The unexpected deaths of 11 patients known to mental health services are among the serious incidents Cardiff and Vale University Health Board (UHB) has reported to the Welsh Government.
The board said it was thought that the coroner was likely to conclude suicide in three of the patients' deaths while the circumstances for the deaths of the remaining eight patients were not yet confirmed.
Their deaths were among 76 serious incidents the health board has reported to the Welsh Government in September and October.
Ruth Walker, executive nurse director at Cardiff and Vale UHB, told a board meeting on November 29 that not all the deaths were related to the patients' mental health - she said one died on the day of release from prison, another in prison and another from coronary artery disease.
A total of 47 of those serious incidents related to pressure ulcers across several services and departments of the hospital board.
Work has been done with district nurses to improve the reporting of pressure damage in community care settings, which is contributing to the number of related serious incidents being reported, a health board report said.
The health board reported eight falls where patients suffered significant injuries.
A patient had an incorrect lens inserted during a ophthalmology procedure on their eye. The procedure was being managed by an external provider commissioned by the health board.
This incident is now being treated as a 'never event' - classed as serious, largely preventable and that should not have happened.
In another incident reported to Welsh Government, a patient was discharged from a ward and unexpectedly readmitted five days later - and died following his readmission.
Mrs Walker said this was not initially reported at a serious incident at the time as the patient was felt to have been fit for discharge but there was a view more could have been done around discharge planning.
"This is why we reported it as a serious incident, because we want to investigate it more closely," she said.
The plight of one mental health patient...
An incident of "significant" self-harm to a patient who required admission to acute services to tend to her physical wellbeing, prior to transfer to Hafan Y Coed mental health unit, was also reported to Welsh Government.
An unexpected death of a child has also been reported as a serious incident and the procedural response to unexpected death in childhood process has been started.
The health board reports all serious incidents to Welsh Government, the public and to its board members.
Welsh Government guidance also requires the health board to report unexpected deaths of patients who are known to mental health services and die unexpectedly or experience serious harm in a community setting.
A health board spokeswoman said: "Patients and their families are made aware of incidents and are kept informed during investigations and discussions with our clinical teams.
"The increased reporting of pressure damage reflects a period of education and training of staff to improve the quality of data being recorded.
"All incidents are fully investigated and appropriate actions are taken to reduce the risk of recurrence in the future. This enables clinical boards and the corporate teams to identify areas of good practice but also to identify emerging trends and issues that require action in order to improve safety and quality of services."
