South Wales Central
Coroner Area
Reports: 181
Earliest: Aug 2013
Latest: 27 Feb 2026
73% response rate (above 63% average).
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.
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.
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.
Darren Goddard
All Responded
2020-0060
9 Mar 2020
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)
Failures in consent processes, misleading risk information, premature discharge, and significant delays in triage, escalation, fluid/antibiotic administration, and critical care admission collectively led to sepsis complications.
Action Taken
(AI summary)
The Health Board has agreed to use consistent terminology regarding sepsis and exclude reference to the word 'rarely' on the TRUS biopsy consent form. A single leaflet produced by the British Association of Urological Surgeons (BAUS) is now used. Sepsis training is being reinstated for medical and nursing staff.
Jon James
All Responded
2020-0042
20 Feb 2020
National Institute for Health and Care …
Alcohol, drug and medication related deaths
Police related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
There is no national NICE guidance on Acute Behavioural Disturbance, which is vital for emergency services and police, contributing to a rising number of related deaths.
Action Planned
(AI summary)
NICE acknowledges concerns about the need for guidance on acute behavioral disturbance (ABD) and will consider this in a future update to its guideline on violence and aggression (NG10).
Deborah Lamont
All Responded
2020-0008
20 Jan 2020
College of Policing
South Wales Police
Suicide (from 2015)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Police misinterpreted Section 136 of the Mental Health Act, believing they lacked power to detain a suicidal individual in a hotel room. This highlights a need for clearer guidance on how such temporary accommodations are classified under the Act.
Action Planned
(AI summary)
The College of Policing will amend its guidance in respect of the use of s136 powers, circulate a summary of the issue to all police force mental health leads, and work with the Home Office to assess the need for changes to national guidance regarding the use of s136 and hotel rooms. The Chief Constable of South Wales has asked that the Force Mental Health Lead fully consider the use of hotel rooms and s.136, subject to a specific note upon force guidance and within training. The College of Policing will circulate a summary of the issue to all police force mental health leads and has raised the issue with the Home Office to assess the need for changes to national guidance.
Connor Davies
All Responded
2019-0412
29 Nov 2019
Cwm Taf Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Suicide (from 2015)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Repeated cancellation of consultant psychiatrist appointments without clinical input on patient urgency meant individuals at serious need could "fall through the net," as a preventative system was not yet operational.
Action Planned
(AI summary)
The University Health Board has developed an action plan to address the matters raised during the inquest and all outstanding actions are being implemented by the Mental Health Directorate.
Paul Mclean
All Responded
2019-0347
22 Oct 2019
Welsh Ambulance Service NHS Trust
Emergency services related deaths (2019 onwards)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Ambulance call scripting for seizures is inadequate, failing to ascertain fit duration for correct callback advice and lacking clear protocols for urgent upgrades when airways are compromised. There's also no pathway for updating prison staff or facilitating dialogue with hospital EDs on call categorisation.
Action Taken
(AI summary)
The Welsh Ambulance Service NHS Trust has expanded its Healthcare Professional (HCP) triage team, enabling them to filter HCP calls and escalate urgent clinical discussions. They use the Medical Priority Dispatch System (MPDS) for call categorization and prioritization.
Jane Livingston
All Responded
2019-0359
4 Oct 2019
ABMU Health Board
Mental Health related deaths
Suicide (from 2015)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Gateway assessors lacked full access to patient notes, risking incomplete assessments and treatment plans based on insufficient information.
Action Taken
(AI summary)
• A detailed review of the information in the report has been undertaken by the Quality and Safety team for the Mental Health Swansea locality at Swansea Bay University Health Board.
• A full investigation has been conducted into the events of the 14th December.
• The Health Board confirms that the PARIS system has been audited during our investigation, and can confirm that the CMHT staff accessed the system at 12.29hrs on the 14th December 2018 to document the duty assessment conducted on Ms Livingston.
Annette Hewins
All Responded
2019-0310
24 Sep 2019
Cwm Taf Morgannwg University Health Boa…
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Inconsistent and inadequate nursing documentation for FACE records and NEWS charts, missed observations, ad hoc ECG request systems, and poor detail in patient observation charts indicate significant training and procedural failures.
Action Taken
(AI summary)
The Health Board developed and is implementing an action plan to address the matters raised during the inquest with a number of the issues already addressed and marked as complete.
Christopher Summerhayes
All Responded
2019-0263
22 Aug 2019
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)
Complex polypharmacy involving Clozapine led to severe side effects and potential misinterpretation of overdose symptoms, while a possible contraindicating familial lipid disorder was not confirmed.
Action Planned
(AI summary)
The Health Board reported the death to the Medicines and Healthcare products Regulatory Agency (MHRA). A project proposal is in development by the Mental Health Clinical Board, Pharmacy and Information Technology to develop an interface between PARIS and PMS to improve the transfer of information.
Jenson Francis
All Responded
2019-0158
17 May 2019
Cwm Taf University Health Board
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)
A dysfunctional team exhibited unclear clinical leadership, poor CTG interpretation and communication, inadequate record-keeping, and insufficient staffing, with junior staff unable to challenge decisions.
Action Taken
(AI summary)
The University Health Board has implemented an Organisational Development Action Plan, including study days and mandatory training on communication and escalation, and has fully implemented PROMPT training. They have also implemented a new escalation policy, senior midwife on-call rota, and a birthrate plus acuity system for the labour ward.
Marion Prance
All Responded
2019-0154
15 May 2019
Welsh Ambulance Service
Emergency services related deaths (2019 onwards)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Paramedics lacked awareness and training regarding the dangers of administering anticoagulants like Rivaroxaban to elderly fall patients with head injuries, requiring enhanced caution.
Action Planned
(AI summary)
The Trust acknowledged a paramedic's lack of awareness regarding Rivaroxaban and is implementing an action plan for individual learning and organizational changes. They will ensure all clinical staff are aware of the effects of Novel Oral Anti-coagulant drugs.
Jennifer Handy
All Responded
2019-0121
5 Apr 2019
Cwm Taf Health Board
General Medical Council
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)
The inability to trace a doctor who left the UK after treating a patient compromised the investigation and prevented the clinician from learning from issues raised.
Noted
(AI summary)
The Health Board now contacts the Assistant Medical Director for Professional Regulation and Standards to check for ongoing GMC concerns when a doctor leaves. The GMC states that its statutory powers only extend to doctors registered with the GMC, the Medical Act makes provision to erase doctors who fail to maintain an effective registered address, international regulators have data sharing practices, and information about a doctor's fitness to practise history can be publicly accessed on the online register, LRMP, therefore no further action is required.
Jack May
All Responded
2019-0078
1 Mar 2019
Cardiff University
Community health care and emergency services related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Inadequate university mental health services, characterized by long waits and limited appointments, combined with patchy, poorly trained pastoral support from personal tutors, allowed students to "slip through the net."
Noted
(AI summary)
Cardiff University acknowledges the coroner's concerns and provides a detailed explanation of its student support services, personal tutoring policies, and local pastoral care. They state they are not complacent and are putting resources in place, and working with partners, to help meet increased demand.
Lyn Morgan
All Responded
2019-0080
26 Feb 2019
Welsh Government
Road (Highways Safety) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
A road barrier failed to redirect a lorry as designed, causing it to re-enter the carriageway. Given the heavy vehicle use, there's a risk of similar incidents occurring again.
Noted
(AI summary)
The Welsh Government acknowledges the concerns raised about safety barriers. While noting the barriers met standards at the time of the incident, they commit to applying national standards, working with National Highways, adopting policy changes, and monitoring incidents.
Keith Heatley
All Responded
2019-0478
26 Feb 2019
ABMU Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with inconsistent recording of MDT meetings and no clinical review before high-risk patient leave.
Action Taken
(AI summary)
The health board implemented a checklist to ensure multidisciplinary team members, including the Community Mental Health Team and family, can express their views on patient leave. They also appointed a ward clerk, developed a carers' forum, implemented a risk assessment model (WARNN), created a Patient Experience Group (PEG), involved carers in 15-step reviews, and arranged a learning event.
Matthew Lewis
All Responded
2019-0048
13 Feb 2019
College of Policing
South Wales Police
Emergency services related deaths (2019 onwards)
Suicide (from 2015)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Confusing and inconsistent call handler instructions to police officers during a hanging incident created ambiguity between scene preservation and life preservation, risking unsuccessful rescue attempts.
Action Planned
(AI summary)
South Wales Police have developed a procedure for call handlers that incorporates guidance highlighting the presumption that 'life is not extinct' in hanging scenarios. This procedure is now part of call handler training. The College of Policing will amend learning standards for contact management staff within the next month to reflect the importance of preserving life. They have also asked for a summary of the issue to be circulated to heads of contact management across England and Wales.
Calary Davis
All Responded
2019-0043
11 Feb 2019
Cwm taf University Health Board
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)
Maternity services suffered from an incomplete action plan, institutional stress from a merger, a culture of not performing essential procedures at night, poor information sharing, insufficient staffing, and a lack of leadership.
Action Taken
(AI summary)
A corrective Action Plan for Improvement was developed following Calary Davis' death and has been updated to reflect the concerns identified within the Regulation 28 Report. Staffing has significantly improved since August 2018 and the Health Board has a vacancy of 15 WTE Midwives.