South Wales Central
Coroner Area
Reports: 182
Earliest: Aug 2013
Latest: 27 Feb 2026
71% response rate (above 62% average).
Stephen Owens
Historic (No Identified Response)
2014-0222
19 May 2014
Rhondda Cynon Taf County Borough Council
Road (Highways Safety) related deaths
Concerns summary
Unilluminated and obscured street lamps caused dangerously poor road illumination, likely impairing the driver's ability to see the deceased on the carriageway.
Christopher Shapley
Historic (No Identified Response)
2014-0121
11 Mar 2014
HM Prison Cardiff
Home Office
State Custody related deaths
Concerns summary
Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the PER form, leading to inadequate assessment and observation of the prisoner.
John Morgan
Partially Responded
2013-0372
17 Dec 2013
Welsh Government Health and Social Care
Cardiff and Vale University Health Board
Mental Health related deaths
Concerns summary
Over-reliance on whiteboards rather than patient notes, the potential for human error to input incorrect information, and the use of a misleading DNR "red star" system pose risks to patient care.
Action taken summary
The Welsh Government has issued a request to all Nurse Directors for Health Boards and Trusts to review incident circumstances and make changes. They have also requested the CMO/CNO to …
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
Winston Llewellyn Johns
Historic (No Identified Response)
2013-0279
30 Oct 2013
Welsh Ambulance Service NHS Trust
Department of Health and Social Care
Community health care and emergency services related deaths
Concerns summary
Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process clinical details led to inappropriate CPR advice.
Terence O’Connell
Partially Responded
2013-0218
28 Aug 2013
ABMU Health Board
Grove Medical Centre
Monkstone House Care Home
Community health care and emergency services related deaths
Concerns summary
A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not being seen, alongside a lack of vital clinical monitoring for two days.
Action taken summary
The care home, through Gabbandco, disputes the coroner's finding of a communication breakdown involving them. They assert that any breakdown occurred between the district nurses and the out-of-hours 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