Glangwili General Hospital

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First report 20 Mar 2014•Latest report 30 May 2019

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 5
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from Glangwili General Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

30 May2019
Carmarthenshire and Pembrokeshire
Concerns raised3
1. Failure to preserve handover records
2. Failure to keep risk management strategies up to date in records
3. Lack of an overarching risk management plan for treating and caring for patients
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Emily Katherine Inglis · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Emily Katherine Inglis was found deceased in her bedroom at Prince Philip Hospital on 22 April 2016, with a plastic bag over her head; the cause of death was given as plastic bag asphyxia. The inquest identified concerns about the absence of an overarching risk management plan and deficiencies in record-keeping, including risk management strategies and handover records.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glangwili General Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to preserve handover records
Wider context from the report
“(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 and in preserving handover records. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glangwili General Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to keep risk management strategies up to date in records
Wider context from the report
“(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 and in preserving handover records. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glangwili General Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of an overarching risk management plan for treating and caring for patients
Wider context from the report
“(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. ”
Open source report
6 Nov2018
Carmarthenshire and Pembrokeshire
Concerns raised4
1. Failure to ensure nursing staff are trained to use the nutritional-needs diagnostic tool correctly
2. Failure to discuss disputed acute dietetic referrals at a multidisciplinary team meeting
3. Failure of nursing staff to act on referrals to the acute dietetic service
1. Insufficient staffing of the acute dietetic service for timely referral response
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Gerwyn James Thomas · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Gerwyn James Thomas was admitted to hospital after a domestic fall that caused a fractured femur and required surgery. He later developed an infection and died after being readmitted to hospital three times; the inquest recorded sepsis, multi-organ failure and infected hip surgery as the medical cause of death. Concerns included delays in responding to acute dietetic referrals, insufficient staffing, and inadequate training in nutritional assessment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glangwili General Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure nursing staff are trained to use the nutritional-needs diagnostic tool correctly
Wider context from the report
“2. The use of the diagnostic tool to assess a patient’s nutritional need, which nursing staff apply when a patient is admitted, requires training. When wrongly applied, this diagnostic tool will give an unreliable assessment. Training in the use of this diagnostic tool should be made mandatory for all nursing staff. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glangwili General Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to discuss disputed acute dietetic referrals at a multidisciplinary team meeting
Wider context from the report
“3. When a treating doctor identifies a need for a patient to be referred to the acute dietetic service, nursing staff should act upon this referral and in circumstances where nursing staff believe that such a referral is unnecessary this should be discussed at a multi-disciplinary team meeting. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glangwili General Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of nursing staff to act on referrals to the acute dietetic service
Wider context from the report
“3. When a treating doctor identifies a need for a patient to be referred to the acute dietetic service, nursing staff should act upon this referral and in circumstances where nursing staff believe that such a referral is unnecessary this should be discussed at a multi-disciplinary team meeting. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glangwili General Hospital; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staffing of the acute dietetic service for timely referral response
Wider context from the report
“1. The acute dietetic service lacks sufficient staff to respond to referrals in a timely way. ”
Open source report
3 May2016
Carmarthenshire and Pembrokeshire
Concerns raised1
1. Failure to provide ligature-free windows in service user areas
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mihangel ap Dafydd · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mihangel ap Dafydd was detained under the Mental Health Act and placed under 15-minute observations after being assessed as at risk of self-harm. On 16 February 2014 he was found hanging from a window using a bag strap; concerns included the incorrect removal of potentially harmful property and windows that had not been adapted to prevent their use as ligature points, which the jury found contributed to his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glangwili General Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide ligature-free windows in service user areas
Wider context from the report
“The windows in service user areas at Morlais Ward are not ligature free and whilst it is intended to make them so following the death of Mr ap Dafydd this work has not yet been undertaken. ”
Open source report
12 Feb2016
Carmarthenshire and Pembrokeshire
Concerns raised2
1. Failure to ensure monitoring of creatinine clearance
2. Failure to ensure safe tinzaparin prescribing and blood-level monitoring
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Margaret Hions · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Margaret Hions was admitted to Glangwili Hospital on 1 July 2013 and later transferred to Prince Philip Hospital, where she died on 27 August 2013. During her admission, a large bruise rapidly expanded after warfarin was replaced with tinzaparin. Concerns were raised about tinzaparin prescribing, monitoring of blood levels, and monitoring creatinine clearance, with the inquest identifying shortcomings in the management of her care at Glangwili Hospital.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glangwili General Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure monitoring of creatinine clearance
Wider context from the report
“(1) That there should be a review of the current Health Board practice in the prescribing of tinzaparin medication and the monitoring of blood levels. (2) That the importance of monitoring creatinine clearance as per Health Board clinical pharmacy policy to be reiterated to medical team and pharmacists. These matters were identified by a Root Cause Analysis Investigation report but it was unclear at the inquest whether these recommendations have yet been acted upon. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glangwili General Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure safe tinzaparin prescribing and blood-level monitoring
Wider context from the report
“(1) That there should be a review of the current Health Board practice in the prescribing of tinzaparin medication and the monitoring of blood levels. (2) That the importance of monitoring creatinine clearance as per Health Board clinical pharmacy policy to be reiterated to medical team and pharmacists. These matters were identified by a Root Cause Analysis Investigation report but it was unclear at the inquest whether these recommendations have yet been acted upon. ”
Open source report
20 Mar2014
Carmarthenshire and Pembrokeshire
Concerns raised2
1. Failure to make CT scan results promptly available to departments involved in patient care
2. Failure to act on CT scan results without delay within a reasonable time-scale
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Robert Erryl Jones · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Robert Erryl Jones was admitted for bowel surgery and remained in hospital as his health declined. Delays in reporting and acting on the results of an emergency CT scan led to a significant delay in further surgery. The principal concern was that CT scan results should be made available promptly to the relevant departments and acted upon without delay where appropriate.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glangwili General Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to make CT scan results promptly available to departments involved in patient care
Wider context from the report
“That when a CT scan is performed the results should be made available promptly to the departments involved in the care of the patient and where appropriate the results should be acted upon without delay and within a reasonable time-scale. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Glangwili General Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to act on CT scan results without delay within a reasonable time-scale
Wider context from the report
“That when a CT scan is performed the results should be made available promptly to the departments involved in the care of the patient and where appropriate the results should be acted upon without delay and within a reasonable time-scale. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised3

Failure to preserve handover records

Failure to keep risk management strategies up to date in records

Lack of an overarching risk management plan for treating and caring for patients

Concerns raised4

Failure to ensure nursing staff are trained to use the nutritional-needs diagnostic tool correctly

Failure to discuss disputed acute dietetic referrals at a multidisciplinary team meeting

Failure of nursing staff to act on referrals to the acute dietetic service

Insufficient staffing of the acute dietetic service for timely referral response

Concerns raised1

Failure to provide ligature-free windows in service user areas

Concerns raised2

Failure to ensure monitoring of creatinine clearance

Failure to ensure safe tinzaparin prescribing and blood-level monitoring

Concerns raised2

Failure to make CT scan results promptly available to departments involved in patient care

Failure to act on CT scan results without delay within a reasonable time-scale