Unwitnessed fall during ward transfer
Health Inspectorate Wales received 2 coroners' reports about this hazard between 16 Apr 2015 and 24 Jun 2026.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from Health Inspectorate Wales was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“He was transferred between wards at 1am in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed.”
Original on judiciary.uk ↗ No published response from Health Inspectorate Wales was found for this report.
- 11 years 2 months laterClosely relatedConfidence 0.85 · higha different coroner
“Delay in transferring between Antenatal and HDU wards. The delay in transferring [the deceased]'s mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised.”
Original on judiciary.uk ↗ Repeated from the earlier report:betweenwards
The most recent report. A response may not be due or published yet.
- All reports to Health Inspectorate Wales
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2015 → 2026Nola-Reign Morgan11 years 2 months after Robert Payne · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight problems with the timing and documentation of patient transfers between wards, creating periods where patients are left unmonitored or unsafe.
Robert Payne · 16 Apr 2015
“He was transferred between wards at 1am in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed.”
Original on judiciary.uk ↗ Nola-Reign Morgan · 24 Jun 2026
“Delay in transferring between Antenatal and HDU wards. The delay in transferring [the deceased]'s mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised.”
Original on judiciary.uk ↗
No published response from Health Inspectorate Wales was found for this report.
No published response from Health Inspectorate Wales was found for this report. It is the most recent report, so a response may not be due or published yet.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Health Inspectorate Wales at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2015 → 2026 | 0.64 | 0.04 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.