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
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.
Lewys Crawford
Historic (No Identified Response)
2020-0046 28 Feb 2020
Cardiff and 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) A&E consultants and agency nurses lacked adequate training in paediatric sepsis identification and management, including using risk stratification tools and appropriate terminology. Failures were noted in considering alternative antibiotic administration methods.
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.
Mark Anderson
Historic (No Identified Response)
2019-0435 17 Dec 2019
Cardiff Council
Road (Highways Safety) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Motorcyclists using Trelai Park as an unfettered racing area pose a significant safety risk to the general public, particularly children and the elderly.
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.
Thomas Browne
Historic (No Identified Response)
2019-0401 25 Nov 2019
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) Patients on finite oxygen supplies risk being unmonitored; oxygen administration training is incomplete, and there are no formal procedures for tracking oxygen expiry times. The root cause analysis was also deficient.
Pamela Moran
Historic (No Identified Response)
2019-0367 12 Nov 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) Missed opportunities for a CT scan and lack of a system for overnight consultants to authorise scans contributed to delayed diagnosis and potentially preventable death.
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.
Jane Livington
Historic (No Identified Response)
2019-0359-wp26871 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 had incomplete access to patient notes, potentially resulting in inadequate assessments and treatment plans due to missing critical information.
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.
Ffion Jones
Historic (No Identified Response)
2019-0298 16 Sep 2019
Welsh Ambulance Service
Emergency services related deaths (2019 onwards) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The improvement plan failed to address specific issues, and there's no dedicated pathway for urgent clinical discussions between external healthcare professionals and ambulance staff to ensure proper assessment of response urgency.
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.
Barbara Humphreys
Partially Responded
2019-0246 23 Jul 2019
Care Inn Limited Care Inspectorate Wales Crosfield House Ltd +1 more
Care Home Health related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Inadequate bed rail safety was due to incorrect mattress use, poor staff training, absent risk assessments and policies, and delays in care plan completion. There was also a failure to inform families of medically relevant events.
Action Taken (AI summary) The health board detailed actions taken in response to the Adult Protection General Protection Plan, addressing concerns 1-5, and confirmed circulation of MHRA guidance on safe use of bed rails to care home providers. They also outlined actions taken to improve clarity and transparency in GP interactions, documentation, discussions with patients, and DNACPR procedures, as well as reviewing DOLs for residents using bed rails.
Glenys Button
Partially Responded
2019-0192 10 Jun 2019
Cardiff and Vale University Health Board Cwm Taf Morgannwg University Health Boa… Hwyel Dda University Health Board +3 more
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Inefficient and outdated neurosurgical referral systems, relying on switchboards and bleeps, cause delays and miscommunications, with no backup for busy on-call doctors. Modern digital solutions are available but not utilized.
Action Planned (AI summary) An e-referral system is being piloted, with an evaluation to follow three months after the pilot starts; however, networking issues have delayed the pilot's extension. In the interim, additional measures and email communication have been implemented to avoid delays in urgent referrals.
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.
John Preece
All Responded
2019-0019 15 Jan 2019
Cardiff & Vale University Health Board Nursing & Midwifery Council
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Significant failures in falls management, head injury recognition, and neuro observation training among staff, compounded by a lack of appropriate monitoring and early warning systems for mentally unwell patients.
Noted (AI summary) The Health Board has implemented a falls training program developed by Practice Nurse Educators, introduced an escalation policy specifically for St Barruc ward, and uses NEWS across MHSOP wards in University Hospital Llandough with clear escalation policies. The NMC outlines its regulatory role in setting and maintaining standards for registered nurses and refers to new standards and assurance processes to ensure nurses entering the register are properly trained. They will pursue any regulatory concerns which it is appropriate for them to take, through their fitness to practise procedures.