“as follows The MATTERS OF CONCERN are as follows”
Dated 16 Mar 2017, from the coroner for South Wales Central. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 11 May 2017. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated16 Mar 2017
- Deadline11 May 2017
- Published on judiciary.uk24 Mar 2017
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Cwm Taf Morgannwg University Health Board | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 11 May 2017. A reply may have been sent and not yet published. |
| Welsh Assembly Government | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 11 May 2017. A reply may have been sent and not yet published. |
The coroner’s concerns
as follows The MATTERS OF CONCERN are as follows. – (1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations. On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM. The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter. Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been. It was accepted at the inquest that this was a failure for which no explanation was forthcoming.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2017-0074
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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