Wales prevention of future deaths reports

PFD Category
Reports: 186 Areas: 7 Earliest: Jan 2019 Latest: 6 Mar 2026

83% response rate (above 62% average). 51% of classified responses show concrete action taken. Reports rose 112% from 17 (2023) to 36 (2024).

Response Status
Responded 155 Historic 24 Pending 7
AI Classification
Action Taken 51%
Action Planned 29%
Noted 10%
Disputed 10%
Based on 115 classified responses
Reports by Quarter
Clear
PFD Reports
138 results
Christopher Summerhayes
All Responded
2019-0263 22 Aug 2019 South Wales Central
Cardiff & Vale University Health Board
Concerns summary Complex polypharmacy involving Clozapine led to severe side effects and potential misinterpretation of overdose symptoms, while a possible contraindicating familial lipid disorder was not confirmed.
Carl Sargeant
All Responded
2019-0236 11 Jul 2019 North Wales (East and Central)
Welsh Government
Concerns summary Lack of appropriate support channels for high-profile individuals removed from government positions, especially concerning media interest and potential mental vulnerabilities.
Jenson Francis
All Responded
2019-0158 17 May 2019 South Wales Central
Cwm Taf University Health Board
Concerns summary A dysfunctional team exhibited unclear clinical leadership, poor CTG interpretation and communication, inadequate record-keeping, and insufficient staffing, with junior staff unable to challenge decisions.
Marion Prance
All Responded
2019-0154 15 May 2019 South Wales Central
Welsh Ambulance Service
Concerns summary Paramedics lacked awareness and training regarding the dangers of administering anticoagulants like Rivaroxaban to elderly fall patients with head injuries, requiring enhanced caution.
Michael Davies
All Responded
2019-0134 25 Apr 2019 Camarthenshire and Pembrokeshire
Welsh Ambulance Trust
Concerns summary The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.
Jennifer Handy
All Responded
2019-0121 5 Apr 2019 South Wales Central
General Medical Council Cwm Taf Health Board
Concerns summary The inability to trace a doctor who left the UK after treating a patient compromised the investigation and prevented the clinician from learning from issues raised.
Kristopher McDowell
All Responded
2019-0083 7 Mar 2019 North Wales (East and Central)
Canal and River Trust
Concerns summary The aqueduct's parapet upright spacing is dangerously wide for current standards, creating a fall risk, and inspection procedures for upright embedment are subjective and inadequate to ensure structural integrity.
Jack May
All Responded
2019-0078 1 Mar 2019 South Wales Central
Cardiff University
Concerns summary Inadequate university mental health services, characterized by long waits and limited appointments, combined with patchy, poorly trained pastoral support from personal tutors, allowed students to "slip through the net."
Keith Heatley
All Responded
2019-0478 26 Feb 2019 South Wales Central
ABMU Health Board
Concerns summary There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with inconsistent recording of MDT meetings and no clinical review before high-risk patient leave.
Lyn Morgan
All Responded
2019-0080 26 Feb 2019 Swansea Neath & Port Talbot
Welsh Government
Concerns summary A road barrier failed to redirect a lorry as designed, causing it to re-enter the carriageway. Given the heavy vehicle use, there's a risk of similar incidents occurring again.
Matthew Lewis
All Responded
2019-0048 13 Feb 2019 South Wales Central
College of Policing South Wales Police
Concerns summary Confusing and inconsistent call handler instructions to police officers during a hanging incident created ambiguity between scene preservation and life preservation, risking unsuccessful rescue attempts.
Calary Davis
All Responded
2019-0043 11 Feb 2019 South Wales Central
Cwm taf University Health Board
Concerns summary Maternity services suffered from an incomplete action plan, institutional stress from a merger, a culture of not performing essential procedures at night, poor information sharing, insufficient staffing, and a lack of leadership.
John Preece
All Responded
2019-0019 15 Jan 2019 South Wales Central
Cardiff & Vale University Health Board Nursing & Midwifery Council
Concerns summary Significant failures in falls management, head injury recognition, and neuro observation training among staff, compounded by a lack of appropriate monitoring and early warning systems for mentally unwell patients.