South Wales Central

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

73% response rate (above 63% average).

Response Status
Responded 132 No Response 2 Historic 47
AI Classification
Action Taken 43%
Action Planned 37%
Noted 18%
Disputed 2%
Based on 181 classified responses
Top Categories
Wales prevention of future deaths … (89) Hospital Death (Clinical Procedure… (78) 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: +103 reports · +10pp response rate
vs national average: +97 reports · +10pp response rate
181 results
Yvonne Rankin
All Responded
2022-0404 13 Dec 2022
Cardiff and Vale University Health Boar…
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The family and patient lacked understanding of specific sepsis signs, delaying emergency intervention. Distributing information cards on sepsis to at-risk patients in the community could prevent future delayed recognition and response.
Action Taken (AI summary) Cardiff and Vale UHB has updated the eCORFLO booklet to include reference to sepsis and will provide an additional information sheet for early warning signs of sepsis. They will also provide adult and paediatric symptom cards to patients and parents and advise other Welsh health boards of these actions. Cardiff and Vale UHB updated patient information for new PEG patients to include sepsis signs (updated Jan 30, provided from Feb 6). The ANA team will ensure new patients receive this info by March 1. Cardiff and Vale UHB also ordered Adult and Paediatric Symptom Cards to give to patients with infection signs, with the ANA team distributing them by March 1.
Susan Perry
All Responded
2022-0382 28 Nov 2022
MIRUS Wales
Alcohol, drug and medication related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Medication cupboard keys were left in easily accessible, unlocked locations nearby, compromising medication security and creating a significant risk of service users accessing and misusing drugs.
Action Taken (AI summary) Mirus Wales has taken action by removing key storage from unlocked locations and reinforcing medication policies and training.
Maria Whale
All Responded
2022-0362 9 Nov 2022
Cardiff and Vale University Health Board Welsh Ambulance Service NHS Trust
Emergency services related deaths (2019 onwards) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The report identifies that the emergency services repeatedly advised a gravely ill, disabled woman to take a taxi to A&E, and a call responder concluded that if she could scream then she was not a priority.
Noted (AI summary) Cardiff and Vale University Health Board reviewed the patient's triage and management by the Out of Hours GP Service, sharing their initial findings. The board acknowledges that there was poor communication at the inquest hearing which may have led to some of the recommendations. The Welsh Ambulance Services NHS Trust acknowledges the concerns raised regarding triage and response times and the impact of system pressures. The Trust says it will continue to press for real systemic change at every opportunity.
John White
Historic (No Identified Response)
2022-0337 25 Oct 2022
South Wales Police
Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The distribution of ligature cutters to frontline police officers remains incomplete, posing a risk in emergency situations. Additionally, bespoke training for officers responding to mental health crisis incidents is not widely available.
Matthew Rouch
All Responded
2022-0335 24 Oct 2022
Vale of Glamorgan Council
Road (Highways Safety) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The A48 'Forage roundabout junction' is deemed dangerous, requiring urgent changes to enhance road user awareness and implement traffic calming measures to prevent further fatalities.
Disputed (AI summary) The Vale of Glamorgan Council disputes that the 'Forage roundabout junction' is dangerous, asserting it conforms to design guidance and that advanced warning signage is adequate. However, the Council has published a Legal Order (TRO) with the intention of reducing the speed limit on the A48 Cowbridge bypass subject to identifying available budget.
Robert Evans
All Responded
2022-0322 18 Oct 2022
HMP Swansea
Other related deaths State Custody related deaths
Concerns summary (AI summary) HMP Swansea has a repeated history of self-inflicted deaths soon after arrival. Critical witness accounts were not immediately captured after a death, hindering investigations and preventing lessons from being learned.
Action Planned (AI summary) HM Prison and Probation Services is drafting a new HMPPS Policy Framework, updating the policy for prisons to follow in the event of a death in custody, including guidance to ensure that staff who have relevant information are identified and prompted to make a record of this at an early stage.
Aaron Edwards
All Responded
2022-0302 27 Sep 2022
Merthyr Tydfil County Borough Council
Road (Highways Safety) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) A dangerous road junction with poor visibility, exacerbated by school traffic, requires safety improvements to prevent further deaths from high-speed driving.
Action Planned (AI summary) Merthyr Tydfil Council disputes the coroner's concern about visibility at the junction. However, they state that planned road layout changes as part of the Welsh Governments A465 dualling project will remove the bridge/parapet obstruction, and the Gurnos Ring Road will become 20mph in September 2023.
Samuel Gomm
All Responded
2022-0163
Powys County Council Powys Teaching Health Board
Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) The WARRN risk assessment tool for self-harm lacked optimal visibility and update mechanisms for fluctuating risks, potentially causing new users to underestimate risk and miss referral opportunities.
Action Taken (AI summary) Powys County Council and Powys Teaching Health Board have fully implemented the Welsh Applied Risk Research Network technique and the Welsh Community Care Information System for case recordings in all Community Mental Health Teams. They are also reviewing and updating risk assessment policies, privacy statements, and reminding practitioners to co-produce documents with patients.
Hemanta Rai
Partially Responded
2022-0232 26 Jul 2022
Brecon Beacons National Park Authority Natural Resources Wales Neath Port Talbot Council +2 more
Other related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Inadequate and unclear signage at a waterfall location fails to explicitly warn visitors of drowning risks. Furthermore, responsibility for safety in this multi-jurisdictional area is poorly defined.
Action Planned (AI summary) Brecon Beacons National Park Authority and Neath Port Talbot Council have jointly commissioned an independent reviewer to conduct a comprehensive signage review in public access areas and advise on creating user-friendly signage, also implementing a uniform signage approach. Brecon Beacons National Park Authority and Neath Port Talbot Council have jointly commissioned an independent reviewer to conduct a comprehensive signage review in public access areas and advise on creating user-friendly signage, also implementing a uniform signage approach.
Donald Compton
Historic (No Identified Response)
2022-0090 20 Mar 2022
Cwm Taf University Morgannwg Health Boa…
Alcohol, drug and medication related deaths Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Other related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Multiple prescribing and dispensing errors occurred due to an electronic prescribing tool that allowed bypassing allergy checks and a lack of specific knowledge about constituent drugs among prescribers and pharmacists.
Margaret Lewis
Partially Responded
2022-0080 14 Mar 2022
Canal and River Trust Powys County Council
Road (Highways Safety) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Highway safety risks exist for pedestrians crossing a 60mph road from a canal towpath, compounded by quiet electric cars, earphone use, and sun glare, increasing accident reoccurrence.
Action Planned (AI summary) The Trust will install warning signage on both sides of 40 kissing gates (30 in Wales, 10 in England) along the Montgomery canal to alert towpath users to an upcoming road crossing.
Sarah Gilbert-Jones
All Responded
2022-0037 4 Feb 2022
Welsh Ambulance NHS Trust
Alcohol, drug and medication related deaths Emergency services related deaths (2019 onwards) Mental Health related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Emergency call handling failed to appropriately categorise a time-critical overdose due to protocol shortcomings and clinical misjudgment, leading to significant delays and inconsistent response vehicle deployment.
Action Planned (AI summary) The Welsh Ambulance Services NHS Trust is considering a specific question set within the Medical Priority Dispatch System (MPDS) to identify propranolol overdoses, and has an existing Standard Operating Procedure for flagging overdose cases to dispatchers. The trust is also proposing further actions outlined in an attached plan.
Manon Jones
Historic (No Identified Response)
2022-0174 26 Jan 2022
Cwm Taf Morgannwg University Health Boa…
Mental Health related deaths Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Clinicians lacked access to comprehensive patient records from community care and the unit's internal records were fragmented, impairing assessment, observation setting, and safeguarding measures.
Eva Wheeler
All Responded
2021-0424 21 Dec 2021
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) Communication errors led to delayed ambulance calls and incorrect patient preparation. The hospital lacks robust processes for documenting/chasing emergency ambulances, clear NBM protocols, and joint registrar consultation for common conditions like bowel obstructions.
Action Taken (AI summary) The Health Board has taken action to address communication errors and review procedures for escalating concerns about deteriorating patients, primarily through computerisation of notes, NEWS audits, and practice development sessions. They concluded there was no need for an on-call shared discussion protocol.
Robert Ellery
All Responded
2021-0390 19 Nov 2021
HM Prison Cardiff
State Custody related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The prison control room delayed relaying critical information to the ambulance service, and a lack of direct communication between emergency operators and prison first responders hindered resuscitation efforts.
Action Taken (AI summary) HMP Cardiff has devised a Local Operating Protocol and will pilot a mobile phone carried by officers to enable direct communication with the Welsh Ambulance Service.
Daniel Hall
All Responded
2021-0381 10 Nov 2021
University of South Wales
Mental Health related deaths Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) University students face lengthy delays accessing mental health support, even when expressing suicidal ideation and having known risk factors like ASD.
Action Taken (AI summary) The University has commissioned an independent external review of wellbeing policies and procedures. Since October 2021, it has worked to improve understanding of support services and has improved and extended its training program for students and staff.
Robert Wright
All Responded
2021-0374 4 Nov 2021
Cwm Taf University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Internal hospital referrals were paper-based and not promptly integrated into patient notes, leaving busy clinicians without immediate access to complete patient referral information.
Action Planned (AI summary) CTM UHB is exploring implementing electronic referrals and triaging, and is benchmarking practice with a neighbouring Health Board. A future project would be to consider an electronic patient pathway.
Suzanne Regan
Partially Responded
2021-0247 16 Jul 2021
South Wales Trunk Road Agent Welsh Government
Road (Highways Safety) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The failure to replace old-style road barriers with modern, safer alternatives creates an ongoing risk of further deaths and serious injuries.
Action Planned (AI summary) The Welsh Government will replace two non-compliant terminals at junctions 44 and 45 of the M4 by April 2023, conduct a review of terminals at all motorway exit slip roads in Wales by April 2022, and continue proactively replacing non-compliant terminals.
Catherine Best
All Responded
2021-0244 15 Jul 2021
Swansea Bay University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) An inadequate nasogastric tube feeding regime resulted in inconsistent calorie intake, compromising the patient's ability to fight infection.
Action Taken (AI summary) The Health Board has made changes to policies, procedures, guidance and training regarding nutrition and hydration since 2012. They have also adopted Clinical Standards for Inpatient Nutritional Support since 2017, with audits every 2 years.
David Blinman
All Responded
2021-0054 24 Feb 2021
DHL Supply Chain UKI
Police related deaths Road (Highways Safety) related deaths
Concerns summary (AI summary) Deficient risk assessments failed to incorporate local knowledge, inadequately addressed vehicle blind spots during reversing, and did not mandate crucial mitigating measures like cameras or banksmen.
Action Taken (AI summary) DHL has standardised a base vehicle safety specification which is updated following incident reviews and technology developments, including fitting 4-camera systems to all rigid vehicles procured directly by them since 2015. They will also ensure risk assessors are aware of the need to use clear terminology when describing delivery control measures in the revised Nisa DPRA process.
Samuel Morgan
All Responded
2020-0276 9 Dec 2020
Department of Health and Social Care Medicines and Healthcare products Regul…
Suicide (from 2015)
Concerns summary (AI summary) Patient information leaflets for SSRIs lack immediate, high-impact warnings, such as a "Black Box Warning," to clearly highlight the increased risk of suicidal thinking in young adults.
Noted (AI summary) The Department of Health and Social Care acknowledges concerns about the presentation of risks associated with citalopram and lack of a follow-up appointment, but does not commit to specific changes beyond noting existing guidance and MHRA's monitoring. The MHRA acknowledges the concerns, highlights existing warnings about suicide risk with SSRIs, and states that the information has been used to generate a Yellow Card report for continuous monitoring, but does not commit to specific changes.
Brian Griffiths
All Responded
2020-0203 9 Oct 2020
South Wales Police
Road (Highways Safety) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) An opportunity was missed to assess an elderly driver's fitness after a previous collision, highlighting the need for robust driver referral schemes to take unsafe drivers off the road.
Action Planned (AI summary) South Wales Police plans to implement an elderly person referral scheme by May 2021, informed by a similar scheme in Dyfed Powys Police, and are discussing implementation with Criminal Justice Services, the Motoring Unit and the Wales Mobility Driver Assessment Service.
Andres Roberts
All Responded
2020-0182 23 Sep 2020
Department of Health and Social Care Welsh Ambulance Services NHS Trust
Emergency services related deaths (2019 onwards) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Delays in emergency department arrival for acute stroke patients may delay critical treatment, raising concerns about stroke patient categorisation, specific time targets, and ambulance service resources.
Action Planned (AI summary) The Trust disagrees with the need for action regarding stroke patient grading and resource allocation. However, it describes several ongoing actions to reduce hospital delays, including expanding clinical desk staff, developing out-of-hospital pathways, supporting patient discharge, and recruiting Advanced Paramedic Practitioners. The Welsh Government describes ongoing efforts to improve ambulance response times for stroke patients and wider improvements to urgent and emergency care services, including the establishment of a Ministerial Ambulance Availability Taskforce and additional funding for transformation projects.
Dean George
Partially Responded
2020-0104 24 Apr 2020
Department of Health and Social Care Minister for Health Welsh Assembly
Alcohol, drug and medication related deaths State Custody related deaths Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Welsh prisons lack an integrated treatment system, failing to automatically offer opiate substitution therapy to new arrivals addicted to opiates, creating an inequality in healthcare provision compared to England.
Action Taken (AI summary) Opiate substitution therapy is now offered routinely in HMP Swansea the day following admission, where appropriate and safe; healthcare team in the prison is expanding, and an Early Days Opiate Treatment Pilot was launched. A new Substance Misuse Treatment Framework is being developed.
Ian Weeks
All Responded
2020-0064 12 Mar 2020
Cardiff and Vale NHS Trust
State Custody related deaths Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Failures in checking medical records upon prison admission led to missed antidepressant medication, exacerbated by staff shortages, heavy workloads, and the absence of a "red flag" warning system for suicide risk.
Action Planned (AI summary) Cardiff and Vale NHS Trust has reviewed the records, processes, and systems related to the death, noting a difference between NHS Wales and England regarding GP record access for prisoners. They have recently gained funding for an IT data specialist to improve IT in the prison, with recruitment to be pursued once a workforce review is complete.