“There are two cases that have recently come to my attention within the Cardiff area where…”
Dated 1 Oct 2025, from the coroner for South Wales Central. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 26 Nov 2025. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated1 Oct 2025
- Deadline26 Nov 2025
- Published on judiciary.uk3 Oct 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| The Minister for Health and Social Services of Wales | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| [REDACTED] | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Digital Health and Care WalesNamed in the report as “[REDACTED] Chief Executive of Digital Health & Care Wales” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
(1) There are two cases that have recently come to my attention within the Cardiff area where patients have been diagnosed with Barrett’s, lost to follow-up and have gone on to die from oesophageal cancers; (2) There are inadequate processes in place to address this lacuna, particularly in primary care where a patient may not be a regular attender; (3) GPs frequently recall their patients with known, chronic issues such as asthma & diabetes, and there is a process for recalling women for smear tests for example, however Barrett’s does not currently benefit from such a recall exercise/audit, even though it is well-established to be a pre- cancerous condition; and (4) When prescribing drugs such as omeprazole or other PPIs for symptoms which may relate to Barrett’s, there is no prompt for GPs to consider whether the patient hits the relevant red flags which may benefit from endoscopy rather than a course of medication, or whether they have previously been diagnosed with the condition and ought to be under surveillance.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0490
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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