“The clinicians assessing Manon on admission to Ty Llidiard did not have available to them…”
Dated 26 Jan 2022, from the coroner for South Wales Central. Sent to 1 organisation or person.
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 20 Sep 2022, after the 56 days for replies had ended (23 Mar 2022). 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 dated26 Jan 2022
- Deadline23 Mar 2022
- Published on judiciary.uk20 Sep 2022
- Today21 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Cwm Taf Morgannwg University Health Board | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 20 Sep 2022, after the 56 days for replies had ended (23 Mar 2022). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
– (1) The clinicians assessing Manon on admission to Ty Llidiard did not have available to them the records of her care made in the community by the Crisis team, the Community Intensive Treatment team or the University Hospital of Wales (2) The Clinical records in the Ty Llidiard Unit were not all entered contemporaneously in a single clinical record (3) The absence of a single in and outpatient clinical record impaired the ability of the clinicans at the unit on admission to be able to assess Manon, fix a safe levels of observations, and safeguard her.
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, 2022-0174
- 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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