Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0384, written 28 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Jul 2025 |
|---|---|
| Reference | 2025-0384 |
| Deceased | Gareth Tatchell |
| Coroner | Aled Gruffydd |
| Coroner area | Swansea Neath & Port Talbot |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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:
CHIEF EXECUTIVE ABMU HEALTH BOARD
1 TALBOT GATEWAY
BAGLAN ENERGY PARK
BAGLAN
PORT TALBOT
SA12 7BR
1
CORONER
I am Aled Gruffydd, Senior Coroner, for the coroner area of SWANSEA NEATH &
PORT TALBOT
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
On the 19th of June 2024 I commenced an investigation into the death of Gareth Wynne
Tatchell. The investigation concluded at the end of the inquest on the 26th June 2025.
The medical cause of death is
1a) pneumonia
2 squamous cell carcinoma
The conclusion of the inquest as to how Mr Tatchell came to his death was a narrative
conclusion and is as follows:-
the deceased died from the natural cause of pneumonia having undergone treatment for
squamous cell carcinoma which had returned at the time of death. The delay in
providing treatment more than minimally contributed to the deceased’s death.
4
CIRCUMSTANCES OF THE DEATH
The deceased was Gareth Wynne Tatchell and he was pronounced dead on the 9th April
2024 at Princess of Wales Hospital, Swansea. The cause of death was pneumonia.
Squamous cell carcinoma was a contributing factor in his death.
Gareth was referred to the maxillo-facial team at Morriston Hospital on the 12th of April
2023 by his dentist following the discovery of an ulcer in the lower left mandible. The
referral was classed as an urgent suspected cancer (USC) and Gareth was seen in
outpatients clinic on the 28th of April 2023. Cancer was suspected at that point,
specifically a squamous cell carcinoma but it needed to be confirmed by a biopsy. That
1
biopsy took place on 18 May and the result came back on 30 May as a moderately
differentiated squamous cell carcinoma. Gareth was seen again on the 19th of June and
further tests consisting of a CT of the thorax, a CT angiogram of the legs and an MRI
and ultrasound of the neck were undertaken on the 28th. Care was then transferred to
the treating consultant maxillofacial surgeon who first saw Gareth on the 6th of July, and
then on the 27 July to discuss treatment, which would consist of surgery and
radiotherapy. Due to theatre capacity, the earliest date being 13 September. By the
week prior to surgery Gareth had developed a lump both inside and out, meaning that
the lump was visible on the outside but it would also have spread to the blood vessels in
the neck.
The surgery was able to remove the tumour macroscopically i.e all that was visible to the
naked eye, but as it was encasing the carotid it would not be possible to remove it all.
In February 2024 the treating consultant saw Gareth in hospital after he had gone in to
have the AAA repaired. It was then that Gareth complained of a pain in the neck which
prompted the CT scan showing an enlargement and a biopsy then confirmed that the
cancer had returned. Gareth was discharged from hospital following the AAA repair but
was readmitted to hospital on the 8th of March 2024. He subsequently passed away in
hospital on the above date.
5
CORONER’S CONCERNS
During the course of the inquest it transpired that the Suspected Cancer Pathway
introduced for the whole of Wales in 2019 required a suspected cancer to be diagnosed
and staged within 31 calendar days of the date of referral and for treatment to
commence within 62 calendar days from the date of referral. In this case the diagnostic
and staging phase was completed in 97 days from the date of referral and treatment
commenced within 144 days of the date of treatment. The result of that delay was that it
made the carcinoma more difficult to treat in that it would not have had the extracapsular
spread or the encasement of the carotid that was witnessed at the end of August and
which was not present around the end of June when treatment ought to have taken
place. Had the timescales had been complied with then treatment would have been
administered before extracapsular spread had occurred. Evidence was received from
the treating consultant that this contributed towards Gareth’s death.
Evidence was heard that since this incident there had been an improvement in theatre
capacity with additional theatre sessions having been allocated to oral and maxillofacial
surgery, and an additional Consultant Maxillofacial Oncological Surgeon has been
appointed to undertake both surgery and outpatient appointments.
The evidence could not point to improvements in radiology services however, which is
needed to undertake staging scans. This case underwent staging scans in May 2023,
however as recently as May 2025 a letter was sent to the Clinical Lead for Radiology by
two Associate Medical Directors expressing concerns that delays to staging scans are
causing unnecessary risk in aggressive cancers that are at risk of progression and
irresectable.
I am concerned that delays in undertaking staging scans are allowing such cancers to
progress to the point that they are irresectable, resulting in poor prognosis for patients
and reducing survivability rates and life expectancy and 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. There was a delay in both the diagnostic and staging phase and treatment
phase contrary to the timescales in the Suspected Cancer Pathway.
2. Part of the delays resolve around the time taken to undertake staging scans for
2
the purpose of the diagnostic and staging phase.
3. Two Associate Medical Directors have communicated that delays in undertaking
staging scans are ongoing and are having an impact on survivability rates and
prognoses by making treatable cancers irresectable.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you AND/OR
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 22 September 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following 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
28 July 2025 HM SENIOR CORONER ALED GRUFFYDD
3
2 responses 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.
Corporate Legal Services Trust Headquarters 225 Old Street Ashton Under Lyne Lancashire OL6 7SF 29 September 2025 Private & Confidential Chrstopher Morris HM Area Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Mr Morris, RE: Inquest touching on the death of Sasha Drysdale I set out below the Trust’s response to your letter to Pennine Care NHS Foundation Trust (PCFT) and the issuing of a Prevention of Future Deaths Notice (Regulation 28), arising from the inquest into the death of Sasha Drysdale and the proceeding Judicial Review. May I take this opportunity to extend my own condolences to the family of Sasha and apologise that you had to raise concerns relating to the services she accessed prior to her sad death. The Trust sets out its response to the points below raised by HMC’s as areas of concern: Whilst it is understood regular blood tests represent an important monitoring requirement for patients taking Clozapine in view of the serious potential side effects of neutropenia and particularly agranulocytosis, I am concerned that the emphasis on these complications raises a risk that the potential significance of other abnormal results may not be readily or promptly appreciated or acted upon, and remain overlooked or possibly incorrectly attributed to Clozapine therapy. Full Blood Count monitoring: Leucocyte (white blood cells) and neutrophil monitoring is a mandatory requirement for all patients treated with Clozapine in the UK. Summary of product characteristics: Clozaril In addition to the mandatory white blood cells (WBC) and neutrophil monitoring other full blood count parameters are currently monitored as standard either via Point of care haematological testing (PoCHi) or local lab analysis includingpocH-100i - Products Detail: • WBC (white blood cells), RBC (red blood cells), HGB (heamoglobin), HCT (haematocrit), MCV (Mean Corpuscular Volume), MCH (Mean Corpuscular Haemoglobin), MCHC (Mean Corpuscular Haemoglobin Concentration), PLT (platelets), LYM (#,%) (lymphocytes), MXD (#,%) (mixed white blood cells), NEUT (#,%) (neutrophils), These full blood count (FBC) parameters would be recommended as standard for assessment of haematological cancers Ref: Haematological cancers - recognition and referral | Health topics A to Z | CKS | NICE. Abnormal results, including neutropenia but also other abnormalities in FBC differentials obtained within a community setting are escalated to medical staff for review. Results for inpatient monitoring conducted via local labourites would be review directly by medical staff and appropriate action taken for abnormalities, neutropenia or otherwise. Medical staff would following NICE guidelines Haematological cancers - recognition and referral regardless of the original indication for Full Blood Count investigation. Pharmacovigilance Risk Assessment Committee for routine blood count monitoring (PRAC) recommendations PRAC has recently endorsed a direct healthcare professional communication (DHPC) about revised recommendations for the monitoring of the blood count to minimise the risk of severe neutropenia and agranulocytosis with Clozapine Ref: Meeting highlights from the Pharmacovigilance Risk Assessment Committee (PRAC) 7 – 10 July 2025 | European Medicines Agency (EMA) New evidence from the scientific literature suggests that, although Clozapine- induced neutropenia can occur at any time during treatment, it is predominantly observed during the first year, with the incidence peaking in the first 18 weeks of treatment. After this the incidence decreases becoming progressively lower after two years of treatment in patients without previous episode of neutropenia. Therefore, PRAC recommended less frequent blood count monitoring. For example, in patients without neutropenia, the frequency of monitoring is reduced to every 12 weeks after one year, and to once a year after two years of treatment. The product information for all Clozapine-containing medicines will be updated to reflect the monitoring frequency for the risk of Clozapine-related agranulocytosis and the revised ANC thresholds for treatment initiation and continuation. This is anticipated in Autumn 2025. The DHPC for Clozapine will be disseminated to healthcare professionals by the marketing authorisation holders in September 2025, and published on the Direct healthcare professional communications page and in national registers in EU Member States. Currently the UK remain unchanged however the emerging evidence for scientific literature is well known by the monitoring requirements for Clozapine within clinicians and will be circulated clearly to all PCFT prescribers and pharmacists. This will further increase the scrutiny of any abnormal full blood count results in patients on established treatment due to the known unlikelihood of Clozapine as a causative factor. I hope that the information within this response has provided you with the assurance that you were seeking in relation to learning from these events. Should you require any further information or clarification on the details within this letter, please do not hesitate to get in touch with me again. Yours sincerely Chief Executive
Bwrdd Iechyd Prifysgol Bae Abertawe
Swansea Bay University Health Board
Un Porthfa Talbot | One Talbot Gateway
Parc Ynni, Baglan | Baglan Energy Park
Port Talbot SA12 7BR
Dyddiad / Date: 17th September 2025
Mr Aled Gruffydd,
Senior Coroner,
Swansea & Neath Port Talbot.
Dear Mr Gruffydd,
Re: Regulation 28 Response: Mr. Gareth Wynne Tatchell
Thank you for providing Swansea Bay University Health Board with an opportunity to
respond to your concerns raised at the conclusion of the inquest of Mr. Gareth Wynne
Tatchell, on 26th June 2025.
Before addressing your specific concerns, I would like to extend my sincere
condolences to Mr. Tatchell’s family on behalf of Swansea Bay University Health
Board (SBUHB). We understand that bereavement and the inquest process can be
profoundly difficult for families. Although there has been a considerable time lapse
and Swansea Bay University Health Board was not involved in Mr Tatchell's end of life
care, our Care After Death service remains available should his family wish to access
it. For further information or support, please contact my office.
In terms of the concerns, you have expressed and the assurance you are seeking:
1. There was a delay in both the diagnostic and staging phase and treatment
phase contrary to the timescales in the Suspected Cancer Pathway.
While the Health Board has made significant progress in reducing waiting times for
cancer, we, along with many Health Boards, are not delivering the timeliness of care
as consistently as we would like. The challenges of delivering cancer waiting times is
reflected within the Health Board’s Risk Register.
The following actions are in place to address and mitigate this risk:
• Monitoring at an individual patient level is in place with weekly or fortnightly review
meetings depending on the specialty.
• There are explicit targets for each stage of the cancer pathway first appointment
(10 working days) and Decision to Treat (DTT) by Day 31, DTT to First Definitive
Treatment in 32 days. This information is collected for each specialty and reported
monthly.
• Action plans for each specialty are in place targeted at addressing areas of non-
compliance.
Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi.
We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay.
Cadeirydd/Chair: Jan Williams Prif Weithredwr/Chief Executive: Abigail Harris
Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR
Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe
Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR
Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board
• Additional support has been provided to histopathology to facilitate improvement
in the turnaround times, but this is still an area of considerable challenge for the
Health Board.
In order to monitor the effectiveness of the above actions the following assurance
mechanisms have been established:
• Development of digital performance dashboard to provide a “live” performance
status.
• Escalation meetings are held chaired by the Deputy Chief Operating Officer,
Deputy Medial Director and Cancer Lead Clinician as required.
• Monthly performance reported are provided to the Cancer Performance and
Information Group (chaired by the Deputy MD) and the Planned Care and Cancer
Board (chaired by the Chief Operating Officer).
• Monthly review meetings are in place with Welsh Government to monitor Health
Board performance.
The Health Board’s performance for head and neck cancers treated within the 62 days
required by the Single Cancer Pathway, varies month on month with on average 60%
of patient meeting the target over the last 12 months.
There are currently 148 patients on the head & neck cancer pathway in SBUHB. This
includes 16 patients who have been waiting longer than the 62-day target. However,
all 16 of these patients’ waiting times have been prolonged due to patient unavailability
- either the result of patient choice or fitness to undergo treatment. Every effort is
being made to ensure that their treatment is delivered at the earliest opportunity, taking
into account their personal choices and/or the need to ensure that they are well enough
to receive treatment.
2. Part of the delays revolve around the time taken to undertake staging scans
for the purpose of the diagnostic and staging phase.
We have processes in place that enable us to track all cancer patients’ progress
through the pathway. This includes patients who have been referred to regional
specialist services in SBUHB from other Health Boards. While we act as the centre
for delivery of the specialist care for these patients, diagnostic testing and staging are
conducted within their ‘home’ Health Board, as was the case with Mr. Tatchell, who
was a resident of Cwm Taf Morgannwg University Health Board (CTMUHB).
Although we do not directly manage elements of the pathway that occur outside
SBUHB, we have oversight and liaise closely with the parent Health Board to expedite
tests if needed. For example, if a scan has not been booked by Day 5 after a
diagnostic referral has been made, the cancer tracking team in SBUHB will reach out
either directly to the radiology department of the referring Health Board or contact the
local tracking team to escalate on behalf of the patient.
If there is a failure to respond within an appropriate timescale there are clear routes of
escalation via the control measures described above and will include Chief Operating
Officer level, should it be required.
Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi.
We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay.
Cadeirydd/Chair: Jan Williams Prif Weithredwr/Chief Executive: Abigail Harris
Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR
Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe
Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR
Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board
Recent review of the head & neck single cancer pathway, for patient seen between May
2034 and May 2025 (sample n=50) has confirmed positive compliance against key
indicators:
• Urgent suspected cancer referral to 1st Appointment = 8.9 days
• 1st Appointment to Biopsy = 11.5 days
• Referral to Diagnosis = 36.5 days
3. Two Associate Medical Directors have communicated that delays in undertaking
staging scans are ongoing and are having an impact on survivability rates and
prognoses by making treatable cancers irresectable.
Radiology is a national shortage specialty that can be a challenge for recruitment, this
is further compounded when recruiting sub-specialty interest.
Radiology provision to the Head and Neck service is not as robust as the Health Board
would like it to be. We have several highly committed clinicians who deliver this
specialist service as part of their roles, including three at consultant level and one at
Specialty (SAS) Doctor level. We have worked hard to recruit additional staff and
there is a continuous process of advertising and re-advertising in place to actively seek
suitable applicants. Locum cover was in place until May 2025. We advertised for a
replacement, anticipating the locum’s departure, and interviewed two candidates - but
were not able to appoint.
Another round of advertisement has been completed, and we have now secured locum
cover for 12 months commencing in October 2025. You can be assured that we are
making every effort to recruit in a timely way, recognising that there is a challenge
across the UK of recruiting into these highly specialised posts.
While we recognise that the actions and improvements described above cannot alter
the outcome for Mr. Tatchell and his family, I trust this demonstrates the Health Board’s
commitment to addressing the risks identified by his case.
Yours sincerely,
EXECUTIVE MEDICAL DIRECTOR & DEPUTY CHIEF EXECUTIVE
SWANSEA BAY UNIVERSITY HEALTH BOARD
Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi.
We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay.
Cadeirydd/Chair: Jan Williams Prif Weithredwr/Chief Executive: Abigail Harris
Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR
Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe
Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR
Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board
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