Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0063, written 5 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 | 5 Feb 2026 |
|---|---|
| Reference | 2026-0063 |
| Deceased | Della Calvey |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| 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.
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 2 Chief Executive Of Welsh Ambulance Service Nhs Trust (Wast) 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 16 January 2025 I commenced an investigation into the death of Della Bridget CALVEY aged 78. The investigation concluded at the end of the inquest on 27 January 2026. Della Bridget Calvey died at home on 16/1/2025 from the effects of overwhelming sepsis caused by a urinary tract infection. The conclusion of the inquest was recorded as: Natural Causes The medical cause of death was: I(a) Adrenal insufficiency due to haemorrhage (b) Sepsis (c) Bronchopneumonia (d) Acute Pyelonephritis II COPD, Cor Pulmonale 4 CIRCUMSTANCES OF THE DEATH On Christmas day 2024, DC started to experience back pain which was thought to be the early signs of a Urinary Tract infection. This was eventually diagnosed after a positive urine sample was received on 7/1/25 and DC was started on antibiotics. However, by this time her condition had deteriorated, and she had started to show signs of confusion, and she was not taking an adequate diet. On 10/1/2025 DC’s condition worsened and she collapsed. He daughter called for an ambulance and paramedics attended at 1313 hours. On examination the paramedics determined that DC had a raised NEWS score, had non- resolving infection and was dehydrated. Her condition was considerably below her baseline. She was now unsafe to be left alone and her new incontinence had increased her risk of falling; indeed she had already fallen twice, on one occasion resulting a minor injury to her nose. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Her NEWS score was 5, although both the paramedic (an employee of WAST) and the staff at the FLO centre (employees of ABUHB) considered that it could be safely reduced to 3 on the basis that she had Chronic Obstructive Pulmonary Disease. There were no baseline oxygen saturations known and the court heard there may have been other reasons for her raised NEWS, for example potentially early signs of a chest infection. Had the NEWS score remained at 5, admission to an acute hospital would have been mandated (as opposed to the local general hospital). As it was the inquest concluded that DC was persuaded against hospital admission altogether and to consult her GP. DC died from the effects of urosepsis 6 days later. The inquest determined that Della should have been to hospital but given the nature and severity of her infection could not determine on balance that her death would have been prevented. 5 CORONER’S CONCERNS 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 totality of the evidence indicated that it was not unusual for NEWS scores to be downgraded if a patient had COPD, even when their baseline saturations were not known. The rationale being “COPD sufferers often have lower oxygen saturation levels”. Whilst this may be true, applying this to all COPD sufferers, I consider to be an unsafe practice. 1. Confirmation whether downgrading NEWS scores in the circumstances described is acceptable practice (please note that support for this position was provided by the Clinical Lead who has a training remit) 2. assessments will take place in the future. What action will be taken to ensure that more robust approach to clinical 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 April 02, 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Health Inspectorate Wales 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: 05/02/2026 Caroline SAUNDERS Senior Coroner for Gwent Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Your ref: 00113-2025 26th March 2026 Caroline Saunders Senior Coroner (Gwent) Via email: gwent.coroner@newport.gov.uk Dear Ms Saunders Re: Regulation 28 Report received by Aneurin Bevan University Health Board further to the inquest touching on the death of Della Bridget Calvey which concluded on 27th January 2026. Thank you for your letter and accompanying report, which the Health Board received on 5th February 2026. 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 Della Bridget Calvey. As requested, the information presented below is intended to describe the actions which 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. Confirmation as to whether downgrading NEWS scores in the circumstances described (in the context of COPD) is acceptable practice. 2. What action will be taken to ensure that more robust approach to clinical assessments will take place in the future. With regard to point 1. The adaptation of the NEWS score in the context of patients with known hypercapnic respiratory failure (most commonly due to COPD) is recognised normal clinical practice. This was reinforced and standardised by the introduction of ‘NEWS2’ (first published 2017 but widely adopted across NHS Wales in 2025 – See Welsh Health Circular WHC/2025/002) which specifically has a different oxygen saturation scale for this purpose. Whilst it is recognised that not all patients with COPD will have confirmed hypercapnic respiratory failure and meet this criteria, there is recognition that patients with COPD exacerbations will often tolerate lower oxygen levels safely. This is demonstrated in the NICE Quality Standard on COPD in adults (QS10) that states that people receiving emergency oxygen for an acute exacerbation of chronic obstructive pulmonary disease should have their oxygen saturation levels maintained between 88% and 92%. Overall, this demonstrates that the oxygen saturation aspect of a NEWS score in COPD patients may not trigger the same response as in other patients and should be considered in the context of their overall clinical picture and past history before using this to make clinical decisions. 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. With regard to point 2. NEWS2 was formally launched by the Health Board in September 2025 and all flow centre staff have completed the required training, with ongoing compliance monitored as part of annual staff reviews. As standard practice the call handling staff at the flow centre are trained to calculate the NEWS score based on the observations given and would not adjust this for COPD or other conditions. They now escalate all COPD patient referrals to the qualified nurse, who would consider the NEWS score in the context of the full details of the case including the available past medical history. The qualified nurse would then make any clinically appropriate adjustments to the NEWS2 parameters, with a clear clinical rationale documented. If a patient has COPD but not documented hypercapnic respiratory failure or known low baseline saturations then the qualified nurse would not adjust the NEWS2 score. They may however take the underlying diagnosis of COPD into consideration when assessing how to apply the NEWS to the decision as to where best to send the patient for assessment. Bringing all this information together supports the identification and application of the most appropriate clinical pathway for that patient to follow. I trust that this information reassures you about the Health Board’s processes, guidelines and position with regard to NEWS scores in the context of COPD. However, if you require any further information or assurance, please do not hesitate to contact me. Yours sincerely Prif Weithredwr | Chief Executive
Cadeirydd Chair: s Prif Weithredwraig Chief Executive: Swyddfa’r Prif Weithredwr a’r Cadeirydd Chair and Chief Executive’s Office Our ref: 1362 31 March 2026 FAO Caroline Saunders Senior Coroner Gwent By email only: gwent.coroner@newport.gov.uk Dear Ms Saunders, Prevent Future Death Report relating to Della Bridget Calvey. I am writing in response to the Regulation 28 report to prevent future deaths, that you issued on 5 February 2026. It is noted that the concerns raised were: “The totality of the evidence indicated that it was not unusual for NEWS scores to be downgraded if a patient had COPD, even when their baseline saturations were not known. The rationale being “COPD sufferers often have lower oxygen saturation levels”. Whilst this may be true, applying this to all COPD sufferers, I consider to be an unsafe practice. Mae’r Ymddiriedolaeth yn croesawu gohebiaeth yn y Gymraeg neu’r Saesneg, ac na fydd gohebu yn Gymraeg yn arwain at oedi The Trust welcomes correspondence in Welsh or English, and that corresponding in Welsh will not lead to a delay www.ambulance.wales.nhs.uk Pencadlys Rhanbarthol Ambiwlans Regional Ambulance Headquarters Beacon House William Brown Close Llantarnam, Cwmbran NP44 3AB Ffôn/Tel 01633 626262 1. Confirmation whether downgrading NEWS scores in the circumstances described is acceptable practice (please note that support for this position was provided by the Clinical Lead who has a training remit) 2. What action will be taken to ensure that more robust approach to clinical assessments will take place in the future.” WAST response to your concerns To inform the Trust response, the inquest bundle has been reviewed by the Regional Clinical Lead-Consultant Paramedic for Southeast Wales. The opinion reached has been supported by the Trust Associate Medical Director and Executive Director for Paramedicine. The National Institute for Health and Care Excellence (NICE) describe Chronic Obstructive Pulmonary Disease (COPD) as a common, treatable (but not curable), and largely preventable lung condition. It is characterised by a persistent symptom such as breathlessness, cough and sputum due to airflow obstruction that is the result of chronic inflammation caused by exposure to noxious particles or gasses, usually from tobacco smoke or environmental and occupational exposure. The British Thoracic Society (BTS) identifies that oxygen saturation levels for patients who are acutely ill who are not at risk hypercapnic respiratory failure is 94-98%, and for those with known COPD, or other known risk factors for hypercapnic respiratory failure, a target saturation range of 88-92% is suggested pending the availability of blood gas results. As you will be aware NEWS is a National Early Warning Score to support the identification of deterioration in patients who are acutely unwell. It measures the respiratory rate, pulse, oxygen saturation levels, systolic blood pressure, consciousness and temperature. When considering oxygen saturation levels there are two scales that could be considered. Scale 1 would be for most patients who are not at risk of hypercapnic respiratory failure, and scale 2 is intended for patients who suffer with conditions such as COPD who are at risk of hypercapnic respiratory failure. NEWS and similar scoring systems (such as those used in paediatric patients, etc) are designed to identify patients at risk of deterioration, in order to identify a requirement for review by a clinician. While such scores are of value in both identifying unwell patients, and tracking trends, there is no specific score value at which hospital admission is mandatory. Once an ambulance clinician has reviewed a patient, they will take into account all of their findings – including the history, examination findings (including vital signs / NEWS score), any investigations they have undertaken, along with the patient’s wishes before determining the most appropriate next step in management, which may include conveyance to hospital. But this is not determined by parameters such as NEWS score in isolation. In conclusion, and in response to the concern raised within the PFD, namely: “Confirmation whether downgrading NEWS scores in the circumstances described is acceptable practice (please note that support for this position was provided by the Clinical Lead who has a training remit).” The Trust would not support its clinicians to routinely downgrade a NEWS score. However, within NEWS there are 2 scales for patients who are either at risk of hypercapnic respiratory failure and those patients who are not. Evidence presented identifies that patients with COPD are at risk of hypercapnic respiratory failure. To utilise scale 2 of the National Early Warning Score is not considered to be down grading a NEWS but utilising the system to appropriately recognise a patient deterioration. Organisational learning has taken place. In 2021 WAST introduced its ePCR. This electronic record calculation for NEWS is automated following entry of observation by attending clinician. It will be noted above the second NEWS recorded for Mrs Calvey was 4, this may suggest improvement in a patient’s condition. However, this score was calculated with an incomplete set of observation (temperature not repeated). Changes are being made to the ePCR that will stop a NEWS being calculated without a complete set of observations ensuring an accurate entry. With regard to “What action will be taken to ensure that more robust approach to clinical assessments will take place in the future.” The Trust does not intend to take any further action, over and above the organisational learning shared above. I would like to again offer my sincere condolences to Mrs. Calvey’s family on their sad loss. Any reference to the support of the actions taken by our staff is in no way intended to be dismissive of the unacceptable and tragic loss of life and the grief her family are experiencing. If you wish to take up the offer of a meeting with myself or a member of my Executive Legal Services Manager, who will be happy to team, please contact arrange this. Her contact email is and her telephone number is: contact you as soon as possible). (please leave a message if your call is unanswered and she will Yours sincerely CHIEF EXECUTIVE
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