Medical Officer for Welsh Government
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Source · Prevention of Future Deaths
Glyn Pressley
Ref: 2026-0342
Date: 17 Jul 2026
Coroner: Frazer Stuart
Area: Gwent
1 response identified · 1 indexed addressee
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Response deadline: 11 November 2026 (estimated from the Judiciary.uk publication date).
Date
17 Jul 2026
56-day deadline
11 Nov 2026 est.
estimated from the Judiciary.uk publication date
Responses identified
1 of 1
Coroner's concerns
1 am concerned that clinicians in secondary care are not aware of how their correspondence to primary care is handled upon receipt. If correspondence from secondary to primary care does not contain a specific instruction for further action, it is not viewed by a clinician but categorised by administrative staff, and uploaded to a patients...
View full coroner's concerns
1 am concerned that clinicians in secondary care are not aware of how their correspondence to primary care is handled upon receipt. If correspondence from secondary to primary care does not contain a specific instruction for further action, it is not viewed by a clinician but categorised by administrative staff, and uploaded to a patients file with no action being taken. It became apparent during the course of the inquest hearing that secondary care clinicians are not aware of this process and believed that every letter sent to a GP surgery would be passed to a GP or other medically qualified person for review. The inquest heard how this is the position across Wales, and was not limited to the ABUHB area. 1 am concerned that these circumstances create a risk that the need for a referral to a specialist could be missed, resulting in a risk of death following delayed or missed diagnosis and treatment.
Responses
Report sections
Investigation and inquest
On 03 September 2024, the Senior Coroner for Gwent commenced an investigation into the death Glyn Richard Pressley aged 55 years. The medical cause of death was: 1A Hypertensive Heart Disease 2 Coronary artery atherosclerosis & obesity The investigation concluded at the end of the inquest on 16 July 2026. The conclusion of the inquest was that: Mr Pressley died on the 20 August 2024, at 11B Turner Street, Newport, as a result of heart failure My conclusion was one of Natural Causes.
Circumstances of the death
In November 2021, Mr Pressley underwent a hip replacement. As part of the pre-operative procedure, he underwent an ECG and echo cardiogram examination which revealed he was suffering from a Left Bundle Branch Block, an ejection fraction of 48% alongside a grade 1 diastolic dysfunction. This was not an impediment to having his hip operation, but the anaesthetist wrote to Mr Pressley’s GP to inform him of the findings with a view to exploring the issues in more detail. These circumstances give rise to a risk of future deaths due to missed opportunities for referral to specialists for diagnosis and treatment.
Action should be taken
In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and 1 believe each of you have the power to take such action.
Similar PFD reports
Report details
- Reference
- 2026-0342
- Date of report
- 17 July 2026
- Coroner
- Frazer Stuart
- Coroner area
- Gwent
Responses identified
Responses identified
1 of 1
All listed responses identified
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 11 Nov 2026 (estimated from the Judiciary.uk publication date).
Sent to
- Chief Medical Officer for Welsh Government