Summer Mant

Dear Ms Knight,

Inquest into the death of Summer Rae Mant

Thank you for your Report to Prevent Future Deaths dated 27 February 2026, issued following the inquest into the death of Summer Rae Mant.

The Health Board wishes to express its sincere condolences to Summer’s family.

While this case did not involve services provided by Betsi Cadwaladr University Health Board, we have nonetheless considered the matters raised carefully and have treated the report as an important opportunity for shared learning across our Health Board and NHS Wales.

The Health Board has given detailed consideration to the concerns raised. This has included senior clinical review and direct consideration by our Resuscitation Service, together with discussion with pharmacy and medicines management colleagues and consideration of the wider national position.

We recognise the concern that variation in resuscitation trolley configuration may contribute to delays in accessing critical medicines, particularly in time‑critical situations involving staff who are unfamiliar with local arrangements.

By way of context, the Health Board has had standardised cardiac arrest trolleys in place across its acute hospital sites for a number of years, aligned to the Resuscitation Council UK standards for equipment and drug lists. These arrangements are supported through established governance processes, including local resuscitation and medicines management arrangements.

As part of our considerations, we have also taken account of work undertaken at an all‑Wales level through the Welsh Resuscitation Forum and associated professional groups. This work has confirmed both the degree of variation that exists across organisations and the practical challenges associated with full standardisation of resuscitation trolleys in different clinical settings.

This work has also highlighted the importance of human factors, including staff familiarity with local equipment, particularly in time‑critical events and where staff rotate between organisations.

In North Wales, this consideration is particularly relevant. The Health Board’s workforce includes clinicians and trainees rotating not only across Welsh organisations but also through links with both the Bangor and Mersey deaneries. This means that staff may be accustomed to a wider Ein cyf / Our ref: Eichcyf / Your ref: Dyddiad / Date: 26 June 2026 Rachel Knight HM Coroner for South Wales Central The Coroner’s Office The Old Courthouse Courthouse Street Pontypridd CF37 1JW Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG

range of equipment configurations across both Wales and north‑west England, and reinforces the importance of local familiarity, induction and clear system design rather than reliance on a single national configuration.

The Health Board’s Resuscitation Service has been actively engaged in national discussions and has contributed to consideration of potential approaches to improving consistency, particularly in relation to the availability and location of essential resuscitation drugs.

In response to the concerns raised, the Health Board can confirm the following:

• A standardised approach to resuscitation trolleys and drug provision is in place across our acute sites, aligned to national standards;
• Local arrangements have been reviewed by our Resuscitation Service and relevant clinical leads in light of the issues identified;
• The Health Board is engaged in national work to explore opportunities for greater consistency, particularly in relation to the availability and presentation of core resuscitation drugs;
• The Health Board has recently updated its Resuscitation Policy, which includes strengthened expectations in relation to the checking, stocking and layout of resuscitation equipment; and
• Supporting practical measures are in place to promote staff familiarity with equipment, including visual guidance tools (“My Kit Check”) to assist staff in understanding the contents and layout of resuscitation trolleys, alongside local induction, training and checking processes within clinical areas.

In considering further action, the Health Board supports the principle of improving consistency in the availability and location of key resuscitation drugs. However, consistent with the national work undertaken to date, we consider that full standardisation of resuscitation trolley configuration across all settings will be difficult in practice and may not address all of the contributory factors identified particularly given our need to work the NHS in north‑west England.

The Health Board will continue to contribute to the national programme of work to identify as evidence‑based approach, while maintaining safe and effective local arrangements, with particular focus on supporting staff familiarity and safe access to essential drugs in emergency situations.

We trust this response provides assurance that the concerns identified have been carefully considered and that the Health Board has robust local arrangements, whilst assuring that further action has been taken and is being progressed in collaboration with partners across NHS Wales.

Dear Miss Knight,

Regulation 28: Report to prevent Future Deaths - Inquest into the death of Summer Rae Mant

Thank you for your Regulation 28 Report issued following the inquest into the death of Summer Rae Mant.

On behalf of Cwm Taf Morgannwg University Health Board (CTMUHB), I would like to express our sincere condolences to Summer’s family. We are grateful to you for identifying matters of concern arising from the evidence heard at inquest and for the opportunity to set out the actions taken and planned in response.

The Health Board acknowledges the concerns raised in relation to a delay in obtaining adrenaline during resuscitation, variation in crash trolley layout and design and the risk posed by inconsistent systems for rotational junior doctors.

It is further acknowledged that the Health Board accepts that variation in the visual layout and accessibility of resuscitation equipment presents a human factors risk, particularly in time-critical emergency situations.

The Health Board has actively contributed to the Welsh Government-led All-Wales response to this Regulation 28 report, recognising the importance of a consistent national approach to patient safety improvement.

Cyfeiriad Dychwelyd/ Return Address: Bwrdd Iechyd Prifysgol Cwm Taf Morgannwg Pencadlys Parc Navigation, Abercynon CF45 4SN

Cwm Taf Morgannwg University Health Board Headquarters Navigation Park Abercynon CF45 4SN

Croeso i chi gyfathrebu â’r bwrdd iechyd yn y Gymraeg neu'r Saesneg. Byddwn yn ymateb yn yr un iaith a ni fydd hyn yn arwain at oedi. You are welcome to correspond with the Health Board in Welsh or English. We will respond accordingly and this will not delay the response.

In addition, following receipt of the Regulation 28 report, the Health Board established a multidisciplinary Task and Finish Group to oversee the local response and provide assurance of delivery. This group includes representation from resuscitation services, pharmacy, clinical services and clinical education.

The group has:  Developed and is overseeing delivery of a comprehensive Action Plan  Ensured actions are clinically informed and aligned to human factors principles  Provided coordinated oversight across all relevant services and sites  Established a clear mechanism for monitoring progress and evidencing assurance

The Action Plan is being used as the Health Board’s live assurance document and is supported by regular oversight through Patient Safety and Legal Services governance arrangements, including scheduled follow-up meetings to monitor progress and delivery.

The Health Board has undertaken a comprehensive review of resuscitation trolley arrangements across all acute hospital sites. This confirmed that whilst the contents of cardiac arrest drug trays are standardised in line with Resuscitation Council guidance, there remained variation in visual layout and presentation, particularly at Princess of Wales Hospital (POW), which presents a recognised human factors risk in time-critical situations. In response, immediate action has been taken to align POW paediatric resuscitation trolleys with the established model used at Prince Charles Hospital and Royal Glamorgan Hospital. This includes the removal of red paediatric drug boxes and the introduction of a clear tray system to improve visibility and rapid access to emergency medication. Implementation is being supported through a structured rollout programme, including ward-based engagement, communication and standardised visual guidance materials.

This programme of standardisation is being delivered in a phased and clinically led manner and extends beyond paediatric areas. Neonatal resuscitation arrangements, recognised as requiring a distinct approach, have been reviewed, with minor inconsistencies identified and actions agreed to ensure alignment across sites. In addition, all clinical environments where a resuscitation event may occur including wards, theatres, emergency departments and specialist services are being incorporated within the scope of this work to ensure consistency and reduce variation across the Health Board

In parallel, a review of medicines governance identified inconsistencies between Pharmacy Standard Operating Procedures and the overarching Resuscitation Policy, particularly in relation to roles and responsibilities for checking, replenishment and expiry monitoring.

Croeso i chi gyfathrebu â’r bwrdd iechyd yn y Gymraeg neu'r Saesneg. Byddwn yn ymateb yn yr un iaith a ni fydd hyn yn arwain at oedi. You are welcome to correspond with the Health Board in Welsh or English. We will respond accordingly and this will not delay the response.

These risks have been addressed through clear delineation of responsibilities, with nursing teams responsible for daily checks of resuscitation trolleys and Pharmacy responsible for ongoing stock management and expiry control. Work is underway to rationalise and align all relevant policies and SOPs, ensuring that a single, current and consistent set of guidance is available across the organisation, supported by appropriate document control arrangements.

The Health Board has also strengthened training and induction arrangements to address human factors risks associated with staff unfamiliarity. Whilst nursing staff already receive resuscitation trolley orientation as part of induction and mandatory training, gaps were identified within medical induction, particularly for rotational and out-of-hours staff. In response, work is underway with Medical Education to embed resuscitation trolley orientation within formal induction programmes for all incoming medical staff. Interim arrangements have been introduced to provide immediate assurance, alongside the development of updated training resources, including visual guides and instructional materials, to support consistent staff familiarisation with the standardised trolley layout.

The Health Board recognises the seriousness of the concerns raised and is committed to ensuring that robust, standardised systems are in place to support safe and effective emergency care.

Significant progress has already been made, with strong governance arrangements now in place to oversee delivery and ensure sustained improvement.

We hope this response provides assurance that appropriate and proportionate action is being taken to mitigate the risks identified and prevent future deaths.

If you require further information please liaise with , Lead for Legal Services who will be able to assist.