Pamela Singh

I am Gavin Knox HM Coroner , for the coroner area of South Wales Central

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.

During the course of the inquest the evidence revealed matters giving rise to concern. In  my opinion there is a risk that future deaths will occur unless action is taken. In the  circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (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’

In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.