“In the Emergency Department, and whilst patients were awaiting admission to a Ward, their…”
Dated 12 Nov 2018, from the coroner for South Wales Central. 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 12 Apr 2019, after the 56 days for replies had ended (7 Jan 2019). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated12 Nov 2018
- Deadline7 Jan 2019
- Published on judiciary.uk12 Apr 2019
- Today22 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” | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 12 Apr 2019, after the 56 days for replies had ended (7 Jan 2019). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) In the Emergency Department, and whilst patients were awaiting admission to a Ward, their PODS remained with them unsecured in a bay (or similar). Exposing the medication to potential further use/mis-use by the patient, another patient or relative, or theft and mis-use (2) On ward B5, the policies in place at the time in relation to PODS were not followed, allowing Mr Page's medication to remain unsecured on the Ward, exposing the medication as in (1) above. (3) | received evidence that the Patient Property Policy and Medicines Code were in the process of being updated to address (1) & (2), but this exercise not expected to be completed until March 2019. Thereafter, & on the evidence ——_— it was not clear when implementation of the updated policies would take effect. (4) Whilst the specific events that unfolded in relation to Mr Page on the morning of 23.3.18 may have been unforeseeable, the current arrangements/policies in place for the receiving, utilising and storing of PODS at UHW, Cardiff, could give rise to a risk of future deaths in a variety of different ways. (5) Once completed the exercise of implementing the new Policy & Code needs to be thorough and extensive to ensure that all doctors & nurses throughout the Cardiff & Vale University Health Board (whether full time, part-time or Agency/locum) not only are aware of the revised Policy/Code, but clear on its interpretation//requirements.
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, 2018-0347
- 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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