Pamela SINGH · Prevention of Future Deaths report

On 6 June 2022 I commenced an investigation into the death of Pamela SINGH. The investigation concluded at the end of the inquest on 18 September 2025. The conclusion of the inquest was Natural Causes.

1a Bronchopneumonia

1b

1c

II

These were recorded as :-

Pamela Singh died of pneumonia, the signs and symptoms of which had progressed over the course of 3 days. These signs and symptoms were difficult for family and professional care staff to identify and attribute to a potential illness. As a consequence no contact was made with a medical professional until after she went into cardiac arrest. She died on 29 May 2022 at 14 Taymuir Road Splott Cardiff. If she had received medical attention at hospital before she went into cardiac arrest it is likely her death would have been avoided.

(1) The deceased had a learning disability and died of a community acquired pneumonia, the death being avoidable if there had been earlier recognition of an acute deterioration in her health;

(2) The evidence heard from a Learning Disability Psychiatrist and expert in Critical Care was that people with a Learning Disability generally have a significantly increased mortality risk;

(3) The most common cause of avoidable deaths in people with a Learning Disability is pneumonia;

(4) Delays in recognising, escalating and responding to an acute deterioration is a significant factor in avoidable deaths of people with a Learning Disabilities;

(5) Family and professional care staff did not have any specific practice tool to help them recognise, escalate and ensure a response to concerns about signs of a potential acute deterioration;

(6) Neither the GP, Social Worker, or commissioned care provider were familiar with any such tool being used in Wales notwithstanding a recommendation in The Learning Disabilities Mortality Review (LeDeR) Programme Annual Report 2019 to "Adapt (and then adopt) the National Early Warning Score 2 regionally, such as the Restore2TM in Wessex, to ensure it captures baseline and soft signs of acute deterioration in physical health for people with learning disabilities"