South Wales Central

Coroner Area
Reports: 181 Earliest: Aug 2013 Latest: 27 Feb 2026

73% response rate (above 63% average).

181 results
Ian Jones
Partially Responded
2025-0085 7 Feb 2025
Department for Transport Welsh Government
Product related deaths Road (Highways Safety) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The easy accessibility of electric motors and parts enables the conversion of pedal bicycles into high-powered, throttle-controlled scooters, posing dangers to both riders and the public.
Noted (AI summary) The Department for Transport acknowledges the concerns about e-cycle modification but states that existing regulations and enforcement powers are sufficient. They highlight regulations concerning e-cycles, the responsibilities of manufacturers and retailers, and the role of the Office for Product Safety and Standards and Local Authority Trading Standards.
Donald Mitchell
Partially Responded
2025-0042 17 Jan 2025
Bridgend County Borough Council Welsh Government
Road (Highways Safety) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) A dangerous 5.75-mile stretch of the A48 road, with varying speeds and no dedicated cyclist safety infrastructure, has a high number of fatal and serious collisions, particularly for cyclists.
Noted (AI summary) Bridgend County Borough Council acknowledges concerns about the A48 Laleston, Bridgend, but states existing signage and road markings meet regulations. The Council continues to monitor personal injury collision data and will implement measures to make the highways network safer where appropriate.
Jackson Yeow
All Responded
2025-0032 17 Jan 2025
Cwm Taf Morgannwg University Health Boa…
Child Death (from 2015) Emergency services related deaths (2019 onwards) Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due to significant delays in discharging medically fit patients.
Action Taken (AI summary) Cwm Taf Morgannwg University Health Board is working to reduce reliance on corridor care through investment in additional nursing staff, transformation programmes, improvements in patient flow, and enhanced escalation processes. They have implemented the Discharge to Recover then Assess (DZRA) model and developed the Discharge Hub as a centralised resource for patient flow and community bed allocation.
Muhammad & Naemat Esmael
All Responded
2024-0643 22 Nov 2024
Mid and West Wales Fire and Rescue Serv… Welsh Government
Product related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Welsh housing legislation requiring only two hard-wired smoke alarms in rented properties is insufficient, as alarms failed to activate in a contained bedroom fire, posing a risk to life. Crucial items were also prematurely removed from the fire scene, hindering investigation into the cause.
Noted (AI summary) Mid and West Wales Fire and Rescue Service supports increasing smoke alarm coverage to the highest standard in all new build premises in Wales and will support any proposals for legislative enhancement by the Welsh Government. They do not propose any action regarding police primacy at fire scenes. The Welsh Government acknowledges the concern regarding smoke alarms and refers to the Renting Homes (Wales) Act 2016, which mandates landlords to ensure rented homes are fit for habitation and to install a smoke alarm on each storey. The findings of the Regulation 28 report will be considered alongside findings from the independent evaluation of the Act.
Peter Parker
All Responded
2024-0565 22 Oct 2024
SWANSEA BAY UNIVERSITY HEALTH BOARD WELSH AMBULANCE SERVICE NHS TRUST WELSH ASSEMBLY GOVERNMENT
Emergency services related deaths (2019 onwards) Other related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Significant ambulance response delays, exceeding the expected survivability of severe injuries, were caused by ambulances being held up at Emergency Departments, preventing them from attending new calls.
Noted (AI summary) The Trust details existing processes for prioritising calls and rapid handover of patients, and offers a meeting to discuss their response and commitment to improvement. Swansea Bay University Health Board outlined existing plans to reduce delays within acute unscheduled care pathways, including reducing bed numbers and improving flow, implementation of a frailty assessment unit and SDEC, and providing alternative pathways for patients presenting to the Emergency Department. The Welsh Government notes that the Health Board and Ambulance Service will respond separately and summarises pressures on urgent and emergency care services in Wales, as well as the actions being taken to address them including '50 day challenge' and escalation of Swansea Bay University Health Board to level 4.
Leighton Dickens
All Responded
2024-0522 29 Sep 2024
South Wales Police
Mental Health related deaths Police related deaths
Concerns summary (AI summary) Police officers face severely limited access to qualified mental health advice and patient records when responding to mental health crises, due to withdrawn triage support and unimplemented alternative services.
Action Planned (AI summary) South Wales Police will continue to work in partnership with NHS Wales and health boards to ensure officers can obtain medically qualified advice for people in crisis at any time.
Sara Grinnell
All Responded
2024-0497 17 Sep 2024
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) Extensive and repeated delays in urgent gynaecology appointments, relying only on written correspondence, resulted in a significant 24-month diagnostic delay. There were missed opportunities to escalate urgency upon re-referral.
Action Planned (AI summary) Cwm Taf Morgannwg University Health Board is undertaking several actions to address referral delays including implementation of a new RTT pathway, harm review process, and workforce improvements including securing administrative support and appointing a team leader for Gynae Hub.
Isobel Stapleton
All Responded
2024-0341 25 Jun 2024
Cwm Taf Morgannwg University Health Boa… Welsh Government
Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Mental health practitioners lack easy access to complete patient records across Wales and NHS England. Acute and home treatment teams also suffer from a lack of clinical psychologists and lengthy psychotherapy waiting lists.
Action Planned (AI summary) Digital Health and Care Wales is developing a business case for the introduction and deployment of mental health systems across health boards in NHS Wales, with a phased approach anticipated over a number of years. The Welsh government is also working to improve discharge arrangements and the quality of care and treatment planning through a Strategic Mental Health Programme and a Mental Health Patient Safety Programme. CTMUHB has made a dedicated psychological professional available for direct assessment and treatment in all three CRHTTs, eliminating the waiting list. They also contact people on the waiting list for psychological therapies in Local Primary Mental Health Support Services after two weeks and 6 months of waiting, using CORE-10 to monitor and escalate changes in clinical presentation or risk.
Stefan Walker
All Responded
2024-0319 17 Jun 2024
Welsh Ambulance Service NHS Trust
Alcohol, drug and medication related deaths Emergency services related deaths (2019 onwards) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Paramedics do not routinely carry flumazenil, an antagonist that could be life-saving in acute circumstances, highlighting a potential gap in emergency medical equipment and protocols.
Noted (AI summary) The Welsh Ambulance Service explains why it carries naloxone but not flumazenil, stating that flumazenil is not safe for widespread use and that ambulance personnel are trained in more appropriate techniques for benzodiazepine overdose.
Clara Winter
All Responded
2024-0289 28 May 2024
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) Critical staff training on timely escalation and maintaining fluid balance charts is not fully rolled out due to resource issues, nor is it compulsory, leaving a significant learning gap.
Action Taken (AI summary) Cwm Taf Morgannwg UHB has provided training to staff on surgical wards in PCH to recognise and manage acutely unwell patients, with nearly all staff trained or booked for training by the end of 2024. Outreach staffing will be at full establishment from August 2024 and will deliver training on the deteriorating patient.
Nicholas Harrison
All Responded
2024-0224 24 Apr 2024
City and County of Swansea NHS Wales Swansea Bay University Health Board
Mental Health related deaths Other related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The Approved Mental Health Practitioner service repeatedly failed to conduct legally compliant Mental Health Act assessments, including insufficient collateral information gathering and inadequate medical attendance, despite family requests.
Action Planned (AI summary) The Welsh Government is focusing on improvements within several wards across health boards in Wales, including Ward F at Neath Port Talbot Hospital, setting national standards for risk assessment and discharge planning, and will monitor related metrics at regular intervals through UHB meetings. The council will continue to work with Swansea Bay University Health Board (SBUHB) to ensure mental health professionals who require access to the WCCIS system are granted access, and discussions are underway to ensure patient clinical notes are available across relevant systems accessed by both organisations. Swansea Bay University Health Board has implemented anti-ligature training, updated its observation policy, created a new assessment tool for environmental risks, established a process to review patients who do not attend appointments, and implemented a monthly monitoring system for Assertive Outreach Team referrals. The health board is reminding all clinical staff to ensure care plans are placed at the front of clinical notes or on the digital front page in WCCIS, and that plans are shared directly with relevant team members.
Alan Davies
All Responded
2024-0160 21 Mar 2024
Cardiff and Vale University Health Board HMP Cardiff Ministry for Justice +1 more
State Custody related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) There was limited communication between Caswell Clinic and HMP Cardiff regarding the patient's condition; discharge information was not provided in a clear format, and the patient was transferred without being accompanied by a member of Caswell Clinic staff.
Action Taken (AI summary) The Department of Health and Social Care outlines national measures to improve urgent and emergency care, including funding increases for ambulance trusts, hospital beds, and discharge support. It also notes improved Category 2 ambulance response times nationally and in the NWAS region, and decreased patient handover times. HMPPS has received assurance from the Governing Governor at HMP Cardiff that all staff are aware of emergency medical codes via the radio system. The Governor is also committed to encouraging staff to raise concerns about an individual's management and will discuss with the Head of Healthcare how healthcare staff can be empowered to do so. Swansea Bay University Health Board has developed a Standard Operating Procedure for transferring individuals with mental/physical health needs into their care. They have also improved the service level agreement with a local GP practice, recruited additional GPs and implemented changes to the night shift pattern to alleviate staff workload.
Jean Thomas
All Responded
2024-0121 4 Mar 2024
Swansea Bay University Health Board Welsh Ambulance Service
Emergency services related deaths (2019 onwards) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Significant ambulance and hospital offload delays, far exceeding targets, led to the formation and exacerbation of a pressure sore due to prolonged patient immobility.
Action Planned (AI summary) Welsh Ambulance Service NHS Trust is not planning further action on ambulance delays, but highlights work to reduce patient harm from pressure damage including a new device. The Trust is finalising steps before beginning a pilot of the new mattress. Swansea Bay University Health Board is working on several initiatives to address access to emergency care and falls prevention, including reviewing referral processes, working with the Welsh Ambulance Service Trust to improve response times, implementing a digital application for non-injurious falls, utilizing the "Dance to Health" program, introducing a Podcast Series, and implementing an Intergenerational Falls Prevention Programme.
Joseph Cattle
All Responded
2024-0107 22 Feb 2024
Minister for Health and Social Services…
Alcohol, drug and medication related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The Welsh Ambulance Service experienced significant delays in allocating an ambulance for an urgent call, partly due to hospital handover delays. The number of funded ambulances appeared insufficient.
Action Planned (AI summary) The Welsh government outlines its overall management strategy to support improvement in ambulance patient handover performance and describes funding and monitoring processes. A new NHS Joint Commissioning Committee was established on 1 April 2024 and now has responsibility for planning and securing emergency ambulance services.
Brian James
All Responded
2024-0064 7 Feb 2024
Welsh Ambulance Service NHS Trust
Emergency services related deaths (2019 onwards) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Ambulance service instructions not to call back and inadequate welfare checks during delayed responses risk callers failing to recognize deterioration or feeling unable to re-contact emergency services, missing critical reassessment opportunities.
Action Planned (AI summary) The Welsh Ambulance Service is reviewing and changing its Emergency Medical Dispatcher call script to ensure callers are appropriately advised on when to call back. A support role for dispatch will be created to undertake welfare calls and technology is being explored to ensure provision of welfare calls to patients waiting in the community.
Christopher Kapessa
All Responded
2024-0039 25 Jan 2024
Coal Authority
Child Death (from 2015) Other related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The Coal Authority lacked accessible risk information, specific water safety policies, and effective inspection protocols, failing to address deep, fast-flowing water dangers and implement identified safety works.
Action Taken (AI summary) The Coal Authority has addressed the coroner's concerns by implementing a Water Safety Procedure and reviewing the Public Safety Risk Assessment process. They have also enhanced the follow-up of actions arising from site inspections and increased the authority of Project Managers to organise immediate repairs.
Lynda Blackmore
All Responded
2024-0069 15 Nov 2023
Aneurin Bevan University Health Board Department of Health and Social Care Welsh Ambulance Service NHS Trust
Emergency services related deaths (2019 onwards) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Significant ambulance handover delays at hospitals are severely impacting emergency response times, causing patients to wait many hours for treatment or conveyance. These delays pose a critical risk to patient safety.
Noted (AI summary) Welsh Ambulance Services NHS Trust does not propose further action directly, but is working with Aneurin Bevan University Health Board to implement additional measures in January 2024 to reduce conveyances to The Grange Hospital through direct admission to alternative sites, and the introduction of a new temporary facility. They also offer to meet to discuss the response in more detail. The Health Board acknowledges handover delays and that an ACA2 crewed ambulance could have attended. It states that reducing patient handovers is a focus and that the Chief Operating Officer and Clinical Executives are providing leadership to address the issue. NICE acknowledges the concerns but states that existing guidelines on fever, sepsis, and sore throat cover the diagnosis and early management of relevant symptoms, and they have not been asked to produce specific guidance on Group A streptococcus.
Ocean-Leigh Hayes
All Responded
2023-0455 15 Nov 2023
Cardiff and Vale University Health Board
Child Death (from 2015)
Concerns summary (AI summary) Health visitors are inconsistently conducting physical reviews of sleeping arrangements for babies, missing opportunities to risk assess co-sleeping environments and advise parents on dangers.
Action Planned (AI summary) Cardiff and Vale UHB will monitor and implement an assurance plan to completion through the Children and Women Clinical Board assurance framework, to address issues around health visitor communication regarding safe sleeping practices and visual assessment of sleeping areas.
Bronwen Morgan
Historic (No Identified Response)
2023-0409 25 Oct 2023
Department for Digital, Culture, Media … Ofcom Welsh Health Minister +1 more
Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to acquire information and means to cause their own death.
Leighton Dickens
Historic (No Identified Response)
2023-0367 29 Sep 2023
South Wales Police
Child Death (from 2015) Mental Health related deaths
Concerns summary (AI summary) Police officers have limited access to qualified mental health advice and clinical records when responding to mental health crises, as urgent support teams are not readily available and a promised service is unimplemented.
Christopher Locke
All Responded
2023-0310 24 Aug 2023
JD Wetherspoon PLC
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Pub staff lack CPR training, leaving them unable to provide lifesaving treatment in emergencies, especially given the increased risk of injuries and potentially impaired bystanders in such environments.
Noted (AI summary) JD Wetherspoon expresses condolences but states they will not change their policy of relying on emergency services for medical care, rather than providing CPR training to staff, citing advice from their Primary Authority.
Shane West
All Responded
2023-0267 19 Jul 2023
Swansea Bay University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inconsistent medication records, challenges in assessing a learning-disabled patient's condition, and an unclear appreciation of respiratory risks associated with laxative administration for abdominal distension.
Action Planned (AI summary) Swansea Bay University Health Board will develop an explicit clinical management plan to address clinical issues throughout a patient's treatment, to be changed on a multi-professional basis. They will remind staff prescribing medications to select the correct drug and report adverse reactions and have reported the death nationally via the "Yellow Card" scheme.
Samuel Morgan
All Responded
2023-0163 18 May 2023
Swansea Bay University Health Board
Suicide (from 2015)
Concerns summary (AI summary) A lack of integrated electronic records between alcohol/drug addiction and mental health services prevents effective information sharing, particularly for complex dual diagnosis cases. This poses a significant risk that critical patient safety information will be lost between agencies.
Action Planned (AI summary) For Swansea based teams, technical changes to enable two-way information sharing between community mental health teams and drug and alcohol services via WCCIS will be completed within 10 working days, commencing 7th August 2023. For NPT based teams, access to WCCIS on a read-only basis will be extended, with implementation planned from 4th September 2023.
Hannah Warren
All Responded
2023-0055Deceased 13 Feb 2023
College of Policing Home Office Metropolitan Police Service +1 more
Other related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) There is a national lack of formal guidance and training for correlating missing person risk assessments with vehicle stop priorities, leading to dangerous mismatches and inappropriate response levels.
Noted (AI summary) The NPCC and College of Policing state that missing persons APP sets out clear processes and procedures and that current ACT instructions should be followed with an instruction to STOP in similar cases. NPCC will raise the issues apparent in the case through appropriate portfolio areas. The Metropolitan Police Service is developing a training package on ANPR and ACT reports, to be rolled out within 12 months. A new Service Level Agreement will require higher authorisation for ACT reports and nominated contacts for updates. The Home Office acknowledges the concerns and states that the College of Policing sets standards for police investigations, including ACT reports. They have consulted with the College, Metropolitan Police and NPCC and are satisfied that current guidance is in place.
Akeem Rhoden
All Responded
2022-0414Deceased 13 Dec 2022
Brecon Beacons National Park Authority,…
Other related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Waterfall signage is inadequate, poorly placed, and lacks clear, concise warnings about water dangers, particularly for non-swimmers, contributing to a lack of awareness of potential drowning risks.
Action Planned (AI summary) Natural Resources Wales is commissioning a report from an independent expert concerning visitor safety management including signage in Waterfall Country. Pending the report, semi-permanent signs are being erected at various locations in Waterfall Country. The council acknowledges concerns and will consider signage at the site, undertaking a signage review and implementing necessary actions. The Neath Port Talbot website has been updated to advise individuals of potential risks involved and signs will be erected to advise individuals of unpredictable water flow.