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
Clear 107 results
Elsie Hayward
All Responded
2015-0224 19 Mar 2015
Cardiff and Vale NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Overstretched medical staff due to excessive patient ratios led to care deficiencies, including neglected neuro observations and poor note-taking. This resulted in significant confusion and communication breakdowns between nursing and medical teams.
Action Taken (AI summary) Cardiff Vale University Health Board has already undertaken actions including ward-level board rounds, safety briefings, MDT meetings, disciplinary investigation of a nurse, and staff retraining, following an internal investigation and continuous improvement plan.
Barrie Lewis
All Responded
2015-0065 19 Feb 2015
Cwm Taf Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The provided text is incomplete and does not contain any discernible coroner's concerns.
Action Taken (AI summary) A corrective Action Plan for Improvement was developed, and actions have been taken to improve communication and documentation, including a review of the Care Treatment Plan Policy, a new procedure on the role of the duty officer, and improved monitoring of recording systems.
Phyllis Barlow
All Responded
2015-0027 29 Jan 2015
NHS Wales
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Widespread ignorance among GP practices of NICE guidelines means patients on warfarin with head injuries are not being admitted to hospital for CT scans as required.
Action Planned (AI summary) Welsh Government officials are developing a Patient Safety Notice to raise awareness of NICE guideline 176 regarding head injuries in patients on warfarin, which will be issued to all local health boards and general practices in Wales. Full compliance with the notice is expected within a month of circulation and will be monitored.
Brendan Ryan
All Responded
2014-0541 18 Dec 2014
Powys County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) The provided text only describes the vehicle leaving the road and colliding with a fence, resulting in death, without detailing specific preventative concerns related to highway safety.
Action Taken (AI summary) Following a fatal collision, the council undertook surveys and implemented a reprofiling scheme funded by the Welsh Government. They also introduced double solid white centre lines and additional warning signs, plus verge marker posts.
Marcus Szigetvari
All Responded
2014-0503 14 Nov 2014
Rhondda Cyon Taff Highways Department
Road (Highways Safety) related deaths
Concerns summary (AI summary) The busy road during rush hour presented a high risk of drivers misjudging motorcycle headlights for distant cars, especially in poor conditions, contributing to a history of multiple collisions and fatalities.
Disputed (AI summary) The Council argues that the junction complies with modern design standards and the layout was not a contributory factor in the collision. They state that poor weather conditions, the speed of the motorcyclist, and the actions of the driver pulling out of the junction all played a part in the collision, and therefore propose no further action.
Vivian Hunt
All Responded
2014-0363 6 Aug 2014
Cwm Taff Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.
Action Taken (AI summary) The Health Board developed a Corrective Action Plan for Improvement to ensure effective action regarding compliance with neurological investigations post head injury, with actions taken by the Mental Health Directorate.
Sandra Wordingham
All Responded
2013-0373 17 Dec 2013
Springbank Care Home Limited
Care Home Health related deaths
Concerns summary (AI summary) A nursing home failed to seek timely medical opinion for an unconscious resident, delaying identification of a severe condition and risking unnecessary death if early intervention was possible.
Action Planned (AI summary) Springbank Nursing Home has produced a protocol for managing unconscious residents, including training for staff, clearer risk assessments, and mandatory summoning of emergency services in cases of doubt. The protocol has been provided for all staff working at Springbank Nursing Home.