“At inquest, the errors in assessing the urgency of the need for medical assistance and…”
Dated 7 Aug 2018, from the coroner for South Wales Central. Sent to 5 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
Report put online after its 56 daysOrganisations 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; a reply may have been sent and not yet published.
judiciary.uk put this report online on 25 Oct 2018, after the 56 days for replies had ended (2 Oct 2018). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated7 Aug 2018
- Deadline2 Oct 2018
- Published on judiciary.uk25 Oct 2018
- Today28 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Welsh Ambulance Services University NHS TrustNamed in the report as “Welsh Ambulance Services NHS Trust” | Response publishedPublished on judiciary.uk in October 2018. |
| Cwm Taf University Health Board | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 25 Oct 2018, after the 56 days for replies had ended (2 Oct 2018). These dates can’t tell us whether a reply was due before it went online. |
| Cardiff and Vale University Health Board | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 25 Oct 2018, after the 56 days for replies had ended (2 Oct 2018). These dates can’t tell us whether a reply was due before it went online. |
| NHS Wales Shared Services Partnership | Response publishedPublished on judiciary.uk in October 2018. |
| REDACTED | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 25 Oct 2018, after the 56 days for replies had ended (2 Oct 2018). These dates can’t tell us whether a reply was due before it went online. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch's death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following: i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays; ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital: iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay; iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation.
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, 2018-0267
- 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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