“5 Following Mrs”
Dated 28 May 2024, 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
All responses publishedReplies were due by 23 Jul 2024.
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; a reply may have been sent and not yet published.
- Report dated28 May 2024
- Deadline23 Jul 2024
- Published on judiciary.uk31 May 2024
- Today24 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Cwm Taf Morgannwg University Health Board | Response publishedPublished on judiciary.uk in May 2024. |
The coroner’s concerns
5 Following Mrs. Winter’s death, her family raised concerns about her post operative care. I did not find that her post operative care more than minimally contributed to Mrs. Winter’s death. However, following an internal review: 1. The Health Board accepted that significant learning was required by staff regarding timeliness of escalation and maintenance of fluid balance charts and recommended that all registered nurses from surgical wards should attend an ‘Acutely Unwell’ study day, before the end of 2023. 2. This ‘significant learning’ has not been fully rolled out due to resourcing issues. No completion date could be provided to me because the training is not considered to be compulsory.
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, 2024-0289
- Added to Minute Book
- 8 Oct 2026
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- 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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