108 Prevention of Future Deaths reports from the South Wales Central coroner area, 2016–2026. Each one is a coroner's formal warning that something could cause more deaths unless it changes. Full text of every report is on this site.
89 of 108 (82%) have at least one response published on judiciary.uk.
This counts responses published against the report by anyone, not whether a particular body replied. Publication is at the Chief Coroner's discretion and was far less consistent in the corpus's early years, so read a low figure as a prompt to open the reports, not as a finding.
| Date | Report | Coroner | Category | Responses |
|---|---|---|---|---|
| 2026 | Summer Mant | Rachel Knight | Child Death (from 2015), Wales prevention of future deaths reports (2019 onwards) | |
| 2026 | Helen Patching, Rachael Patching and Corey Longdon | Rachel Knight | Other related deaths, Wales prevention of future deaths reports (2019 onwards) | |
| 2026 | Joan Read Prevention of future deaths report | Rachel Knight | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2026 | Ryan Harding Prevention of future deaths report | David Regan | Alcohol, drug and medication related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2026 | Lyn Maher | Rachel Knight | Alcohol, drug and medication related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2025 | Theo Treharne-Jones | Gavin Knox | Child Death (from 2015), Other related deaths | 2 |
| 2025 | Milos Jankovic | Rachel Knight | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 2 |
| 2025 | Pamela Singh | Gavin Knox | Other related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2025 | Gareth Johnson | Kerrie Burge | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 2 |
| 2025 | Peter Thomas | Rachel Knight | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2025 | Lewis Petryszyn | Patricia Morgan | State Custody related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2025 | Liliwen Thomas | Rachel Knight | Child Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2025 | Valerie Hill | Graeme Hughes | Care Home Health related deaths, Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2025 | Valerie Hill | Graeme Hughes | Emergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2025 | Robert Smith | Andrew Morse | Suicide (from 2015), Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2025 | Martin Saunders | Kerrie Burge | Road (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2025 | Colin Colley | Rachel Knight | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2025 | Annette Lewis | Kerrie Burge | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2025 | Ian Jones | Gavin Knox | Road (Highways Safety) related deaths, Product related deaths | 1 |
| 2025 | Donald Mitchell | Patricia Morgan | Road (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2025 | Jackson Yeow | David Regan | Child Death (from 2015), Emergency services related deaths (2019 onwards) | 1 |
| 2024 | John Follon | Gaynor Kynaston | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2024 | Leighton Dickens | David Regan | Police related deaths, Mental Health related deaths | 1 |
| 2024 | Sara Grinnell | Patricia Morgan | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2024 | Isobel Stapleton | David Regan | Suicide (from 2015), Wales prevention of future deaths reports (2019 onwards) | 2 |
| 2024 | Clara Winter | Kerrie Burge | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2024 | Alan Davies | David Regan | State Custody related deaths, Wales prevention of future deaths reports (2019 onwards) | 3 |
| 2024 | Joseph Cattle | Gavin Knox | Alcohol, drug and medication related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2024 | Brian James | Patricia Morgan | Emergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2024 | Christopher Kapessa | David Regan | Child Death (from 2015), Other related deaths | 1 |
| 2023 | Lynda Blackmore | Graeme Hughes | Emergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards) | 3 |
| 2023 | Ocean-Leigh Hayes | Rachel Knight | Child Death (from 2015) | 1 |
| 2023 | Bronwen Morgan | Graeme Hughes | Suicide (from 2015), Wales prevention of future deaths reports (2019 onwards) | |
| 2023 | Leighton Dickens | David Regan | Mental Health related deaths, Child Death (from 2015) | |
| 2022 | Yvonne Rankin | Rachel Knight | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 2 |
| 2022 | Akeem Rhoden | Rachel Knight | Other related deaths, Wales prevention of future deaths reports (2019 onwards) | 2 |
| 2022 | Susan Perry | Graeme Hughes | Alcohol, drug and medication related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2022 | Maria Whale | Sarah Jane Richards | Wales prevention of future deaths reports (2019 onwards), Emergency services related deaths (2019 onwards) | 2 |
| 2022 | John White | Graeme Hughes | Suicide (from 2015), Wales prevention of future deaths reports (2019 onwards) | |
| 2022 | Matthew Rouch | Rachel Knight | Wales prevention of future deaths reports (2019 onwards), Road (Highways Safety) related deaths | 1 |
| 2022 | Aaron Edwards | Rachael Knight | Road (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2022 | Hemanta Rai | Rachel Knight | Other related deaths, Wales prevention of future deaths reports (2019 onwards) | 2 |
| 2022 | Samuel Gomm | Graeme Hughes | Mental Health related deaths, Suicide (from 2015) | 1 |
| 2022 | Donald Compton | Dr Sarah Jane Richards | Wales prevention of future deaths reports (2019 onwards), Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2022 | Margaret Lewis | Dr Sarah Jane Richards | Wales prevention of future deaths reports (2019 onwards), Road (Highways Safety) related deaths | 1 |
| 2022 | Sarah Gilbert-Jones | Graeme Hughes | Emergency services related deaths (2019 onwards), Mental Health related deaths | 1 |
| 2022 | Manon Jones | David Regan | Mental Health related deaths, Suicide (from 2015) | |
| 2021 | Eva Wheeler | Rachel Knight | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2021 | Robert Ellery | David Regan | State Custody related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2021 | Daniel Hall | Dr Sarah Jane Richards | Mental Health related deaths, Suicide (from 2015) | 1 |
| 2021 | Robert Wright | David Regan | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2021 | David Blinman | Graeme Hughes | Road (Highways Safety) related deaths, Other related deaths | 1 |
| 2020 | Ian Weeks | Geraint Williams | State Custody related deaths, Suicide (from 2015) | 1 |
| 2020 | Darren Goddard | Sarah Jane Richards | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2020 | Lewys Crawford | Graeme Hughes | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | |
| 2020 | Jon James | Rachel Knight | Alcohol, drug and medication related deaths, Police related deaths | 1 |
| 2020 | Deborah Lamont | Graeme Hughes | Suicide (from 2015), Wales prevention of future deaths reports (2019 onwards) | 2 |
| 2019 | Mark Anderson | Sarah Jane Richards | Road (Highways Safety) related deaths, Wales prevention of future deaths reports (2019 onwards) | |
| 2019 | Connor Davies | Geraint Williams | Hospital Death (Clinical Procedures and medical management) related deaths, Suicide (from 2015) | 1 |
| 2019 | Thomas Browne | David Regan | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | |
| 2019 | Paul Mclean | Graeme Hughes | Emergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2019 | Annette Hewins | Graeme Hughes | Hospital Death (Clinical Procedures and medical management) related deaths, Mental Health related deaths | 1 |
| 2019 | Ffion Jones | David Regan | Emergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards) | |
| 2019 | Christopher Summerhayes | Sarah Jane Richards | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2019 | Barbara Humphreys | Ian Boyes | Care Home Health related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2019 | Glenys Button | Rachel Knight | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2019 | Jenson Francis | David Regan | Child Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2019 | Marion Prance | Rachel Knight | Emergency services related deaths (2019 onwards), Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2019 | Jennifer Handy | Rachael Knight | Child Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2019 | Jack May | Rachel Knight | Community health care, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2019 | Keith Heatley | Ian Boyes | Hospital Death (Clinical Procedures and medical management) related deaths, Wales prevention of future deaths reports (2019 onwards) | 1 |
| 2019 | Matthew Lewis | Graeme Hughes | Emergency services related deaths (2019 onwards), Suicide (from 2015) | 2 |
| 2019 | Calary Davis | David Regan | Child Death (from 2015), Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2019 | John Preece | Roger Barkley | Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2018 | Janice Davies | Graeme Hughes | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2018 | Joseph Page | Graeme Hughes | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2018 | Deidre Harvey | Christopher Woolley | Hospital Death (Clinical Procedures and medical management) related deaths, Mental Health related deaths | 5 |
| 2018 | Steven Welch | Sarah Jane Richard | Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2018 | Richard Barrett | Rachel Knight | Community health care and emergency services related deaths | 2 |
| 2018 | Howard Winter | Graeme Hughes | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2017 | Stephanie Cave | Philip Spinney | Mental Health related deaths, Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2017 | Lesley Hanson | Philip Spinney | Community health care and emergency services related deaths | 2 |
| 2017 | Hedley Greenland | Andrew Barkley | Care Home Health related deaths | 1 |
| 2017 | David Sewell | Andrew Barkley | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2017 | Dennis Redmore | Andrew Barkley | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2017 | Sheila Gaskin | Andrew Barkley | Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2017 | Percy Jacks | Andrew Barkley | Community health care and emergency services related deaths | 4 |
| 2017 | Khuong Lam | Christopher Woolley | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2017 | Russell Sherwood | Philip Spinney | Community health care and emergency services related deaths | 1 |
| 2017 | Anton Kusz | Andrew Barkley | Community health care and emergency services related deaths | 1 |
| 2017 | Harold Mullins | Andrew Barkley | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2017 | David Evans | Philip Spinney | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2017 | Robert Owens | Andrew Barkley | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2017 | Patricia Donovan | Philip Spinney | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2017 | Clive Davies | Andrew Barkley | Hospital Death (Clinical Procedures and medical management) related deaths | |
| 2017 | Ceriann Richards | Andrew Barkley | Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2017 | Ashley Talbot | Andrew Barkley | Child Death (from 2015), Road (Highways Safety) related deaths | 2 |
| 2017 | David Griffiths | Philip Spinney | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2016 | Edwina Moses | Andrew Barkley | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2016 | David Cooper | Andrew Barkley | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2016 | Maurice Isaacs | Andrew Barkley | Hospital Death (Clinical Procedures and medical management) related deaths | 1 |
| 2016 | Colin Wellings | Andrew Barkley | Road (Highways Safety) related deaths | 1 |
| 2016 | Imad Hassan | Graeme Hughes | Hospital Death (Clinical Procedures and medical management) related deaths | 2 |
| 2016 | James Hedge | Andrew Barkley | Hospital Death (Clinical Procedures and medical management) related deaths | 4 |
| 2016 | Lee Davies | Andrew Barkley | Community health care and emergency services related deaths | 1 |
| 2016 | Gillian Taylor | Andrew Barkley | Mental Health related deaths, Suicide (from 2015) | 3 |
| 2016 | Ronald Hamer | Graeme Hughes | Community health care and emergency services related deaths | 1 |
| 2016 | Corey Price | Andrew Barkley | Road (Highways Safety) related deaths |
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