“5 During the resuscitation of Summer at Prince Charles Hospital in theatre following…”
Dated 27 Feb 2026, from the coroner for South Wales Central. Sent to 9 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 24 Apr 2026. 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 dated27 Feb 2026
- Deadline24 Apr 2026
- Published on judiciary.uk3 Mar 2026
- Today28 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Cardiff and Vale University Health BoardNamed in the report as “Cardiff & Vale University Health Board” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 24 Apr 2026. A reply may have been sent and not yet published. |
| Cwm Taf Morgannwg University Health BoardNamed in the report as “Cwm Taf Morgannwg University Health” | Response publishedPublished on judiciary.uk in March 2026. |
| Powys Teaching Health Board | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 24 Apr 2026. A reply may have been sent and not yet published. |
| Hywel Dda University Health Board | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 24 Apr 2026. A reply may have been sent and not yet published. |
| Betsi Cadwaladr University Health Board | Response publishedPublished on judiciary.uk in March 2026. |
| Aneurin Bevan University Health Board | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 24 Apr 2026. A reply may have been sent and not yet published. |
| Swansea Bay University Health Board | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 24 Apr 2026. A reply may have been sent and not yet published. |
| Velindre University NHS Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 24 Apr 2026. A reply may have been sent and not yet published. |
| Department of Health and Social CareNamed in the report as “Department for Health and Social Care” | Response publishedPublished on judiciary.uk in March 2026. |
The coroner’s concerns
5 During the resuscitation of Summer at Prince Charles Hospital in theatre following intubation, there was a delay in obtaining adrenaline. The incident occurred at night and it involved a skeleton staff including some junior doctors, fairly new to the hospital. The delay in finding adrenaline, was likely due to the fact that there is no standardised crash trolley, and junior doctors frequently rotate between hospitals and health boards and encounter different set-ups. Paediatric crash trolleys are necessarily different to adult crash trolleys, but there was consensus in evidence that it would be safer if there was a single standardised version of each type across every hospital setting in which junior doctors rotate, to minimise confusion at a time critical moment.
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, 2026-0118
- 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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