Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0238, written 21 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 May 2025 |
|---|---|
| Reference | 2025-0238 |
| Deceased | Marina Waldron |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | 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.
Regulations 28 and 29 of the Coroners’ (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS 1 2 3 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive of Aneurin Bevan University Health Board CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent 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 INVESTIGATION AND INQUEST On 28/2/2024 an investigation was opened touching upon the death of Marina Lorraine Waldron The investigation concluded at the end of the inquest on 9/5/2025 The conclusion of the inquest was recorded as A Narrative Conclusion in the following terms: “Marina Lorraine Waldron died from the effects of aortic valve disease contributed to by the side effects of treatment for ischaemic heart disease on 15/2/2024 at the Grange University hospital in Llanfrechfa. Her death was also contributed to by malnutrition. The medical cause of death was: 1a) Lower Gastro-intestinal bleeding from angiodysplasia 1b) Aortic Stenosis 4 2. Ischaemic heart disease with recent stent placement. Malnutrition. CIRCUMSTANCES OF THE DEATH Marina Waldron was admitted to hospital on 17/12/2023 with evidence of gastrointestinal bleeding. I will not describe in detail the investigations performed or the treatment she received thereafter. I found that this difficult situation was investigated and managed appropriately. Despite receiving all appropriate treatment the gastrointestinal bleeding, caused by angiodysplasia, an uncommon complication of aortic stenosis, proved overwhelming and MW died on 15/2/2024. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: - During the 8 ½ weeks of MW’s hospital admission, her nutritional needs were poorly considered or managed. Examples of this include: 1. An ongoing failure to heed the family’s concerns that from admission to hospital, MW was not eating or drinking adequately 2. A failure to formally monitor MW’s dietary intake 3. A failure to respond to a low Albumin level which is a sign of malnutrition 4. Dietary advice and parenteral feeding were not properly considered until 29/1/2024 (6 weeks after admission) The medical staff who gave evidence agreed that malnutrition contributed to MW’s death. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. Whilst the cause of the malnutrition was likely to be multi-factorial, nonetheless basic steps to address the situation were not taken. I am concerned that poor attention to the basic nutritional needs could give rise to future deaths, especially in the elderly and those with depleted physiological reserves. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely I, the Coroner, may extend this 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 necessary COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) The family of Marina Lorraine Waldron I am also under a duty to send the Chief Coroner a copy of your response. 6 7 8 The Chief Coroner may publish either or both in a complete or redacted 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 DATE 20/5/2025 Signed Caroline Saunders His Majesty’s Senior Coroner for Gwent.
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.
, Cadeirydd | Chair , Prif Weithredwr | Chief Executive Your ref: Private and Confidential Caroline Saunders Senior Coroner for Gwent Sent by email to: Dear Ms Saunders Thursday 17 July 2025 Response to Regulation 28 Report received following the inquest touching on the death of Marina Lorraine Waldron Thank you for your letter and accompanying report, which the Health Board received on 22 May 2025. I am writing to provide you with the Health Board’s response to the Regulation 28 report to prevent future deaths, following the inquest into the death of Marina Lorraine Waldron. To provide assurance to the Coroner that sustained improvements are being embedded across our organisation, we have established a dedicated governance structure focused on nutrition and hydration. This structure strengthens our ability to deliver coordinated quality improvement initiatives and ensures systematic oversight through our Quality Management System. The governance model comprises a strategic group supported by two operational sub-groups, each with defined responsibilities and multi-disciplinary representation to ensure robust oversight from board to ward. The Strategic Nutrition and Hydration Group provides senior leadership and organisational accountability. It is chaired by the Assistant Director for Allied Health Professions and Health Science, with Deputy Director-level representation from Nursing and Medicine. Membership includes colleagues from finance, digital, quality and patient safety, with Llais invited to participate to ensure the voice of service users is reflected. The group meets every two months and has standing agenda items including review of incident trends, risk register monitoring, and oversight of strategic improvement programmes. It also acts as an expert advisory group to the wider organisation on matters relating to nutrition and hydration safety. Two operational sub-groups report directly to the Strategic Group: • Food Standards Group – A multi-disciplinary group with responsibility for day-to-day operational oversight of food service delivery and specialist dietary needs. The group reviews incidents, identifies service improvements, and plays a key role in implementing the updated All-Wales Nutrition and Catering Standards for Food and Fluid Provision for Hospital Bwrdd Iechyd Prifysgol Aneurin Bevan Pencadlys, Ysbyty Sant Cadog Ffordd Y Lodj, Caerllion, Casnewydd NP18 3XQ Aneurin Bevan University Health Board Headquarters, St Cadoc’s Hospital Lodge Road, Caerleon, Newport NP18 3XQ 01633 436 700 BwrddIechydPrifysgol BIPAneurinBevan 01633 436 700 AneurinBevanHealthBoard AneurinBevanUHB Rydym yn croesawu gohebiaeth yn Gymraeg a byddwn yn ymateb yn Gymraeg heb oedi. Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan. We welcome correspondence in Welsh and we will respond in Welsh without delay. Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board. Inpatients. This group meets monthly and escalates key issues and recommendations to the Strategic Group. • Clinical Standards Group – A multi-professional group overseeing clinical practice and standards relating to nutrition and hydration across acute, community, maternity, paediatric, and older adult services. This group ensures consistent clinical standards, monitors nutrition- related incidents, oversees risk assessments, and drives delivery of associated action plans. It also meets monthly and reports directly into the Strategic Group. The introduction of this governance framework has already supported the implementation of key improvement actions at pace, including enhanced monitoring of fluid balance, improved escalation protocols for malnutrition risk, and strengthened documentation and compliance monitoring. These initiatives are being embedded within our Quality Management System and have enabled a more responsive and accountable approach to preventing avoidable harm. In summary, this strengthened governance structure ensures senior oversight, operational alignment, and service user involvement in driving continuous improvement in nutrition and hydration safety. It provides a clear mechanism for ensuring that learning from serious incidents translates into meaningful and sustainable change across the organisation. As requested, the information presented below outlines the actions that have been taken and are being taken by Aneurin Bevan University Health Board to mitigate the risk of similar incidents occurring in future. These actions are framed within a comprehensive, multi-professional, timed improvement programme which is included as an appendix to this letter. Concern 1: Failure to heed the family’s concerns about poor nutritional intake We acknowledge the family's repeated concerns and regret that these were not adequately responded to. To address this, the Health Board has implemented or will implement actions under Recommendation 1 of the attached plan, including: • Introduction of ward-level reflection sessions using anonymised case studies to explore communication challenges. • Piloting of the divisional communication tool, AIDET and “difficult conversations” training. • Promotion of the “Call for Concern” protocol to enable families to escalate issues directly. • Inclusion of Llais (the patient voice) within the Nutrition & Hydration strategic group Concern 2: Failure to formally monitor dietary intake To improve compliance and accuracy in monitoring nutritional intake, Recommendation 2 of the action plan focuses on: • Development and deployment of a “Gold Standard” food chart and supporting 7-minute staff briefing. • Reinforcement of red tray and visual identifiers for patients requiring dietary monitoring. • Use of Audit Management and Tracking system (AMaT) data to assess and improve ward- level compliance with food chart use. • Exploration of environmental barriers such as early tray clearance or single-room isolation. Concern 3: Failure to respond to low albumin levels Under Recommendation 3, we are strengthening escalation frameworks to support timely clinical decision-making. Key actions include: • Dissemination of a Clinical Escalation Framework across all clinical divisions. • • Initiating a thematic review of delayed escalations related to nutritional concerns. Incorporation of learning into multidisciplinary forums such as Patent Safety & Quality Learning & Improvement forum Concern 4: Delayed dietary advice and parenteral feeding consideration The need for earlier specialist involvement and clear documentation around nutritional care is being addressed through Recommendation 4, including: Improved recording of patient capacity and preferences in feeding decisions. • • Review of SBAR (document designed to ensure accurate patient information is recorded and passed to receiving clinician following patient moves) and transfer documentation to include specific prompts on nutrition • Reassessment of patient transport and discharge processes to ensure nutritional needs are considered. To embed sustained improvement and shared learning across the organisation, Recommendation 5 focuses on: • Nutrition & Hydration-focused divisional learning days. • Presentations of Nutrition & Hydration quality improvement initiatives at key governance forums. Integration of progress updates into Quality Safety Learning and Improvement structures. • Ongoing Monitoring and Governance This action plan has been jointly developed by senior nursing, medical and allied health professions leadership with oversight from the Executive Director of Allied Health Professions (AHP) & Health Science and Executive Director of Nursing. A full governance route is in place, including the Nutrition & Hydration strategic group, Clinical Nutrition & Hydration sub-group, Ward Accreditation processes, and integration into the Health Board’s risk register and quality reporting structures. I would like to personally assure you that there is organisational-wide commitment to ensuring that the circumstances surrounding Mrs Waldron’s death led to meaningful and lasting improvements in the care of vulnerable patients. Please find enclosed our detailed action plan for your review. Should any further clarification or assurance be required, we would be happy to provide it. Yours sincerely, Prif Weithredwr | Chief Executive Enclosed: Action Plan
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