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).
PFD Reports
186 resultsMichael 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.
Meirion James
Historic (No Identified Response)
2019-0460
4 Mar 2019
Pembrokeshire & Camarthenshire
Dyfed Powys Police
Hywel Dda Health Board
National Police Chief’s Council
Concerns summary
Concerns exist regarding the content of police training for restraint and Appropriate Adult responsibilities. Criteria for identifying and transporting individuals to a place of safety under MHA 1983 also require review.
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.
Madeline Staples
Historic (No Identified Response)
2019-0041
11 Feb 2019
North Wales (East and Central)
Betsi Cadwaladr University Health Board
Welsh Ambulance Services NHS Trust
Concerns summary
Persistent, unacceptable delays in patient handovers at emergency departments continue to result in long ambulance waits and unavailable resources, despite previous warnings, placing patients' lives at ongoing risk.
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.