“(brief summary of matters of concern) The totality of the evidence indicated that it was…”
Dated 5 Feb 2026, from the coroner for Gwent. Sent to 2 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
All responses publishedReplies were due by 2 Apr 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 dated5 Feb 2026
- Deadline2 Apr 2026
- Published on judiciary.uk10 Feb 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Anueron Bevan University Health Board | Response publishedPublished on judiciary.uk in February 2026. |
| Welsh Ambulance Services University NHS TrustNamed in the report as “Welsh Ambulance Service NHS Trust” | Response publishedPublished on judiciary.uk in February 2026. |
The coroner’s concerns
(brief summary of matters of concern) The totality of the evidence indicated that it was not unusual for NEWS scores to be downgraded if a patient had COPD, even when their baseline saturations were not known. The rationale being “COPD sufferers often have lower oxygen saturation levels”. Whilst this may be true, applying this to all COPD sufferers, I consider to be an unsafe practice. 1. Confirmation whether downgrading NEWS scores in the circumstances described is acceptable practice (please note that support for this position was provided by the Clinical Lead who has a training remit) 2. What action will be taken to ensure that more robust approach to clinical assessments will take place in the future.
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, 2026-0063
- 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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