Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0473, written 18 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Sep 2025 |
|---|---|
| Reference | 2025-0473 |
| Deceased | Pamela Singh |
| Coroner | Gavin Knox |
| Coroner area | South Wales Central |
| Category | Other related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
GRAEME HUGHES HIS MAJESTY’S SENIOR CORONER SOUTH WALES CENTRAL CORONER AREA ANNEX A CORONER’S OFFICE THE OLD COURTHOUSE COURTHOUSE STREET PONTYPRIDD CF37 1JW REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Minister for Health and Social Care in Wales CORONER 1 2 3 I am Gavin Knox HM Coroner, for the coroner area of South Wales Central. CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW On 6 June 2022 I commenced an investigation into the death of Pamela SINGH. The investigation concluded at the end of the inquest on 18 September 2025. The conclusion of the inquest was Natural Causes. 1a Bronchopneumonia 1b 1c II CIRCUMSTANCES OF THE DEATH These were recorded as :- 4 Pamela Singh died of pneumonia, the signs and symptoms of which had progressed over the course of 3 days. These signs and symptoms were difficult for family and professional care staff to identify and attribute to a potential illness. As a consequence no contact was made with a medical professional until after she went into cardiac arrest. She died on 29 May 2022 at 14 Taymuir Road Splott Cardiff. If she had received medical attention at hospital before she went into cardiac arrest it is likely her death would have been avoided. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 5 (1) The deceased had a learning disability and died of a community acquired pneumonia, the death being avoidable if there had been earlier recognition of an acute deterioration in her health; (2) The evidence heard from a Learning Disability Psychiatrist and expert in Critical Care was that people with a Learning Disability generally have a significantly increased mortality risk; (3) The most common cause of avoidable deaths in people with a Learning Disability is pneumonia; Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW (4) Delays in recognising, escalating and responding to an acute deterioration is a significant factor in avoidable deaths of people with a Learning Disabilities; (5) Family and professional care staff did not have any specific practice tool to help them recognise, escalate and ensure a response to concerns about signs of a potential acute deterioration; (6) Neither the GP, Social Worker, or commissioned care provider were familiar with any such tool being used in Wales notwithstanding a recommendation in The Learning Disabilities Mortality Review (LeDeR) Programme Annual Report 2019 to 'Adapt (and then adopt) the National Early Warning Score 2 regionally, such as the Restore2TM in Wessex, to ensure it captures baseline and soft signs of acute deterioration in physical health for people with learning disabilities' ACTION SHOULD BE TAKEN 6 7 In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18 November 2025. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the following who may find it useful or of interest: Family of Pamela Singh 8 Director of Adult Social Services, Cardiff Council Chief Executive Swansea Bay University Local Health Board Health Education and Improvement Wales Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW ADSS Cymru Chief Executive NHS Wales Care Inspectorate Wales Social Care Wales IOS Care Limited I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 18 September 2025 SIGNED: 9 Gavin Knox HM Coroner for South Wales Central Coroner Area Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
AS/MS
Ysgrifennydd y Cabinet dros Iechyd a Gofal Cymdeithasol
Cabinet Secretary for Health and Social Care
Gavin Knox
Coroner, South Wales Central
Coroner’s Office
The Old Courthouse
Courthouse Street
Pontypridd
CF37 1JW
18 November 2025
Dear Mr Knox,
Regulation 28 Prevention of Future Deaths report – Pamela Singh (deceased)
Thank you for your letter of 18 September, enclosing a copy of a Regulation 28 Prevention
of Future Deaths report following the conclusion of the inquest into the death of Pamela
Singh. Please extend my condolences to Ms Singh’s family.
I am aware of the evidence highlighting the significantly increased mortality risk among
people with a learning disability, as well as the challenges in recognising signs of
deterioration. Pneumonia remains an important cause of avoidable death.
I acknowledge the importance of ensuring care staff are equipped with the appropriate
resources and training to identify and escalate concerns about acute deterioration,
particularly in people with learning disabilities and in a community setting.
All providers of regulated services are required, under Care Inspectorate Wales (CIW)
regulations, to ensure their staff are fully competent to carry out their roles. As the workforce
regulator, Social Care Wales mandates continuous professional development as a condition
of registration.
It is the responsibility of the local authority or commissioning body, when setting care plans,
to ensure appropriate and relevant training, such as RESTORE2, is in place for care
workers to support individual’s needs.
Bae Caerdydd • Cardiff Bay
Caerdydd • Cardiff
CF99 1SN
Canolfan Cyswllt Cyntaf / First Point of Contact Centre:
0300 0604400
Gohebiaeth.Jeremy.Miles@llyw.cymru
Correspondence.Jeremy.Miles@gov.wales
Rydym yn croesawu derbyn gohebiaeth yn Gymraeg. Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd
gohebu yn Gymraeg yn arwain at oedi.
We welcome receiving correspondence in Welsh. Any correspondence received in Welsh will be answered in Welsh and corresponding
in Welsh will not lead to a delay in responding.
RESTORE2 is a physical deterioration and escalation tool based on nationally recognised
methodologies. It prompts consideration of presenting indications of someone who has
presented as unwell and stands for Recognise Early Soft-signs, Take Observations,
Respond, Escalate.
In April 2022, the Welsh Government launched the foundation phase of the Paul Ridd
Learning Disability Awareness Training Programme for NHS staff. This was created in
memory of Paul Ridd, a man with a learning disability who died in 2009 due to avoidable
failures in hospital care in Wales. His family campaigned for better training for healthcare
staff, which led to this programme becoming mandatory for all public-facing NHS Wales
staff. To date, more than 80,000 NHS staff from across Wales have completed the training.
The training is available through NHS Wales platforms, like the Electronic Staff Record
(ESR) and Learning@Wales and is supported by the Paul Ridd Foundation. While
RESTORE2 focuses on identifying and responding to physical deterioration (especially in
care homes), the Paul Ridd training focuses on recognising and supporting people with
learning disabilities in all healthcare settings.
The Welsh Government is working with NHS Performance and Improvement, Social Care
Wales and Health Education Improvement Wales (HEIW) to adapt the Paul Ridd to roll it out
to the social care workforce and to the wider public sector. In addition, we are working
closely with HEIW to develop tier 2 (enhanced) and tier 3 (advanced) training for health and
social care professionals who work more regularly or intensely with people with learning
disabilities.
From 1 April 2025, learning disability annual health checks have been incorporated into the
GP Wales core contract. Previously, these checks were only offered by some GP practices.
Now, all adult patients with a learning disability who are registered with a GP practice are
entitled to receive a learning disability check every year. The purpose of these checks is to
aid early identification, diagnosis and treatment of health issues, helping to prevent and
manage health concerns while also providing education and healthcare advice to
individuals.
Health boards are responsible for ensuring every adult with a learning disability is offered an
annual health check. The Welsh Government is providing health boards with additional
funding this year to embed the change and support GP practices. We are also improving
data reporting by requesting GP registers of learning disability patients are up to date,
eligible individuals are offered a health check, and the number of people taking up this offer
is recorded. Working with NHS Performance and Improvement, we are supporting
enhancements to ensure high-quality checks are undertaken. This year is likely to be a
transitional year while the new process beds in and staff are trained. We will be closely
monitoring uptake and impact to ensure the needs of people with learning disabilities are
being met.
Yours sincerely,
Ysgrifennydd y Cabinet dros Iechyd a Gofal Cymdeithasol
Cabinet Secretary for Health and Social Care
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