Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0490, written 1 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Oct 2025 |
|---|---|
| Reference | 2025-0490 |
| Deceased | Milos Jankovic |
| Coroner | Rachel Knight |
| 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 ANNEX A CORONER’S OFFICE THE OLD COURTHOUSE COURTHOUSE STREET PONTYPRIDD CF37 1JW 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 Minister for Health and Social Services of Wales, Chief Executive of Digital Health & Care Wales CORONER 1 2 3 I am Rachel Knight 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 Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW On 26 November 2024 I commenced an investigation into the death of Milos JANKOVIC. The investigation concluded at the end of the inquest on 18/09/2025. The narrative conclusion of the inquest was that Mr Jankovic had been diagnosed with Barrett’s Oesophagus in 2014, but lost to follow up surveillance due to a bowel cancer taking priority. Sadly, in 2024 he began to show symptoms of cancer and testing established that he had developed brain metastases of a primary oesophageal cancer. Had Mr Jankovic been under surveillance, it is more likely than not that he would have by 2023, been seen by specialists in Barrett’s Oesophagus who would have been able to offer various options for ongoing surveillance and potential treatments. However, there is insufficient evidence that this would have changed the outcome for Mr Jankovic, given the nature of the disease and its known poor outcomes despite surveillance. 1a Metastatic Oesophageal Cancer 1b Barrett's Oesophagus 1c II CIRCUMSTANCES OF THE DEATH The Inquest focused upon:- 4 a. The practical aspects of administration of surveillance for Barrett’s patients in primary and secondary care; and b. Whether the outcome would have been different for Mr Jankovic if surveillance had occurred as it should have . 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. 5 The MATTERS OF CONCERN are as follows. Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW (1) There are two cases that have recently come to my attention within the Cardiff area where patients have been diagnosed with Barrett’s, lost to follow-up and have gone on to die from oesophageal cancers; (2) There are inadequate processes in place to address this lacuna, particularly in primary care where a patient may not be a regular attender; (3) GPs frequently recall their patients with known, chronic issues such as asthma & diabetes, and there is a process for recalling women for smear tests for example, however Barrett’s does not currently benefit from such a recall exercise/audit, even though it is well-established to be a pre- cancerous condition; and (4) When prescribing drugs such as omeprazole or other PPIs for symptoms which may relate to Barrett’s, there is no prompt for GPs to consider whether the patient hits the relevant red flags which may benefit from endoscopy rather than a course of medication, or whether they have previously been diagnosed with the condition and ought to be under surveillance. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisations 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 26th 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 and Mr Jankovic’s GP 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 Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW 6 7 8 publication of your response by the Chief Coroner. 1st October 2025 SIGNED: 9 Rachel Knight 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.
Prifysgol Cardiff and Vale University Health Board Bwrdd lechyd Caerdydd a’r Fro University Hospital of Wales Ysbyty Athrofaol Cymru 17th March 2026 Dear HM Coroner, I am writing to provide an update regarding the current position of the Barrett’s oesophagus surveillance programme within the Endoscopy Service at Cardiff and Vale University Health board. The Standard Operating Procedure for Surveillance has now been fully implemented. This ensures a consistent and robust process for clerical validation of all surveillance waiting lists, alongside our other endoscopy waiting lists. Significant progress has been made in reducing overall waiting times. The total endoscopy waiting list has decreased from approximately 6200 patients in January 2025 to 1200 patients in February 2026. This improvement has been supported by temporary measures supported by Welsh Government funding, including insourced weekend endoscopy lists and a mobile endoscopy unit in Llantrisant. Although the mobile unit did not directly undertake Barrett’s surveillance procedures, its use contributed to reduce the overall waiting times and thereby improved capacity for Barrett’s surveillance. In addition, successful recruitment of speciality doctors and nurse clinical endoscopists has strengthened the service. All patients who remain on the waiting list continue to be reviewed and undergo clinical validation to ensure appropriate prioritisation. Waiting lists are reviewed weekly to maintain oversight and progress. At present, the patient who has been waiting the longest for an Oesophago-Gastro-Duodenoscopy (OGD) on the Barrett’s surveillance waiting list was originally due in January 2026, representing a delay of approximately two months. All patients whose procedures became overdue in January are being scheduled for appointments this week to address and clear the backlog. The approach to surveillance grading has been revised. The previous 4a, 4b, and 4c categorisation system, introduced during the pandemic, has now been discontinued. Surveillance intervals will instead be determined using evidence-based recall periods in line with disease specific British Society of Gastroenterology (BSG) guidance. This includes the application of appropriate calculations to determine the extent to which patients are overdue and the utilisation of disease-specific coding to support accurate clinical prioritisation. Additionally, we are exploring the introduction of capsule sponge procedures in line with the National Endoscopy Programme for Wales, which is currently under development. This innovation is expected to enhance our surveillance capacity and improve patient pathways. Yours sincerely, Interim Lead Nurse Specialised Medicine
Ysgrifennydd y Cabinet dros Iechyd a Gofal Cymdeithasol Cabinet Secretary for Health and Social Care Rachel Knight HM Coroner for South Wales Central 4 February 2026 Dear Rachel Knight, Regulation 28 Report – Milos Jankovic Please accept my apologies for the delay in responding to your Regulation 28 report into the death of Milos Jankovic. I was sorry to read about the circumstances which led to Mr Jankovic’s death and would like to take this opportunity to offer my condolences to Mr Jankovic’s family and friends. I was concerned to read about the issues highlighted in your Regulation 28 report. Health boards in Wales are responsible for delivering healthcare, in line with recommended clinical practice, which includes the provision of surveillance procedures for conditions such as Barrett’s Oesophagus. Health boards should offer people with Barrett’s Oesophagus surveillance endoscopy every two to three years and more frequently if they develop pre-cancerous cells. A small proportion of people with Barrett’s Oesophagus will go on to develop oesophageal cancer. In terms of recalling people with Barrett’s Oesophagus for surveillance procedures, it is the secondary care team which manages this process. The need for surveillance is added to a patient’s record by the patient administration system used by the health board. Health boards operate standardised recall procedures and follow-up procedures for non- responders to invite people for their surveillance appointments. I am not of the view that GPs should be engaged in recalling individuals or that their clinical record systems should be amended to include prompts to recommend surveillance. This would lead to a confusion of responsibilities and duplication in terms of booking procedures. GP systems should in general not use digital flags to prompt recommended clinical practice, as GPs should apply their training, clinical guidelines and locally-agreed clinical pathways for the management of any condition. Digital flags in GP systems should be reserved to highlight serious patient safety risks, such as allergies or safeguarding issues. 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. With regard to the secondary care management of surveillance lists, unfortunately, there is a risk that process or administrative errors can occur. This may happen if, for example, clinical teams do not act on pathology results; if records are inaccurate or are misplaced; if validation or booking procedures are not completed accurately, or if there are breakdowns in communication with independent sector providers. It is with regret that I am unable to comment on whether such factors may have played a role in the death of Mr Jankovic. The responsibility for the operational delivery of the surveillance list rests with the health board concerned for his treatment – the Welsh Government has no access to health board records or digital systems and processes. The power and expertise to investigate the circumstances of Mr Jankovic’s death – and that of the other case you refer to – and the processes involved in managing the surveillance, lie with the health board. Could I therefore suggest, in this case, that you ask the health board concerned how it manages the surveillance waiting list for Barrett’s Oesophagus and ask it to identify any administrative failings involved, and how it can strengthen its records and processes to avoid future deaths. Yours sincerely, Ysgrifennydd y Cabinet dros Iechyd a Gofal Cymdeithasol Cabinet Secretary for Health and Social Care
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