“(brief summary of matters of concern) The deceased died from a heart attack and I did not…”
Dated 16 Dec 2025, from the coroner for Gwent. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 10 Feb 2026.
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; a reply may have been sent and not yet published.
- Report dated16 Dec 2025
- Deadline10 Feb 2026
- Published on judiciary.uk19 Dec 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Aneurin Bevan University Health Board | Response publishedPublished on judiciary.uk in December 2025. |
The coroner’s concerns
(brief summary of matters of concern) The deceased died from a heart attack and I did not determine that any omission in the administration of the iron had more than minimally contributed to his death . However the lack of a consistent approach to pre-operative management and administration of iron to a chronically anaemic patient could put patients’ lives at risk in the future. Kindly address the issues raised, namely: 1. Whether there are clinical guidelines which determine the pre-operative administration of iron therapy. 2. Whether there is a process which supports these guidelines 3. Whether there is an agreement between Health Boards in these circumstances regard funding to prevent potentially damaging delays in surgery.
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, 2025-0628
- 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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