“I heard in evidence from emergency medical and nursing staff that, notwithstanding Mr…”

The coroner’s concerns

I heard in evidence from emergency medical and nursing staff that, notwithstanding Mr  Rees died during the pandemic when overcrowding became the norm, overcapacity,  under-establishment of staff and exit block has not materially changed since Mr Rees’  death. I was informed the establishment of staff within the department is based on the  number of patients being between 60-70 and was very concerned to learn that when Mr  Rees was admitted there were 187 patients within the department. The evidence was that “the constraints on nurses now are about the same as when Mr Rees died.” I had further concerns upon hearing that patient numbers have been increasing year on year by 7%  and while the Health Board has implemented changes bringing about some  improvements, they have not made sufficient impact to satisfy me that future deaths due  to over capacity, insufficient staff and exit block will not continue to occur. Mr Rees was  within the Emergency Department ( including the time spent on the ambulance) for eight  and a half hours without the administration of prescribed medication despite clear signs of overwhelming infection. The staff had too many patients with competing priorities to care  for.  The concerns I have were confirmed by the evidence I heard during the course of the  inquest such as “ occupancy is substantially greater than space ……… it’s not just about  numbers, patients aren’t moved through the department ……. there is huge moral injury to  staff …….exit block is still happening, with insufficient space to move patients into ……. it  has been on the health boards risk register for a number of years” the latter comment  suggesting that the risk has been ongoing without resolution for some years.  I was made aware during the course of the inquest that a joint letter from the Royal  College of Emergency Medicine had recently been sent to the Welsh Government raising  the concerns I have highlighted above.  I am informed that the Health Board in conjunction with the Emergency Department has  done all within its powers to bring about positive change with some success, and I am  keen to learn what collaborative measures will be taken by Cardiff and Vale University  Health Board together with the Welsh Government to resolve what has become a chronic, unacceptable and dangerous situation to ensure the care and treatment provided to  patients within the Emergency Department is timely and safe. 11 COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion  should receive it.  I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles] 1. Mr Rees’ Family 2. Public Health Wales I also have a duty to send a copy of the report to the Chief Coroner.  You may make representations to me, the coroner, about the publication of the contents  of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any  representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12 28 July 2026 SIGNATURE Gaynor Kynaston, HM Coroner for South Wales Central Coroner Area Alan Rees – Prevention of future deaths report – 2026-0390_Published Download

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judiciary.uk, Prevention of Future Deaths reports, 2026-0390

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7 Oct 2026

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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