“The inquest identified that there should have been an overarching risk management plan in…”
Dated 30 May 2019, from the coroner for Carmarthenshire and Pembrokeshire. 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
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 2 Aug 2019, after the 56 days for replies had ended (25 Jul 2019). 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 dated30 May 2019
- Deadline25 Jul 2019
- Published on judiciary.uk2 Aug 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Hywel Dda University Health Board | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 2 Aug 2019, after the 56 days for replies had ended (25 Jul 2019). These dates can’t tell us whether a reply was due before it went online. |
| Glangwili General Hospital | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 2 Aug 2019, after the 56 days for replies had ended (25 Jul 2019). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
(1) The inquest identified that there should have been an overarching risk management plan in place to assist medical professionals and staff in treating and caring for Emily. (2) The inquest further identified that there were deficiencies in record-keeping, both in terms of ensuring that risk management strategies remained up-to-date 1 and in preserving handover records.
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, 2019-0177
- 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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