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
Ceriann Richards
All Responded
2017-0041 1 Mar 2017
Neville Hall Hospital Royal Gwent Hospital Welsh Ambulance Service NHS Trust +1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant and prolonged handover delays between ambulance crews and hospital staff led to critical delays in ambulance dispatch and availability, worsening since new guidance.
Action Taken (AI summary) Aneurin Bevan University Health Board describes steps taken to address ambulance handover issues, including establishing an Urgent Care Board, implementing a Standard Operating Procedure for bed management, and introducing 'Breaking the Cycle' to improve patient flow, implementing transfer teams and discharge facilitators. The Welsh Government acknowledges concerns about handover delays and outlines existing initiatives by the Welsh Ambulance Services NHS Trust to limit conveyance rates, including an enhanced clinical desk, alternative pathways, and a frequent callers project.
Ashley Talbot
All Responded
2017-0051 22 Feb 2017
Bridgend County Borough Council Maesteg Comprehensive School
Child Death (from 2015) Road (Highways Safety) related deaths
Concerns summary (AI summary) Poor design of the school service road and bus bay, coupled with insufficient staff supervision, created a highly dangerous situation for children crossing the road, stemming from a lack of accountability in the school's construction.
Action Taken (AI summary) The bus bay has been extended to accommodate seven buses, and the school site is now subject to a lockdown, with no vehicles allowed to enter or move around the site until the children have boarded/alighted. A new drop-off area has been developed approximately 200m from the school gates. The bus bay has been extended, a school lockdown occurs during bus loading, staff supervision has increased, a speed limit is in place, and a vehicle drop-off point has been created.
David Griffiths
All Responded
2017-0013 31 Jan 2017
Cardiff and Vale University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There were no local protocols or specific training for intercostal drain insertion, and recommended real-time ultrasound guidance was unavailable, raising significant safety concerns for patients.
Action Taken (AI summary) The University Health Board has discontinued the practice of inserting chest drains at a 'marked' point and has purchased equipment. A task and finish group will oversee implementation and assessment across the Health Board and will report to the Quality, Safety and Experience Committee.
Edwina Moses
Partially Responded
2016-0462 22 Dec 2016
ABMU Health Board Welsh Assembly Government
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A poor system for requesting and securing one-to-one nursing cover led to frequent unavailability and staff confusion. This resulted in inadequate staffing levels, leaving frontline nurses unable to safely care for vulnerable patients.
Action Taken (AI summary) The University Health Board has reviewed the process around enhanced observation, including risk assessments and staffing level monitoring, and introduced an audit process to monitor adherence to increased nursing observation guidelines.
David Cooper
Partially Responded
2016-0459 21 Dec 2016
ABMU Health Board Welsh Assembly Government
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There was also a lack of 'joined-up' thinking and insufficient systems for booking one-to-one care for high-risk patients.
Action Taken (AI summary) The University Health Board established a Falls Management Group, reviewed policies and training requirements, introduced National Patient Safety Agency's Risk Assessments, devolved falls management to Directly Managed Units, and will continue to meet as a scrutiny panel with a Consultant Physician leading the group.
Maurice Isaacs
Partially Responded
2016-0411 7 Nov 2016
Cardiff and the Vale University Health … Minister for Health Welsh Assembly Gove…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate falls risk assessment, inconsistent 1:1 supervision, understaffing, and untrained staff performing neurological observations contributed to multiple falls and missed assessments.
Action Taken (AI summary) Following an internal investigation, the UHB has already completed an action plan including measures to improve falls risk assessment and recording, neurological observations, and escalation procedures. A Falls Delivery Group has also been established to review and monitor practice, and the Regulation 28 report will be shared with all Clinical Boards.
Colin Wellings
All Responded
2016-0348 5 Oct 2016
Department for Transport
Road (Highways Safety) related deaths
Concerns summary (AI summary) Current legislation exempts older, powerful vehicles from essential safety requirements like helmets or seatbelts, posing significant risks to riders and other road users.
Noted (AI summary) The Department for Transport acknowledges the concerns, explains current regulations regarding tricycle helmets and licensing, and notes that changes to collision reporting codes and helmet regulations are not planned but will be kept under review.
David Phillips
Historic (No Identified Response)
2016-0334 16 Sep 2016
Mitie NHS Wales South Wales Police
Other related deaths
Concerns summary (AI summary) An inappropriate healthcare professional conducted the mental health assessment for a vulnerable older person, and the assessing professional lacked critical access to the detainee's medical records.
Imad Hassan
Partially Responded
2016-0315 5 Sep 2016
ABMU Health Board Cardiff and Vale Health Board CWM Taff Health Board +2 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is no formal backup plan for PCI procedures when primary hospitals lack capacity, and no agreed pathways for accessing critical care beds outside Wales or for unconscious STEMI patients.
Action Planned (AI summary) Cwm Taf University Health Board has been working to develop an interim solution pending the completion of a comprehensive pathway in the summer of 2017. A local corrective Action Plan for improvement was developed and will be shared with clinical colleagues. The United Hospitals University Bristol Trust will accept patients if there is insufficient critical care capacity in South Wales, facilitated by the regional PPCI centre. Work is underway on an all Wales basis to agree a longer term strategy for these patients.
James Hedge
All Responded
2016-wp25334 27 Jul 2016
Medicines and Healthcare Products Regul… NHS England NHS Wales +1 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Insulin pump guidance inadequately highlights misuse dangers from incorrect cartridge insertion, and patient education fails to emphasize the rapid life-threatening nature of hyperglycaemia.
4 responses from Medicine and Healthcare Products Regulatory Agency, Welsh Government, Roche Diabetes Care Limited
Lee Davies
All Responded
2016-0239 29 Jun 2016
Wallich Centre
Community health care and emergency services related deaths
Concerns summary (AI summary) Hostel staff lacked specific training on monitoring and safeguarding residents found after illicit drug use, instead only focusing on overdose recognition, leaving at-risk individuals unmonitored.
Action Planned (AI summary) The Wallich will present a PowerPoint on 'Dealing with Drug Overdose' to staff by the end of August 2016, revise their policy to include Cymorth Cymru's guidance by August 2016, and revise their e-learning module by September 2016.
Gillian Taylor
All Responded
2016-0178 11 May 2016
Department of Health and Social Care Powys Teaching Health Board
Mental Health related deaths Suicide (from 2015)
Concerns summary (AI summary) A lack of acute mental health facilities in Powys forces patients to be moved far from home, causing discontinuity of care and negatively impacting patient engagement, thus increasing self-harm and suicide risk.
Action Planned (AI summary) Following the report, Welsh Government facilitated a meeting between all Health Boards mental health managers to discuss using Welsh NHS beds whenever possible. They also highlighted the existing requirement for care coordinators and treatment plans for all patients in Wales receiving secondary mental health services, even when placed 'out of area'. Powys Teaching Health Board is working to repatriate Mental Health Services for direct delivery, expecting to treat more patients within Powys and reduce out-of-county placements. Kent and Medway NHS Trust revised its 'Unable to Contact' Protocol, launched it at the Acute Leadership Forum, and cascaded training to CRHT teams. The new Protocol is being piloted in CRHTs trust wide for 3 months to ensure the changes are robust and workable.
Ronald Hamer
Partially Responded
2016-0149 20 Apr 2016
Health Inspectorate Wales Minister for Health and Social Services Welsh Ambulance Services NHS Trust
Community health care and emergency services related deaths
Concerns summary (AI summary) An ambulance response was critically delayed by over two hours, and no follow-up calls were made to the patient's family. This was attributed to an absence of clear planning for high call volumes, risking future service failures.
Action Planned (AI summary) The Welsh Ambulance Services NHS Trust has developed an action plan and is monitoring progress through a Task and Finish Group of senior staff, led by the Director of Quality, Safety and Patient Experience.
Corey Price
Historic (No Identified Response)
2016-0146 19 Apr 2016
Powys County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) An advanced warning sign of the approaching left bend on the A470 would assist in warning motorists of the nature of the road ahead and reduce the risk of similar fatalities.
Alesha O’Connor
Historic (No Identified Response)
2016-0146-wp25227 19 Apr 2016
Powys County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) An advanced warning sign of the approaching left bend on the A470 would assist in warning motorists of the nature of the road ahead and reduce the risk of similar fatalities.
Margaret Challis
Historic (No Identified Response)
2016-0146-wp25226 19 Apr 2016
Powys County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) An advanced warning sign of the approaching left bend on the A470 would assist in warning motorists of the nature of the road ahead and reduce the risk of similar fatalities.
Rhodri Miller-Binding
Historic (No Identified Response)
2016-0146-wp25225 19 Apr 2016
Powys County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) A "challenging" A470 road stretch with a history of serious collisions lacks adequate warning signs for an approaching left bend. An advanced warning sign is needed to reduce future fatality risks.
Patricia Thomas
Historic (No Identified Response)
2016-0096 7 Mar 2016
BMA General Dental Council NHS England: Wales and Scotland +2 more
Other related deaths
Concerns summary (AI summary) A significant lack of awareness among health professionals regarding the dangerous interaction between Miconazole Gel and Warfarin, combined with unclear information resources, risks uncontrolled bleeding.
Christopher Connor
All Responded
2015-0461 12 Nov 2015
Welsh Ambulance Trust
Community health care and emergency services related deaths
Concerns summary (AI summary) Ambulance response was delayed, only arriving after police expedited the call, indicating potential issues with emergency service dispatch or prioritization.
Action Taken (AI summary) Following an investigation, the Welsh Ambulance Services NHS Trust addressed failings by an individual staff member and provided additional education and support to call takers involved in the incident; the individual is being managed in line with Trust policies.
Geoffrey Parry
All Responded
2015-0400 7 Oct 2015
Cardiff and Vale University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was accidentally disconnected, highlighting a lack of clear labelling protocols.
Action Taken (AI summary) The University Health Board has reviewed systems for ECG storage, reinforced the use of the MUSE system, and implemented training on intravenous infusion labelling. The learnings from this incident will be shared, and the Regulation 28 report will be shared with all Clinical Boards.
Dilys Jenkins
Historic (No Identified Response)
2015-0399 7 Oct 2015
Intensive Care Society of England and W…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Tracheostomy tube manufacturers may not be keeping pace with population changes, leading to tubes of potentially inappropriate length which could increase dislodgement risk.
Ronald Bonfield
Historic (No Identified Response)
11 Sep 2015
England and Wales Cwm Taf Morgannwg University Health Boa… National Assembly for Wales +1 more
Community health care and emergency services related deaths
Concerns summary (AI summary) Inconsistent practices for monitoring district nurse compliance with delegated INR testing across GP surgeries create a risk of unmonitored over-anticoagulation.
Mary James
Historic (No Identified Response)
4 Sep 2015
Bryntirion Surgery Care & Social Services Inspectorate, We… Aneurin Bevin University Health Board +5 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy for a dementia patient, missing a critical hospital admission opportunity.
Kathleen Neville
Historic (No Identified Response)
2015-0310 7 Aug 2015
Aneurin Bevan University Health Board Betsi Cadwaladr University Health Board Cardiff and Vale University Health Board +6 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a significant risk of future deaths, particularly in other Health Boards without such a policy.
Arthur Cook
Historic (No Identified Response)
2015-0300 27 Jul 2015
Aneurin Bevan University Health Board Bryntirion Surgery Cwm Taf University Health Board +2 more
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Low staffing of Tissue Viability Nurses, inadequate pressure ulcer documentation, and a lack of integrated skin care across services contributed to progression of MRSA-infected pressure ulcers.