Lisa Townsend

Mabon ap Gwynfor AS/MS 
Gweinidog Cabinet dros Iechyd a Gofal 
Cabinet Minister for Health and Care 

Patricia Morgan 
Area Coroner, South Wales Central 
The Old Courthouse 
Courthouse Street 
Pontypridd 
CF37 1JW  

1 July 2026  

Dear Patricia 

I was sorry to read about the circumstances which led to Mrs Townsend’s death and would 
like to take this opportunity to offer my condolences to her family and friends. 

I was concerned to read about the issues highlighted in your Regulation 28 Report. I expect 
health boards in Wales to deliver high quality care and to put in place robust arrangements 
for inter-hospital transfer. 

I note that both health boards named in your report have now responded. These responses 
outline the steps each organisation has taken to improve understanding among the clinical 
teams about the delivering this pathway of care. Both health boards have also reported 
what action they have taken to improve referral and transfer arrangements between their 
organisations. 

As a result, the NHS in Wales has undertaken appropriate and proportionate action in 
response to your report findings and I hope this resolves your concern. My officials will also 
ensure the lessons relating to this case are shared with other health boards to inform their 
pathway arrangements. 

Yours sincerely,  

Gweinidog Cabinet dros Iechyd a Gofal 
Cabinet Minister for Health and Care 

Welsh Government Offices, Cathays Park, 
Cardiff. CF10 3NQ 
Swyddfeydd Llywodraeth Cymru, Parc Cathays, 
Caerdydd. CF10 3NQ 

Canolfan Cyswllt Cyntaf / First Point of Contact Centre:  
0300 0604400 

Gohebiaeth.Mabon.apGwynfor@llyw.cymru           

  Correspondence.Mabon.apGwynfor@gov.wales 

Rydym yn croesawu derbyn gohebiaeth yn Gymraeg.  Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn yr iaith honno 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.

RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS

REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013

When a coroner sends a prevention of future deaths (PFD) report to a person or
organisation, they must respond within 56 days. Recipients of a PFD report can apply to
the coroner for an extension. A response to a PFD report must detail the action taken or
to be taken, whether in response to the report or otherwise, or it must explain why no
action is proposed.

The purpose of the response template below is to promote clarity, ensure that responses
address the coroner’s concerns directly and transparently, and support consistency and
good practice across organisations and sectors.

It does not restrict how a person or organisation formulates their response; recipients
remain responsible for determining what action is appropriate and for ensuring that their
response accurately reflects the steps taken or planned.

In accordance with the Chief Coroner’s PFD Publication Policy (2026),any
representations regarding publication of a response should be sent to the coroner. These
representations should be made at the same time as the response is provided. The
coroner will pass any representations received to the Chief Coroner for a decision.

RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS

REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013

Please do not include any living persons’ names in this document, in accordance with
the Chief Coroner’s PFD Publication Policy (2026).

Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW

 THIS RESPONSE IS BEING SENT TO:

The Senior Coroner, H.M. Patricia Morgna for the Coroner Area South Wales
Central in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION
28’ following an inquest into the death of Lisa Jayne Townsend that concluded on 6
May 2026.

RESPONDENT

1.

2.

In line with our duty under Regulation 29 of the Coroners (Investigations)
Regulations 2013, NAME provides this response within 56 days (plus any
extension granted) of the date of the Report to Prevent Future Deaths.
DATE OF RESPONSE 17 June 2026
CONFIRMATION OF CORONER’S MATTERS OF CONCERN

The Health Board understands the Coroner’s concern to be that there was an
absence of clear guidance and protocol as to when referral should be made from
the local hospital to the tertiary HPB (Hepato Biliary) centre in relation to HPB
conditions, that there was delay in specialist advice being sought and in transfer
taking place, and that there remains no sufficiently established protocol to assist
clinicians in identifying when escalation to tertiary HPB advice and transfer should
occur.

Position of the Health Board in response to that concern

The Health Board accepts that, in this case, there was delay in escalation from the
treating Health Board ensuring referral for specialist HPB input, and it
acknowledges the importance of ensuring greater clarity and consistency in
regional referral arrangements for patients with suspected bile duct injury and other
complex benign HPB pathology. At the same time, the Health Board considers it
important to distinguish between a lack of clinical principles and a lack of formal
commissioning arrangements. The management of suspected bile duct injury is
guided by established national and international clinical standards which support
early recognition, prompt discussion with a specialist HPB centre at the point of
suspicion, and transfer where required for definitive expert management. These
principles are embedded in surgical training and are recognised as standard
practice. This is consistent with the position already set out in the current draft
response.

The Health Board also wishes to clarify the current service context. The HPB team
at University Hospital of Wales provides a highly specialised tertiary HPB service;
however, that service is not formally commissioned or funded as a regional
emergency HPB on-call service for conditions such as bile duct injuries and
complex benign HPB pathology. Notwithstanding that absence of formal
commissioning, the service is routinely approached by other Health Boards for
specialist HPB advice and management. The Health Board’s position is therefore
that specialist expertise is available and is accessed, but the absence of a
commissioned regional on-call model can result in over-reliance on informal
pathways rather than a single formally defined regional referral route. This reflects

Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW

 and develops the commissioning point already included in your current draft.
The Health Board further notes that there have been prior occasions on which
patients with suspected bile duct injury have been referred to the HPB service in a
timely way from the same Health Board, including from the same clinical source.
The Health Board therefore considers that the principal issue arising from this case
was not the absence of specialist knowledge or the impossibility of access to
specialist advice, but rather the failure to apply established escalation principles
promptly and consistently in this specific instance.

DETAILS OF ACTION TAKEN, how has the concern been addressed.

Action already taken

In response to the concern identified, the Health Board has reviewed the issues raised in
relation to regional escalation to specialist HPB services. Immediate work has been
undertaken to reinforce the existing expectation that suspected bile duct injury and
comparable complex benign HPB cases should trigger early consultant-level discussion
with the tertiary HPB centre at the point of suspicion, including where concern arises
intra-operatively or in the post-operative period. This aligns with the emphasis in your
current draft on early identification, timely specialist consultation and appropriate transfer.

The Health Board has also taken steps to remind relevant partners of the existing
escalation framework for HPB complications, including the need for urgent advice to be
sought promptly and for transfer to be considered without avoidable delay where
specialist tertiary management is indicated. As reflected in the current draft, this includes
reinforcing designated contact avenues, urgent advice procedures and the importance of
timely escalation.

In addition, focused communication and educational activity is being used to reinforce the
existing clinical principles underpinning referral and escalation for suspected bile duct
injury. The purpose of this action is to reduce unwarranted variation in practice,
strengthen clinician awareness of when specialist input should be sought, and support
more reliable application of recognised standards across organisational boundaries.

Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW

 DETAILS OF FURTHER ACTION PROPOSED

To address the Coroner’s concern more explicitly and transparently, the Health
Board proposes further work to move from reliance on recognised but partly
informal arrangements to a more clearly documented regional framework. This will
include the development and dissemination of a formalised escalation and referral
framework for suspected bile duct injury and other relevant complex benign HPB
pathology, setting out referral triggers, expected timescales for consultant-to-
consultant discussion, contact arrangements, and expectations regarding transfer
where tertiary management is required. This builds directly on the current draft’s
commitment to improve clarity and consistency through more formal frameworks.
The Health Board also intends to continue engagement with regional partners,
Welsh Government and relevant commissioning bodies regarding the current
service model. As already acknowledged in your draft, the absence of a
commissioned regional HPB on-call rota creates avoidable ambiguity in identifying
a single point of referral. The commissioning of a defined regional emergency HPB
on-call function would provide greater clarity, strengthen accountability, reduce
reliance on informal routes, and support more consistent and timely access to
specialist expertise. The current draft expressly notes that commissioning the on-
call rota would be welcomed to address and mitigate related risks.

The Health Board will additionally ensure that the learning from this case is
embedded through governance processes, with oversight of implementation
through the appropriate clinical governance structure, including confirmation that
the revised escalation arrangements have been communicated and that
compliance can be tested through audit or case review. This expands the
assurance language already present in your draft that the Health Board remains
committed to enhancing educational initiatives and reinforcing assurance
processes

Conclusion

The Health Board recognises the seriousness of the issues identified by the
Coroner and is committed to taking proportionate action to reduce the risk of
recurrence. In summary, the Health Board’s position is that the clinical principles
governing early referral of suspected bile duct injury are established and
understood, but that this case has highlighted the need to strengthen the
consistency, formality and assurance of regional escalation arrangements.
The actions already taken and the further actions proposed are intended to
improve clarity of access to specialist HPB advice, reduce variation in referral
practice, and support safer and more timely escalation for future patients.

SIGNATURE

Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW

RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS 

REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 

When a coroner sends a prevention of future deaths (PFD) report to a person or 
organisation, they must respond within 56 days. Recipients of a PFD report can apply to 
the coroner for an extension. A response to a PFD report must detail the action taken or 
to be taken, whether in response to the report or otherwise, or it must explain why no 
action is proposed. 

The purpose of the response template below is to promote clarity, ensure that responses 
address the coroner’s concerns directly and transparently, and support consistency and 
good practice across organisations and sectors. 

It does not restrict how a person or organisation formulates their response; recipients 
remain responsible for determining what action is appropriate and for ensuring that their 
response accurately reflects the steps taken or planned. 

In accordance with the Chief Coroner’s PFD Publication Policy (2026),any 
representations regarding publication of a response should be sent to the coroner. These 
representations should be made at the same time as the response is provided. The 
coroner will pass any representations received to the Chief Coroner for a decision. 

RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS 

REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 

Please do not include any living persons’ names in this document, in accordance with 
the Chief Coroner’s PFD Publication Policy (2026). 

Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 THIS RESPONSE IS BEING SENT TO: 

The Senior Coroner, H.M. Patricia Morgan for the Coroner Area South Wales 
Central in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 
28’ following an inquest into the death of Lisa Jayne Townsend that concluded on 6 
May 2026. 

RESPONDENT 

1. 

2. 

In line with our duty under Regulation 29 of the Coroners (Investigations) 
Regulations 2013, Cwm Taf Morgannwg University Health Board 
provides this response within 56 days (plus any extension granted) of the 
date of the Report to Prevent Future Deaths. 

DATE OF RESPONSE 2 July 2026 
CONFIRMATION OF CORONER’S MATTERS OF CONCERN 

The MATTERS OF CONCERN were identified in the report are as follows: 

• 

injury to the patient’s bile duct during the procedure, and delay in transfer to a 
tertiary centre. 

3. 
4. 

DETAILS OF ACTION TAKEN, how has the concern been addressed.  
DETAILS OF FURTHER ACTION PROPOSED 

We  have  now  changed  our  pathway  and  follow  up  for  patients  with  this 
complication. Please see the new guidelines of clinicians as set out below. 

Clinical Guidance  
All patients presenting with a suspected or confirmed bile duct injury following an 
operation or procedure must be managed in accordance with the following principles: 

1.  Early Senior Review and Internal Discussion  

o  The responsible clinician must seek a second opinion within their department 

at consultant level at the earliest opportunity.  

2.  Mandatory Early Tertiary Referral  

o  Specialist advice must be sought at the earliest opportunity from the Hepato-

Pancreato-Biliary surgical team at the University Hospital of Wales. (Currently, 
there is no 24/7 Hepato-billary service provided by UHW.)  

o  This discussion must occur as soon as bile duct injury is suspected or 

confirmed to discuss further management or determine the need for transfer to 
UHW.  

3.  Consultant-to-Consultant Communication  

o  All referrals must be conducted consultant-to-consultant  
o  All discussions must be clearly documented within the Welsh Clinical Portal 

(WCP) and the patient’s case notes.  

4.  Transfer to Tertiary Centre  

o  CTM UHB does not provide a 24/7 ERCP service, which is frequently required 

in the management of bile duct injuries. 

Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW 

 
 
 
 
 
 
 
 
 
 
 
 
  
 o  Where indicated and after discussing with HPB team at UHW, patients must 
be transferred promptly to UHW under the care of the HPB surgical team. 

o  Both Health Boards will work collaboratively to ensure: 

▪  Timely acceptance 
▪  Efficient coordination of transfer 
▪  Avoidance of unnecessary delays 

5.  Feedback and Learning  

o  The tertiary centre will provide structured feedback to the referring clinician and 

team, including: 

▪  Management undertaken 
▪  Learning points 

o  This feedback will be shared with the wider surgical team to support organisational 

learning. 

6.  Clinical Governance  

o  All cases of bile duct injury will be mandatorily reviewed at the monthly Morbidity 

and Mortality (M&M) meeting within the Health Board.  

o  These cases will form part of ongoing clinical governance and quality improvement 

processes.  

o  All future cases of bile duct injury within the Health Board will be reviewed against 

this guidance to assess compliance.  

I hope that this assures you that there has been learning from this case and we have 
taken steps to ensure that our processes have been modified accordingly. Should you 
require any further information then please let me know. 

SIGNATURE 

Prif Weithredwr/Chief Executive 

Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW