South Wales Central
Coroner Area
Reports: 182
Earliest: Aug 2013
Latest: 27 Feb 2026
71% response rate (above 62% average).
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.
Action taken summary
The Welsh Government has incorporated annual health checks for people with learning disabilities into the GP Wales core contract from April 2025, providing additional funding to health boards. They ar
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.
Action taken summary
The Health Board has developed an Electrical Failure Emergency Action Card (E1) outlining immediate actions, escalation principles, staff roles, and communication protocols for power failures, with an
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.
Action taken summary
NICE's prioritisation board will reconsider updating the guidance on alcohol withdrawal and pharmacological treatment in February-March 2026, following an earlier conclusion that an update should be c
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.
Action taken summary
The Health Board has reviewed and updated pressure ulcer documentation, introduced a new Tissue Viability Nurse referral proforma, and monitors pressure ulcers via the Datix system. They also plan fur
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.
Action taken summary
G4S Care disputes the concern, stating that specified timeframes for intervention, support, and caseload allocation for prisoners at risk of substance misuse are already contained within existing poli
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.
Action taken summary
Swansea Bay University Health Board has secured 12 months of locum cover for radiology starting October 2025 to address staffing shortages impacting staging scans. An internal audit report of the …
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.
Action taken summary
NICE commits to considering updates to recommendations in their guidelines on inducing labour (NG207) and intrapartum care (NG235). This will specifically include reviewing the frequency of clinical a
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.
Action taken summary
The Council has revised its falls incident reporting process, requiring more detailed staff reports to be reviewed by the Health and Safety Department for environmental factors and trends, with invest
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.
Action taken summary
The First Minister for Wales acknowledges the concerns, outlining the Welsh Government's existing strategic oversight, performance frameworks, and escalation processes for health boards regarding ambu
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.
Action taken summary
The Royal National Lifeboat Institution (RNLI) has commenced daily monitoring of people using Aberavon beach, Little Beach, and the breakwater, starting May 24, 2025, to gather data and inform recomme
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.
Action taken summary
The Health Board has co-produced values-based guidance with families on information sharing and gathering, which will be finalized. They commit to reviewing and updating the patient information leafle
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.
Action taken summary
The Welsh Government states that the A4059 is a local road and the responsibility of Rhondda Cynon Taf County Borough Council, advising the coroner to forward the report to them.
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.
Action taken summary
Cardiff and Vale University Health Board has delivered extensive falls prevention training (March 2025) and launched a new education package (May 2025), with an e-learning module in development. They
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.
Action taken summary
The Department outlines the existing Online Safety Act framework and Ofcom's role in enforcement, noting Ofcom's investigation into a suicide forum. DSIT officials continue to work with DHSC on the …
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.
Action taken summary
Swansea Bay University Health Board has approved and implemented new Standard Operating Procedures for discharge planning requiring mandatory multi-disciplinary team discussions, including the care co
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.
Action taken summary
Cwm Taf Morgannwg University Health Board has implemented an active and updated General Surgery policy, applying to both General Surgeons and the Emergency Department. This policy provides clear guide
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.
Action taken summary
Swansea Bay University Health Board has completed the development of a comprehensive Standard Operating Procedure (SOP) and Care Pathway for individuals with co-occurring mental health and substance u