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recurance

Welsh Government

31
reports received
10
with a published response found
2
recurrence chains
6
reports in those chains
  • Coroner Gaynor Kynaston · South Wales Central

    No published response from this organisation found.

  • Coroner Frazer Stuart · Gwent

    No published response from this organisation found.

  • Coroner Patricia Morgan · South Wales Central

    No published response from this organisation found.

  • Coroner Kerrie Burge · South Wales Central

    No published response from this organisation found.

  • Coroner Kate Robertson · North Wales (East and Central) · in 3 recurrence links

    Response · 1 stated action
    2025-0279-Response-from-Welsh-Government-.pdf ↗
    “All health boards are required to implement the ambulance patient handover guidance - it is one of the five key priorities ('enabling actions') for urgent and emergency care within the NHS Planning Framework for 2025-26 and has been incorporated into the performance criteria for all health board chairs.”
  • Coroner Kerrie Burge · South Wales Central

    No published response from this organisation found.

  • Coroner Gavin Knox · South Wales Central

    No published response from this organisation found.

  • Coroner Patricia Morgan · South Wales Central

    No published response from this organisation found.

  • Coroner Kirsten Heaven · Swansea Neath and Port Talbot

    No published response from this organisation found.

  • Coroner Aled Gruffydd · SWANSEA NEATH & PORT TALBOT · in 9 recurrence links

    Response · 1 stated action
    2024-0565-Response-from-Welsh-Government.pdf ↗
    “Welsh Government has set a priority for improvement in patient flow and the reduction of delayed discharges (pathways of care delays). To build on this, the Welsh Government has also set health boards in-year aspirations in 2024/2025 to reduce ambulance patient handovers over 1 hour by 30% by December 2024”
  • Coroner David Regan · South Wales Central · in 1 recurrence link

    No published response from this organisation found.

  • Coroner Gavin Knox · South Wales Central · in 4 recurrence links

    Response · 1 stated action
    2024-0107-Response-from-Welsh-Government.pdf ↗
    “I have directed each LHB to develop a local 'six goals' programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities.”
  • Coroner John Gittins · North Wales East and Central

    No published response from this organisation found.

  • Coroner Colin Phillips · Swansea and Neath Port Talbot

    Response · 1 stated action
    2021-0247-Response-from-Welsh-Government_Published.pdf ↗
    “Replacement of the two non-complaint terminals at junction 44 and junction 45. This will be progressed by April 2023.”
  • Carl Sargeant11 Jul 2019

    Coroner John Gittins · North Wales (East and Central)

    No published response from this organisation found.

  • Glenys Button10 Jun 2019

    Coroner Rachel Knight · South Wales Central

    Response · 1 stated action
    2019-0192-Response-by-NHS-Wales.pdf ↗
    “The current system for urgent and immediate care of patients with Emergency Neurosurgery needs will continue with the referral being made through the bleep system to the on call Neurosurgical Registrar. [name redacted] effect from Monday 23rd September 2019 the referrer will be asked a question to gauge if the call is urgent or routine in nature. The urgency of the call will be communicated to the r Registrar via the bleep system which will enable them to prioritise urgent calls over less urgent tasks. If”
  • Lyn Morgan26 Feb 2019

    Coroner Aled Gruffydd · Swansea Neath & Port Talbot

    No published response from this organisation found.

  • Deidre Harvey8 Aug 2018

    Coroner Christopher Woolley · South Wales Central

    Response
    Response · 1 stated action
    2018-0266-Response-by-NHS-Improvement.pdf ↗
    “We stand ready to support the MHRA in ensuring any future changes to monitoring reach all appropriate healthcare professionals and patients, including through our shared national network of Medication Safety Officers.”
    Response · 1 stated action
    2018-0266-Response-by-MHRA.pdf ↗
    “We have further considered your concerns that there may be other dependent persons suffering from lupus (or other conditions for which hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of hydroxychloroquine in their system unbeknown to their carers. Some”
  • Jac Davies21 Aug 2017

    Coroner Aled Gruffydd · Swansea Neath and Port Talbot

    Response · 1 stated action
    2017-0250-Response.pdf ↗
    “The draft regulations therefore, place a legal duty on both social and private landlords to fit smoke and carbon monoxide alarms and if a landlord fails to do so, their dwelling is to be treated as if it were unfit for human habitation.”
  • Percy Jacks27 Jul 2017

    Coroner Andrew Barkley · South Wales Central

    Response · 1 stated action
    2017-0329-Response-by-Welsh-Government.pdf ↗
    “HIW is currently undertaking a review of discharge arrangements focusing on communication and the quality of documentation used to support patient discharge from secondary to primary healthcare.”
    Response · 1 stated action
    2017-0329-Response-by-Rhayader-Group-Practic.pdf ↗
    “Allreferrals for suspected DVT are recorded by the Administrative Team at the practice and followed up 48 hours later to ensure the results have been received”
    Response · 1 stated action
    2017-0329-Response.pdf ↗
    “The process of managing potential DVT patients has been streamlined and a definite pathway introduced. All GP referrals which suspected DVTs are referred direct to the Hospital's Radiology Department as per the attached protocol. It is incumbent on the GPs to commence therapy prior to an ultrasound scan being undertaken. Following their scan, if the result is positive, the patient is referred back to the A & E Department where they are reviewed by the on-call Physicians. There is a pre-printed letter”
  • Clive Davies16 Mar 2017

    Coroner Andrew Barkley · South Wales Central

    No published response from this organisation found.

  • Coroner Andrew Barkley · South Wales Central · in 5 recurrence links

    Response · 1 stated action
    2017-0041-Response-by-Welsh-Government.pdf ↗
    “We recognise lengthy handover delays are clearly unacceptable as they can impact not only on the ambulance service's ability to respond to subsequent calls in the community, but also on patient's experience. Handover delays are often symptomatic of pressures elsewhere within the unscheduled care system and should not be viewed in isolation which is why work is being undertaken nationally and locally to support improvements across the patient pathway through reducing inappropriate admissions to hospital”
    Response · 1 stated action
    2017-0041-Response-by-University-Health-Board.pdf ↗
    “a Health Board we have implemented and reviewed a number of key processes. e An Urgent Care Board (UCB) has been established, and is the main driver for our urgent and emergency care services pathway. The UCB is chaired by an Executive Director and includes multi-disciplinary representation from across the Health Board and partner organisation representatives. The Urgent Care Board is dynamic, it agrees, sets and monitors shared clinical and management action across the care system, providing”
  • Edwina Moses22 Dec 2016

    Coroner Andrew Barkley · South Wales Central

    No published response from this organisation found.

  • David Cooper21 Dec 2016

    Coroner Andrew Barkley · South Wales Central

    No published response from this organisation found.

  • Ronald Hamer20 Apr 2016

    Coroner Graeme Hughes · South Wales Central · in 2 recurrence links

    No published response from this organisation found.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error