Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0055, written 4 Feb 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Feb 2026 |
|---|---|
| Reference | 2026-0055 |
| Deceased | Joan Read Prevention of future deaths report |
| 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 | 1 |
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: 1 2 3 , Chief Executive Cardiff & Vale University Health Board CORONER 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 On 20 March 2025 I commenced an investigation into the death of Joan Marilyn READ . The Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 investigation concluded at the end of the inquest on 03/02/2026 . The conclusion of the inquest was a narrative. The medical cause of death was recorded as follows: 1a Bronchopneumonia 1b Frailty due to B12 deficiency 1c Pernicious anaemia II COVID 19 infection, hypothryoidism, delirium CIRCUMSTANCES OF THE DEATH These were recorded as :- Joan Marilyn Read was aged 91 when on 18th March 2025 she died at the University Hospital of Wales, Cardiff. Joan had been an inpatient in August 2023, and was discharged home whilst a blood test result was pending. There was a missed opportunity to communicate a severely deranged B12 result, and as a consequence, it was not treated in hospital, nor in the community. Joan was admitted to the same hospital in January 2025 with a significant deterioration in her physiological reserves, she was frail and had been less compliant with her medication. Sadly, despite all treatment available, Joan did not recover and continued to decline to her death. 4 Joan was treated at the UHW from mid-January until her death on March 18th 2025. It is more likely than not, that the failure to address her B12 deficiency more than minimally contributed to her death. The Inquest focused upon:- - the processes surrounding deranged test results and their onward communication for action 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. (1) Evidence revealed that a single medical consultant is responsible for geriatric perioperative care (POPS). There is no cross-cover during periods of expected and unexpected absence. There is Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 a risk that deranged test results or other urgent results will be missed when that doctor is absent; (2) Without a robust system for cross-cover 52 weeks per year recognised within another doctor’s job plan, this risk will likely continue, despite huge positive strides in communicating test results within the Trust. 6 7 ACTION SHOULD BE TAKEN 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 3rd April 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 I have sent a copy of my report to family and the clinician concerned, who may find it useful or of interest. 8 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. 4 February 2026 9 Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 SIGNED: Rachel Knight H M Coroner for South Wales Central Coroner Area Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862
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.
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-0326-234
Welsh Health Telephone Network:
30 November 2022
Direct Line/Llinell uniongychol:
30 March 2026
H.M. Senior Coroner Ms R Knight
South Wales Central
Coroner’s Office
The Old Courthouse
Courthouse Street
Pontypridd
CF37 1JW
Dear H.M. Coroner Knight
Response to Regulation 28 Report to Prevent Future Deaths - Death of Mrs
Joan Marilyn Read
Thank you for your Regulation 28 Report issued on 4 February 2026 regarding the
tragic death of Mrs Joan Marilyn Read. We wish to express our sincere
condolences to Mrs Read’s family. We are grateful for the careful consideration
given during the inquest, and we fully acknowledge the concerns you have raised
regarding risks associated with:
1. Single-consultant model within the Perioperative care of Older People
undergoing Surgery (POPS) service, and
2. Risks of missed abnormal or urgent results due to lack of cross-cover
and system limitations.
Cardiff and Vale University Health Board takes these concerns extremely seriously.
We have undertaken a detailed internal Patient Safety Review and enacted several
improvements, many of which were outlined in the evidence provided by Dr Nia
Humphry (Consultant Geriatrician and POPS Clinical Lead). Further actions are
planned to reduce risk and strengthen system resilience.
Below we outline the actions already taken and actions planned, along with
timeframes for full implementation.
Requirement: Improving Cross-Cover and Reducing Dependency on a Single
Consultant
Whilst we acknowledge there is one consultant it should be noted that a team is in
place:
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
• Nurse practitioner 18 hours / week
• Physician Associate - 37.5 hours - works over 4 days and non-working day is
varied according to service needs
• Clinical Fellow - 0.8 WTE.
In addition we are in the process of recruiting a Clinical Nurse Specialist (CNS).
We acknowledge the coroner’s concerns regarding the absence of POPS consultant
cross-cover and the associated risk of delays in reviewing results or acting on
abnormal findings. If further consultant support is needed out of hours, then the on-
call service for hospital cover would be contacted POPS Consultant Cross-Cover –
Interim Mitigation (Implemented).
While recruitment of additional POPS consultant resource is pursued, the following
measures are in place:
• Abnormal results identified by non-medical staff are escalated to the on-call
medical team.
• Urgent diagnostic findings where the POPS consultant is unavailable are
(e.g., general medicine,
the relevant specialty
team
reviewed by
haematology).
• Use of structured documentation and audit trails reduces reliance on a single
individual.
Expansion of the POPS Service – Sustainable Long-Term Plan (In Progress)
Expansion of the POPS service remains a recognised clinical need. Given
organisational financial constraints, this is an ongoing strategic objective, but the
Health Board is committed to:
• Developing a cross-cover rota for POPS.
• Prioritising consultant workforce expansion to ensure 52-week service
continuity.
• Embedding senior decision-making resilience within emergency and surgical
pathways.
Enhancing Discharge Documentation and Information Sharing
Learning from this case has led to major improvements in discharge communication:
POPS Clinical Note System (Implemented October 2023)
A structured clinical note authored at discharge ensures:
• Key assessments,
documented clearly.
investigations, pending results, and
follow-ups are
• Notes are uploaded to WCP, automatically notifying primary care.
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
• Consultant review ensures accuracy and completeness.
Audit of Compliance
A September 2025 audit demonstrated:
• 100% completion of POPS clinical notes.
• Some variation in upload timing during consultant leave.
We recognise this variation and expect the introduction of cross-cover arrangements
to eliminate delays fully.
Requirement:
Results
Improving Communication and Management of Abnormal
Strengthened Laboratory SOP for Critically Low B12 Results (Implemented)
Following the incident in August 2023, the Haematology Laboratory undertook a full
review of its processes and subsequently revised the standard operating procedure
for urgent Vitamin B12 results <50 ng/L. The strengthened protocol now requires:
• Mandatory telephone communication of critically low B12 results before
authorisation.
• Escalation to a Consultant Haematologist if the clinical team cannot be
reached.
• Comprehensive electronic documentation of all attempts to contact the
ward or clinical teams.
Monthly Quality Audit – Providing Assurance
A monthly audit process has been established within our quality system to review all
results <50 ng/L and confirm that a documented telephone call has been made in
in July 2025, demonstrated 100%
every case. The
compliance, providing assurance that the revised process is being followed reliably.
first audit, completed
Further Strengthening of the Procedure
To enhance safety and clarity, the procedure has been further updated to ensure
that:
• Any difficulty in passing on a result triggers mandatory escalation to the
Consultant Haematologist or their deputy, and
• The telephone log includes more detailed documentation, including the nature
of the discussion and the individual to whom the result was communicated.
The revised procedure now states:
“Vitamin B12 <50 µg/L first time. Do not authorise the B12 result until it has been
telephoned to the requestor. If unable to contact the requestor, discuss the
urgency of the result with the clinical director or deputy. Record all attempts
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
at telephoning results in the phone log on LIMS. Record outcome even if engaged,
no answer or patient not known to location.”
Over the past six months, there have been two occasions where difficulty contacting
the clinical team was encountered. In both instances, escalation occurred as
required, the Consultant Haematologist was involved, and the clinical teams were
successfully contacted. This provides additional assurance that escalation processes
are effective in practice.
These measures collectively ensure that critically low Vitamin B12 results are
communicated promptly and appropriately to the clinical team.
A monthly audit process is now in place and early audits show 100% compliance.
Routine Electronic Communication via Welsh Clinical Portal (WCP) –
Reinforced Use
We have strengthened expectations that senior responsible clinicians must:
• Review results within the WCP “Results” tab,
• Acknowledge or comment on findings,
• Ensure timely clinical action.
The POPS Clinical Lead now performs twice-weekly structured checks of the
WCP system to ensure abnormalities are identified even if not flagged automatically.
Timetable of Actions
Action
Status
Completion Date
Revised B12 SOP & monthly audit
Complete
In place since July 2025
Twice-weekly POPS review of WCP results Complete October 2023
POPS clinical discharge note system
Complete October 2023
POPS expansion workforce plan
In progress CNS will be appointed
We thank you for bringing these matters to our attention and for the opportunity to
outline our response. Should you require any clarification or further assurance, we
would be pleased to provide it.
Yours sincerely
Chief Executive
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
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