South Wales Central
Coroner Area
Reports: 181
Earliest: Aug 2013
Latest: 27 Feb 2026
73% response rate (above 63% 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 (AI summary)
The report identifies that a street lamp was unilluminated and another was obscured by foliage, which likely affected the driver's ability to see the deceased.
Christopher Shapley
Historic (No Identified Response)
2014-0121
11 Mar 2014
HM Prison Cardiff
Home Office
State Custody related deaths
Concerns summary (AI 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.
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.
John Morgan
Partially Responded
2013-0372
17 Dec 2013
Cardiff and Vale University Health Board
Welsh Government Health and Social Care
Mental Health related deaths
Concerns summary (AI 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 Planned
(AI summary)
The Welsh Government requested that Health Boards and Trusts review the incident and make changes as appropriate. The Chief Medical Officer and Chief Nursing Officer will write to all Health Boards and Trusts in Wales to reinforce the need for robust systems where PSAG boards are in use. Welsh Government officials will also bring this to the attention of the 1000 Lives improvement service.
Winston Llewellyn Johns
Historic (No Identified Response)
2013-0279
30 Oct 2013
Department of Health and Social Care
Welsh Ambulance Service NHS Trust
Community health care and emergency services related deaths
Concerns summary (AI 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 (AI 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.
Disputed
(AI summary)
The care home disputes that there was a communication breakdown between the care home, district nurses, and the out-of-hours GP service, asserting that communication breakdown was between district nurses and the GP out of hours service. The University Health Board has implemented a clear and accurate message sheet, SBAR (Situation, Background, Assessment, Recommendation), for switchboard staff to record out-of-hours requests for District Nurses in greater detail.