Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0628, written 16 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Dec 2025 |
|---|---|
| Reference | 2025-0628 |
| Deceased | Philip Hoggarth |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Chief Executive Of Aneurin Bevan University Health Board 1 CORONER I am Caroline SAUNDERS, Senior Coroner for the coroner area of Gwent 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 07 April 2025 I commenced an investigation into the death of Phillip Lawrence HOGGARTH aged 87. The investigation concluded at the end of the inquest on 10 December 2025. The conclusion of the inquest was recorded as: Natural Causes The medical cause of death was: 1a) Myocardial Infarction and Pulmonary Oedema 2) Valvular Heart disease, Left Total Hip Replacement, Hypertension, Anaemia 4 CIRCUMSTANCES OF THE DEATH PH was admitted to the Grange University Hospital in Llanfrechfa for a Total hip Replacement, which was successfully performed on 18/3/2025. Post-operatively he deteriorated and suffered a myocardial infarction which resulted in his death on 25/3/2025. PH suffered from chronic iron-deficiency anaemia. The anaesthetists determined that he should have an iron transfusion before his operation. This took place 7 days prior to his admission to hospital. In evidence the inquest was informed that the infusion should have taken place “some weeks” prior to the operation to be effective. The exact number of weeks was unclear, but I was informed that 7 days was not sufficient time for the iron to have any effect. I also heard that there was no apparent consensus between clinicians as to when the infusion should be given, and a lack of communication in this regard may have compounded the problem. Moreover, in this case, the deceased resided in Powys and the iron transfusion (and hence the operation) had previously been postponed as there was a disagreement over which health board should fund the iron infusion. 5 CORONER’S CONCERNS Regulation 28 – After Inquest Document Template Updated 30/07/2021 During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) The deceased died from a heart attack and I did not determine that any omission in the administration of the iron had more than minimally contributed to his death . However the lack of a consistent approach to pre-operative management and administration of iron to a chronically anaemic patient could put patients’ lives at risk in the future. Kindly address the issues raised, namely: Whether there are clinical guidelines which determine the pre-operative 1. administration of iron therapy. 2. 3. regard funding to prevent potentially damaging delays in surgery. Whether there is a process which supports these guidelines Whether there is an agreement between Health Boards in these circumstances 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 February 10, 2026. 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family Members And Next Of Kin I have also sent it to N/A who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 16/12/2025 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Caroline SAUNDERS Senior Coroner for Gwent Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
30th January 2026 Caroline Saunders Senior Coroner (Gwent) Dear Ms Saunders Re: Regulation 28 Report received by Aneurin Bevan University Health Board further to the inquest touching on the death Phillip Lawrence Hoggarth which concluded on 10 December 2025 Thank you for your Regulation 28 Report of 16 December 2025. I am writing to provide you with the Health Board’s response to the Regulation 28 Report to Prevent Future Deaths, which was issued following the inquest into the death of Mr Phillip Lawrence Hoggarth. As requested, the information presented below is intended to describe the actions which have been taken/are being taken by Aneurin Bevan University Health Board to mitigate the risk of future deaths. You require the Health Board to provide you with the following information: 1. Whether there are clinical guidelines which determine the pre-operative administration of iron therapy 2. Whether there is a process which supports these guidelines 3. Whether there is an agreement between Health Boards in these circumstances with regard to funding, to prevent potentially damaging delays in surgery With regard to points 1 and 2. Please find attached to this response the Health Board’s Standard Operating Pathway (SOP) for the management of surgical patients presenting to preassessment clinic with anaemia or iron deficiency. Bwrdd Iechyd Prifysgol Aneurin Bevan Pencadlys, Ysbyty Sant Cadog Ffordd Y Lodj, Caerllion, Casnewydd NP18 3XQ 01633 436 700 BwrddIechydPrifysgol BIPAneurinBevan 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. Aneurin Bevan University Health Board Headquarters, St Cadoc’s Hospital Lodge Road, Caerleon, Newport NP18 3XQ 01633 436 700 AneurinBevanHealthBoard AneurinBevanUHB 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. This links directly to the NHS Wales Preoperative Anaemia Pathway from the Blood Health National Oversight Group (BHNOG), which is embedded within the SOP. This outlines the process for preoperative Intravenous (IV) iron. In figure 2 of the BHNOG pathway it states: "IV iron should be given as soon as possible or preferably at least 4 weeks prior to surgery. With urgent surgery, IV iron should be considered until the day prior to surgery to reduce the need for perioperative transfusion." Our standard IV iron pathway in preassessment includes a blood test at 6 weeks post iron transfusion (where sufficient time is available before surgery) to confirm improvement or inform decision making if a further iron transfusion is required. With regard to point 3. The Health Board confirms that the cost of IV iron is charged to the relevant clinical area or responsible clinician. When the IV iron service was set up, it was agreed that the drug cost of IV iron would be paid for by the surgical specialty the patient belonged to. The service has been running for over two years, with funding provided by the Health Board regardless of patient residence or Health Board boundaries. I trust that this information reassures you about the Health Board’s processes, guidelines and funding position with regard to the pre-operative administration of iron therapy. However, if you require any further information or assurance, please do not hesitate to contact me. Yours sincerely Prif Weithredwr | Chief Executive
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