South Wales Central

Coroner Area
Reports: 182 Earliest: Aug 2013 Latest: 27 Feb 2026

71% response rate (above 62% average).

Response Status
Responded 130 Historic 45 Pending 5
AI Classification
Action Taken 46%
Action Planned 25%
Noted 12%
Disputed 17%
Based on 48 classified responses
Top Categories
Wales prevention of future deaths … (90) Hospital Death (Clinical Procedure… (79) 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: +104 reports · +6pp response rate
vs national average: +99 reports · +9pp response rate
Clear 106 results
Phyllis Barlow
All Responded
2015-0027 29 Jan 2015
NHS Wales
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Brendan Ryan
All Responded
2014-0541 18 Dec 2014
Powys County Council
Road (Highways Safety) related deaths
Concerns 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.
Marcus Szigetvari
All Responded
2014-0503 14 Nov 2014
Rhondda Cyon Taff Highways Department
Road (Highways Safety) related deaths
Concerns 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.
Vivian Hunt
All Responded
2014-0363 6 Aug 2014
Cwm Taff Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.
Sandra Wordingham
All Responded
2013-0373 17 Dec 2013
Springbank Care Home Limited
Care Home Health related deaths
Concerns 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 taken summary Springbank Nursing Home has developed and implemented new policies and protocols for managing residents who become unconscious, including a strict protocol for summoning emergency services and clear g
Samuel Gomm
All Responded
2022-0163
Powys Teaching Health Board and Powys C…
Mental Health related deaths Suicide (from 2015)
Concerns 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 summary Powys County Council and Powys Teaching Health Board have fully implemented the WARRN risk assessment tool in Community Mental Health Teams, with full integration into inpatient Electronic Patient Rec