Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0464, written 12 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Sep 2025 |
|---|---|
| Reference | 2025-0464 |
| Deceased | Gareth Johnson |
| Coroner | Kerrie Burge |
| Coroner area | South Wales Central |
| 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 | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
GRAEME HUGHES HIS MAJESTY’S SENIOR CORONER SOUTH WALES CENTRAL CORONER AREA CORONER’S OFFICE THE OLD COURTHOUSE COURTHOUSE STREET PONTYPRIDD CF37 1JW REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive Cardiff & Vale University Health Board. Cabinet Secretary for Health and Social Care CORONER 1 2 3 I am Kerrie Burge, H.M. Coroner for the coroner area of South Wales Central. 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 18 October 2024 I commenced an investigation into the death of Gareth Idris Johnson. The investigation concluded at the end of the inquest on 01/09/2025. I made the following determinations: Gareth Idris Johnson, aged 41 died at University Hospital of Wales on the 16th of October 2024 due to complications following a catheter directed thrombolysis procedure. I reached a narrative conclusion: After undergoing uneventful catheter directed thrombolysis, Gareth's anti coagulation medication management was sub optimal for a number of reasons, the most significant of which was lack of clarity about the appropriate level of heparin to be administered. On the balance of probabilities, sub therapeutic anti coagulation medication more than minimally, Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW negligibly or trivially contributed to Gareth's death and it is more likely than not that Gareth would have survived had his medication been delivered appropriately The medical cause of death was: 1a Cardiac arrest 1b Pulmonary Embolus CIRCUMSTANCES OF THE DEATH Gareth Idris Johnson attended The Grange hospital on 12.10.2024 and was diagnosed with a moderate to large volume bilateral pulmonary embolism with acute right heart strain. 4 It was the weekend and therefore Gareth was transferred to University Hospital of Wales for catheter directed thrombolysis. Following the procedure, Gareth was one of a small number of patients transferred out of the Critical Care Unit to PACU due to planned building maintenance works. Gareth’s post operative medication management was sub optimal for a number of reasons, including the impact of being cared for outside the main Critical Care Unit. CORONER’S CONCERNS During 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: 5 Due to the age of the hospital building, maintenance is a constant battle. There are also capacity issues in Critical Care due to patient volumes. Building infrastructure had been a constant feature on the corporate risk register and was now scored at its highest level. Whilst measures have been put in place to safeguard against moving patients who require critical care from the Critical Care Unit, there remained fears that these systems would fail during times of pressure. Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW ACTION SHOULD BE TAKEN 6 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th November 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. COPIES and PUBLICATION I have sent a copy of my report to family who may find it useful or of interest. 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. She may send a copy of this report to any person who she 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. 12 September 2025 SIGNED: 7 8 9 Kerrie Burge, H.M. Coroner for South Wales Central Coroner Area Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
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.
Executive Headquarters / Pencadlys Gweithredol
Woodland House
Maes-y-Coed Road
Cardiff
CF14 4HH
Ty Coedtir
Ffordd Maes-y-Coed
Caerdydd
CF14 4HH
Chief Executive
Eich cyf/Your ref:
Ein cyf/Our ref: SR-jb-1125-178
Welsh Health Telephone Network:
30 November 2022
Direct Line/Llinell uniongychol: 029 2183 6010
10 November 2025
Ms Kerrie Burge
H.M. Senior Coroner
South Wales Central
Coroner’s Office
The Old Courthouse
Courthouse Street
Pontypridd
CF37 1JW
Dear Ms Burge
Subject: Response to Regulation 28 Report to Prevent Future Deaths – Gareth
Idris Johnson (2025-0464)
Thank you for your Regulation 28 Report concerning the death of Gareth Idris
Johnson and for highlighting the critical issues regarding patient safety, critical care
capacity, and infrastructure at University Hospital of Wales. On behalf of Cardiff &
Vale University Health Board, I wish to extend our deepest condolences to Gareth’s
family. We take the matters raised in your report with the utmost seriousness and are
committed to taking robust action to prevent future deaths. This response sets out
the actions taken and planned, with direct reference to our policies and procedures.
Infrastructure and Electrical Failure Mitigation
We acknowledge the risks associated with the ageing hospital infrastructure,
particularly regarding electrical supply to critical care areas.
In response, we have developed the Electrical Failure Emergency Action Card (E1,
draft October 2025), which outlines: Immediate actions to confirm and respond to
power failures, including switching to unaffected supplies and declaring an ICU
emergency if required.
Identification of emergency decant areas, ensuring power supply is available
Prioritisation of evacuation for the most vulnerable patients, with guidance on device
battery backup and oxygen supply continuity.
•
before transfer.
• Activation of business continuity plans, including temporary ICU relocation and
mutual aid arrangements.
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro
Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi
The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
Whilst we record on the risk register the challenges that an ageing building poses,
we attempt to mitigate risk as far as possible but acknowledge these are ongoing
challenges.
Critical Care Capacity and Escalation
The Health Board recognises the challenges posed by patient volumes and
infrastructure. To address these, we have implemented the Critical Care Escalation
Plan (October 2024), which details:
• Maintaining a minimum of two level 3 staffed admitting beds at all times, with
overnight plans for four beds.
Strategic Patient Flow Management and Standardised Escalation Procedures for
Delayed Transfers of Care (DToC)
Prioritisation of the most acutely unwell patients for critical care beds, and use of
recovery and PACU areas for lower-risk patients when necessary.
• Clinically led moves out of the Critical Care Unit, with thorough handover and
up-to-date discharge summaries.
• Staged escalation, including internal optimisation, use of recovery/PACU,
postponement of elective activity, and, if required, secondary transfers or
tertiary diversion.
As part of ongoing recovery, refurbishment, and mitigation planning, several critical
infrastructure issues have been identified that require clarification. These include
challenges related to switching to the Uninterruptible Power Supply (UPS) system,
particularly the absence of provisions for transferring equipment to essential power
sockets if a UPS failure occurs.
Risk assessments conducted after multiple UPS failures have assumed that
switching to essential sockets is possible. This capability is important to ensure
operational continuity during the installation and transition to new UPS systems.
For reference, the draft Major Incident Plan has been attached, along with the newly
developed Action Card detailing procedures for power failure scenarios within Critical
Care.
Major Incident Preparedness
The Major Incident Plan v1.04 (DRAFT) provides a comprehensive framework for
emergency preparedness, in line with the Civil Contingencies Act 2004. Key
elements include.
• Clear command and control structures (Strategic/Gold, Tactical/Silver,
Operational/Bronze) for incident management.
• Use of the METHANE model for incident reporting and situational awareness.
• Principles for escalation, evacuation, triage, and transfer of patients
during major incidents.
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro
Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi
The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
• Action cards for critical care staff, ensuring roles and responsibilities are clear
in emergencies.
• Communication protocols, including alternative channels (WhatsApp, Teams,
VHF radio) to ensure effective coordination.
• Annual stress testing and live exercises at least every three years, with
training records maintained by the Critical Care Directorate.
Ongoing Actions and Timetable
• Regular review and simulation of escalation and major incident plans.
•
Infrastructure upgrades, including UPS installations and electrical supply
improvements, scheduled as per the Estates programme.
• Ongoing staff training in major incident response and escalation procedures.
• Governance processes for incident review and dissemination of learning.
In conclusion the Health Board is committed to continuous improvement and
transparency. We will continue to monitor, review, and strengthen our critical care
capacity, infrastructure resilience, and emergency preparedness.
Should you require any further information or clarification, please do not hesitate to
contact us.
Yours sincerely
Chief Executive
Encs:
• Electrical Failure E1 v1.02
• UHW Critical care Escalation Plan
• Major Incident Plan v1.04
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro
Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi
The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
Ysgrifennydd y Cabinet dros Iechyd a Gofal Cymdeithasol Cabinet Secretary for Health and Social Care Kerrie Burge H.M. Coroner for South Wales Central Coroner’s Office The Old Courthouse Courthouse Street Pontypridd CF37 1JW 12 November 2025 Dear Kerrie, Regulation 28 Report – Gareth Idris Johnson I was sorry to hear about the sad circumstances that led to Gareth Idris Johnson’s death and want to take this opportunity to offer my condolences to his family and friends. Below is the Welsh Government response to the Regulation 28 report following the death of Mr Johnson at the University Hospital of Wales (UHW). It is important lessons are identified and learnt from this tragedy and effectively shared across NHS Wales. There are longer term plans being reviewed and considered by the health board for the redevelopment of the University Hospital of Wales site. This response focuses on the short and medium-term actions I will be seeking the health board to review at the site to address patient safety and ensure the continuity of healthcare services to the local population. The day-to-day operation and management of the site and the healthcare services provided remains the statutory responsibility of Cardiff and Vale University Health Board (UHB). There are also actions, which will be highlighted to other health boards in Wales. Specific funding (£0.750m) has been made available to Cardiff and Vale UHB to complete a detailed condition survey of the main buildings on the UHW site to ensure future investment is appropriately targeted. This work will inform short-term investments and whether the buildings are suitable for significant refurbishment in the future. It is recognised there are many areas of the UHW estate that require significant investment. My officials are working closely with colleagues from Cardiff and Vale UHB about the priority areas for investment informed by a recent capital prioritisation exercise. Bae Caerdydd • Cardiff Bay Caerdydd • Cardiff CF99 1SN Rydym yn croesawu derbyn gohebiaeth yn Gymraeg. Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd gohebu yn Gymraeg yn arwain at oedi. We welcome receiving correspondence in Welsh. Any correspondence received in Welsh will be answered in Welsh and corresponding in Welsh will not lead to a delay in responding. The actions we are taking forward as a consequence of the Regulation 28 report are as follows: 1) Officials met Cardiff and Vale UHB on 15 October with NHS Shared Services Partnership-Specialist Estate Services (NWSSP-SES) to discuss the infrastructure issues at the ITU, critical care and theatres departments at the University Hospital of Wales. A business case is being developed to refurbish the ITU. Due to a lack of available space to relocate patients and the nature of the work involved, this work will likely take a number of years to complete. 2) To write to Cardiff and Vale UHB to confirm what clinical governance is in place to approve changes in the location of critical care and to ensure the appropriate clinical cover is in place to provide safe care during future planned maintenance of the critical care unit. 3) To write to selected health boards, including Cardiff and Vale UHB, to request them to respond to the NHS Performance and Improvement critical care network census. This includes questions about the estate, so Welsh Government can develop a national picture with expert context about the estate challenges for critical care across Wales. The census report will be considered by the Welsh Government to inform capital investment plans and health board planning. There are plans being explored for further capital investment at the University Hospital of Wales. While the condition of the existing estate was not the primary cause of Mr Johnson’s death, the need to make estate improvements led to the relocation of patients, which was a contributory factor. I hope the actions I have set out above will result in robust measures being put in place to manage patient moves in the future. Yours sincerely, Ysgrifennydd y Cabinet dros Iechyd a Gofal Cymdeithasol Cabinet Secretary for Health and Social Care
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