, and forwards the report's recommendations to RCTCBC.
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 (AI 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.
Action Taken
(AI summary)
The Health Board is expanding falls prevention training, undertaking improvement work regarding bedrails and auditing their use, updating the enhanced supervision framework and developing a new policy, and piloting education programmes for staff.
Rhiannon Williams
All Responded
2025-0139
12 Mar 2025
Department for Science, Innovation and …
OFCOM
Suicide (from 2015)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI 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.
Noted
(AI summary)
The Department acknowledges the concerns and describes the Online Safety Act 2023 and Ofcom's role in regulating online content, as well as collaboration with the Department of Health and Social Care on suicide prevention. Ofcom has opened an investigation into a suicide forum mentioned in the report and will provide regular updates on its website; it will work directly with service providers to promote compliance and take enforcement action as needed, using coroners' reports to inform policy.
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 (AI 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.
Action Taken
(AI summary)
Swansea Bay University Health Board provided additional training to Serious Incident Investigators, focusing on process mapping to improve analysis of clinical input against specified processes, and implemented regular team meetings to reflect on the review process.
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 (AI 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.
Action Taken
(AI summary)
The Health Board has implemented a General Surgery policy, including guidelines for patients returning to the Emergency Department following discharge, and emphasized the responsibility for acting on test results. They also highlight training in place to support the practical application of the policy.
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 (AI 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.
Action Planned
(AI summary)
Swansea Bay University Health Board acknowledges concerns about treating individuals with both addiction and mental health diagnoses. They are developing a Standard Operating Procedure (SOP) and care pathway to address this, starting meetings in May 2025 to review practices and integrate mental health and substance use services.