Cardiff and Vale University Health Board
NHS / Health Body
Action Taken
• The Health Board has undertaken a detailed internal Patient Safety Review and enacted several improvements. • Further actions are planned to reduce risk and strengthen system resilience. (AI summary)
View full response
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: Eich cyf/Your ref: Ein cyf/Our ref: SR-jb-0326-234 Welsh Health Telephone Network: Direct Line/Llinell uniongychol:
Executive Headquarters / Pencadlys Gweithredol
Woodland House
Ty Coedtir Maes-y-Coed Road
Ffordd Maes-y-Coed Cardiff
Caerdydd CF14 4HH
CF14 4HH
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 reviewed by the relevant specialty team (e.g., general medicine, 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, investigations, pending results, and follow-ups are documented clearly.
• 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: Improving Communication and Management of Abnormal Results 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 every case. The first audit, completed in July 2025, demonstrated 100% compliance, providing assurance that the revised process is being followed reliably. 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.
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: Eich cyf/Your ref: Ein cyf/Our ref: SR-jb-0326-234 Welsh Health Telephone Network: Direct Line/Llinell uniongychol:
Executive Headquarters / Pencadlys Gweithredol
Woodland House
Ty Coedtir Maes-y-Coed Road
Ffordd Maes-y-Coed Cardiff
Caerdydd CF14 4HH
CF14 4HH
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 reviewed by the relevant specialty team (e.g., general medicine, 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, investigations, pending results, and follow-ups are documented clearly.
• 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: Improving Communication and Management of Abnormal Results 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 every case. The first audit, completed in July 2025, demonstrated 100% compliance, providing assurance that the revised process is being followed reliably. 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.