Recurance · prevention of future deaths reports
Pre-inquest brief
Unwitnessed fall during ward transfer
The earlier warning
Robert Payne · 16 Apr 2015 · Andrew Barkley, Powys, Bridgend & Glamorgan Valleys
“He was transferred between wards at 1am in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed.”
judiciary.uk/prevention-of-future-death-reports/robert-payne
What was promised
No published response from Health Inspectorate Wales was found for the earlier reports.
What recurred
- 24 Jun 2026 · Nola-Reign Morgan · Martin Lanchester · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Robert Payne · 16 Apr 2015
“He was transferred between wards at 1am in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed.”
Later · Nola-Reign Morgan · 24 Jun 2026
“Delay in transferring between Antenatal and HDU wards. The delay in transferring [the deceased]'s mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised.”
What happened next
No web check of the stated actions has been published for this chain.