Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0032, written 17 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jan 2025 |
|---|---|
| Reference | 2025-0032 |
| Deceased | Jackson Yeow |
| Coroner | David Regan |
| Coroner area | South Wales Central |
| Category | Child Death (from 2015) · Emergency services related deaths (2019 onwards) · Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Chief Executive of the Cwm Taf Morgannwg University Health
Board
1 CORONER
I am David Regan, Assistant Coroner, for the coroner area of South Wales
Central.
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice
Act 2009 and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013.
3
INVESTIGATION and INQUEST
A Coronial investigation was commenced on 20th April 2022 into the death of
Jackson Yeow, aged 16. The investigation concluded at the end of the inquest
which I conducted on 15th -16th January 2025. The conclusion was a narrative
conclusion and the medical cause of death was 1 (a) cerebral oedema, 1(b)
diabetic ketoacidosis; 2 recent covid 19 infection; pancreatitis
4 CIRCUMSTANCES OF THE DEATH
These were recorded as: -
Jackson Yeow, aged 16 years, suffered autistic spectrum disorder and obesity.
On 28th March 2022 he was assessed by a general practitioner following a
history of abdominal pain and vomiting, diagnosed with suspected gastritis, and
treated. On 4th April 2022 his mother became concerned that his symptoms had
worsened and sought the assistance of the general practice by telephone.
Jackson was unable to mobilise to attend GP consultation in person and his
mother phoned 999 at 12.13. Despite subsequent clinical support desk review
and further 999 calls, an ambulance service resource was not allocated until after
1
Jackson became unconscious at about 19.30, attending at 20.00. Jackson was
subject to a prolonged extrication from his house with fire service and EMERTS
assistance, was intubated and taken to the University Hospital of Wales where
he was diagnosed to be suffering diabetic ketoacidosis, pancreatitis, cerebral
oedema, renal compromise and severe acidosis. Despite intensive treatment
over the subsequent days his condition deteriorated and he died on 9th April
2022.
The narrative conclusion which I returned was:
Jackson Yeow, aged 16, died of diabetic ketoacidosis following a wait for an
ambulance of approximately 9 ½ hours.
The Inquest focused upon: -
a. The fact that Jackson Yeow’s condition deteriorated on 4th April 2022.
His family contacted his GP and was offered a face to face appointment
which he became physically unable to attend.
b. His family telephoned 999 at 12.13 on 4th April 2022.
c. The ambulance service categorised the call as an amber 1 response,
which it characterised as a life threatening call requiring an urgent
response.
d. The evidence of the ambulance service was that its ability to respond to
the call was substantially impaired by the fact that a significant number
of its resources were delayed at hospitals awaiting hand over of patients.
e. An ambulance did not attend until 20.00 on 4th April 2022, by which
time Jackson Yeow had suffered a substantial metabolic derangement,
cardiovascular collapse and renal impairment. He was severely acidotic.
f. The first language of the family was not English. Although some
clinicians were able to use the services of an interpreter, this was not
always employed.
5 CORONER’S CONCERNS
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. –
2
Although the Cwm Taf Morgannwg University Health Board did not provide
direct care to Jackson Yeow during the period within scope, it provided the
evidence of a consultant in emergency medicine to the inquest on the issue of
delays in ambulance handovers at the Princess of Wales Hospital, Bridgend.
That evidence directly identified the following matters of concern:
(1) Care for patients in the emergency department is frequently provided in
the corridor and other non clinical spaces, which:
(a) Impedes efficient clinical assessment, causing clinicians to take
longer performing tasks and rendering clinical care more difficult;
(b) Impedes the ability of staff to recognize a patient’s deteriorating
condition;
(c) Increases patient morbidity
through environmental
factors
compromising a patient’s ability to sleep, hygiene and nutrition.
(d) May slow the process of ambulance handovers.
(2) Care in corridors and other non clinical spaces has been normalized,
which in the opinion of the consultant who gave evidence is unsafe.
(3) When conducted routinely, care in corridors and other non clinical
spaces reduces the capacity of the Emergency Department so that should
acuity escalate, it is likely to cause delays to the release of ambulances.
(4) The underling obstacle to improving flow through the hospital and
relieving pressure on the Emergency Department is the significant
number of patients who are medically fit to be discharged but whose
discharge is delayed due to non medical reasons.
6 ACTION SHOULD BE TAKEN
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.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 14th March 2025. I, the Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken,
setting out the timetable for action. Otherwise you must explain why no action
is proposed.
3
8 COPIES and PUBLICATION
I have sent a copy of my report to the following who may find it useful or of
interest.
The Welsh Government, the Chief Executive of the Welsh Ambulance
Services NHS Trust, the Chief Executive of the Cardiff and Vale University
Health Board; The family; The General Practitioners who were recognised as
interested persons
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or
summary form. He may send a copy of this report to any person who he
believes may find it useful or of interest. You may make representations to me,
the Coroner, at the time of your response, about the release or the publication
of your response by the Chief Coroner.
9
17th January 2025
SIGNED
D Regan
Assistant Coroner
4
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
ckeu GWELA YsHRYDOL | CYNNALEIt IECHYD GOFAL POUL DYFODUL srl Incived Pratysuok " lorgjannayc sy University Healt Board CREATING — IMPROVING INSPIRING SUSTAINING HEALTH CARE PCOPLE OUR FUTURE, Cyfeiriad Dychwelyd/ Return Address: Bwrdd Iechyd Prifysgol Cwm Taf Morgannwg Cwm Taf Morgannwg University Health Board Pencadlys Headquarters Parc Navigation, Navigation Park Abercynon Abercynon CF45 4SN CF45 4SN Ffén/Tel: 01443 744803 Eich cyf/ Your Ref: Ein cyf/Our Ref: PM/DH Ebost Email: Dyddiad/Date: 11 March 2025 D Regan Assistant Coroner The Old Court House Court House Street Pontypridd CF37 1JW Dear Mr Regan, Thank you for your letter to the Health Board on 17" January 2025, and the attached Regulation 28 Report regarding the tragic case of Jackson Yeow. We acknowledge the serious concerns raised about patient care within the Emergency Department (ED) at Princess of Wales Hospital (POWH), particularly the use of corridor spaces for patient care, the impact on ambulance handovers, and broader hospital flow challenges. We would like to reassure you that Cwm Taf Morgannwg University Health Board (CTMUHB) recognises the risks associated with these issues and is taking decisive action to address them. (1) Care for patients in the emergency department is frequently provided in the corridor and other non-clinical spaces, which: (a) Impedes efficient clinical assessment, causing clinicians to take longer performing tasks and rendering clinical care more difficult. CTMUHEB recognises that corridor care presents significant challenges to efficient clinical assessment and patient safety. We are actively working to reduce reliance on non-clinical spaces through investment in additional nursing staff, transformation programmes and improvements in patient flow, and the implementation of enhanced escalation processes. Cadeirydd/Chair: EEE Prif Weithredwr/Chief Executive: Croeso i chi gyfathrebu 4‘ bwrdd jechyd yn y Gymraeg neu'r Saesneg. Byddwn yn ymateb yn yr un iaith a ni fydd hyn yn arwain at oedi. You are welcome to correspond with the Health Board in Welsh or English. We will respond accordingly and this will not delay the response. bttes-//cimuhb.nhs. wales A key element of our improvement strategy has been the full recruitment of additional nursing staff, including an increased number of senior nurses within the department. This ensures that senior clinical oversight is available 24/7, with dedicated senior staff responsible for maintaining patient safety and ensuring timely clinical assessment, initiation of treatment and if required escalation of care. The joint RCEM & Royal College of Nursing (RCN) Nursing Workforce Standards for Type 1 Emergency Departments (2020) clearly outlines the balanced workforce requirements for EDs, ensuring that there is the correct skill mix with appropriate knowledge and skills to provide safe, effective, high-quality emergency care in a timely and sustainable manner. This guidance is not solely based on the numbers required in accordance with staff-to- patient ratios within the ED but has a heavy focus on skill mix, experience, and ‘banding’ of the nurses required. The RCN BEST Tool has been used to determine optimal staffing levels, ensuring the correct distribution of senior and junior nursing staff within the Emergency Department. These measures align with recent Health Inspectorate Wales (HIW) recommendations, which previously identified workforce gaps that required urgent action to improve patient safety. Furthermore, the Welsh Emergency Medicine Workforce Census (2023) highlighted that current staffing shortfalls contribute to increased workload and clinician burnout, ultimately impacting patient care quality. The service's leadership team have a keen focus on the right staffing levels and have attracted significant investment into the ED workforce to ensure the safety and effectiveness of care delivery across Princess of Wales Hospital ED. We are committed to ongoing improvement across our Emergency Departments and working towards the eradication of corridor care unless in extremis. As part of this work the leadership team are working in collaboration with the POW site based team to develop a capital programme to create a dedicated ambulatory bay. The scoping for this work has already happened and capital colleagues are working through feasibility, costing and timeframes for this work. This is a priority to reduce the reliance on non-clinical spaces and to improve patient experience within the ED. Additionally, the STAMP (Strategic Transformation of Acute Medicine Programme) and OPTIMISE programmes have been introduced to improve patient flow across CTM. The Optimise programme utilises real-time digital tools, such as Red2Green and eWhiteboards, to ensure patients are placed in the right clinical area as quickly as possible. Early implementation of these initiatives across Royal Glamorgan and Prince Charles Hospital have significantly reduced patient delays and improved overall care efficiency and the next phase of roll out includes POW site. (b) Impedes the ability of staff to recognise a patient’s deteriorating condition. Ensuring early recognition of patient deterioration is a priority. Any patient placed in an ambulatory area or chair is deemed appropriate to be cared reviewed regularly by senior staff. Those who require a major trolley space are escalated as a clinical priority. This information is captured via the enhancement our real-time documentation, safety huddles and information shared via Safe2Start meetings The float nurse role has been strengthened to provide continuous monitoring of patients in non-clinical spaces. Additionally, DATIX incident reporting is used to capture any patient safety concerns, ensuring rapid escalation to the appropriate senior staff for immediate action. Any patient safety concerns are escalated immediately with prompt transfer of patients to a more clinically appropriate area. This is supported by a ring-fenced escalation space within the ED at POW. Once this space is breached this initiates a site based response to on-board patients into pre-identified areas across the site in order to balance risk. (c) Increases patient morbidity through environmental factors compromising a patient’s ability to sleep, hygiene, and nutrition. Recognising the impact of environmental factors on patient wellbeing, the service is working with the POW ED team on a capital proposal to create a dedicated ambulatory area. This will provide a more appropriate environment for patients who do not require a trolley space but still need ongoing clinical care. We have also implemented strategies to ensure patients in non-clinical spaces have access to adequate nutrition and hydration, with additional staffing to support basic care needs. (d) May slow the process of ambulance handovers. Corridor care can contribute to delays in ambulance handovers. To mitigate this, we have implemented: - A fully recruited nursing workforce, reducing the reliance on agency staff and ensuring a consistent, well-trained team is available to manage ambulance arrivals efficiently and make dynamic risk-based decisions on ensuring timely handover of patients and release of ambulance resources. - We have made significant improvements at POW on ambulance handover times over the past 18 months and we are committed to ongoing improvement in this area. - Adedicated BRATZ assessment area, where patients are triaged quickly to allow for safe and efficient handovers. - Ongoing work with Welsh Ambulance Service Trust (WAST) on optimum clinical patient pathways and the Discharge to Recover then Assess (D2RA) Hub, which has improved discharge planning and increased hospital capacity to accept new admissions . (2) Care in corridors and other non-clinical spaces has been normalised, which in the opinion of the consultant who gave evidence is unsafe. CTMUHB does not consider corridor care to be a safe or acceptable long-term solution. While we acknowledge that corridor care does exist due to extreme capacity pressures, patient safety remains paramount. Recognising this, CTMUHB is reinforcing patient monitoring within the ED through enhanced float nurse roles, strengthened Safe2Start meetings, and optimised escalation processes. These measures will ensure that patients receiving care in non-clinical areas remain under continuous assessment, mitigating risks associated with deterioration and delayed interventions. Our escalation process ensures that any patient who requires a major trolley space is prioritised, with clinical reviews taking place regularly. (3) When conducted routinely, care in corridors and other non-clinical spaces reduces the capacity of the Emergency Department so that should acuity escalate, it is likely to cause delays to the release of ambulances. To prevent corridor care from becoming routine, we in the process of implementing the Optimise programme, which prioritises effective patient flow. Key components include: - The use of digital tools that track patient progress in real-time, ensuring that bottlenecks are identified early. - Implantation of the SAFER board rounds, ensuring all patients receive timely care and are not delayed unnecessarily. - Increased discharge efficiency through collaborative working with community services by implementing the Discharge to Recover then Assess (D2RA) model, reducing the number of medically fit patients occupying acute hospital beds. Following implementation of these models on both the POW site and across our two other acute sides have already improved ambulance offload times, with reduced overcrowding in the ED and improved patient experience. (4) The underlying obstacle to improving flow through the hospital and relieving pressure on the Emergency Department is the significant number of patients who are medically fit to be discharged but whose discharge is delayed due to non-medical reasons. To tackle delayed discharges, CTMUHB has implemented: - The Discharge to Recover then Assess (D2RA) model, ensuring that patients who no longer require acute care are moved to the most appropriate setting as quickly as possible. - We have also developed the Discharge Hub as a centralised resource for patient flow and community bed allocation. - The Safe2Start meeting is now embedded pan CTM where twice a day the site is reviewed as a whole with real time demand and capacity being reviewed. Here clinical priorities are discussed and decisions are made in relation to patient flow, on boarding and balancing risk to ensure each area is safe to start. We continue to work in collaboration with local authority partners to improve social care availability and prevent unnecessary delays. Both the Optimise programme and STAMP programme have been instrumental in their early adoption in improving hospital flow by ensuring that discharge planning starts at the point of admission, reducing bed-blacking and allowing the ED to function more efficiently. We are committed to the roll out of this work pan CTM to continue these improvements. | would like to provide assurance to you that this organisation takes very seriously the issues raised in this inquest and the subsequent Regulation 28. We appreciate the opportunity to provide this response and remain committed to ongoing improvement, patient safety, and working collaboratively with system partners. We would be very keen to meet and discuss any areas you would want further assurance or detail on and our future plans. Yours sincerely, Prif Weithredwr/Chief Executive
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