“Communication and collaboration between primary and secondary care”
Dated 14 Jan 2022, 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 11 Mar 2022.
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 dated14 Jan 2022
- Deadline11 Mar 2022
- Published on judiciary.uk20 Jan 2022
- 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 January 2022. |
| Richmond Clinic | Response publishedPublished on judiciary.uk in January 2022. |
The coroner’s concerns
1. Communication and collaboration between primary and secondary care. Brian Wareham had been admitted to hospital in May 2020 with ongoing symptoms of weight loss, dysphagia and general weakness. He was discharged in June 2020 with a package of care and the treating clinicians felt that his condition had stabilised. There was no immediate cure for Brian's problems and he was provided with advice about a softer, more manageable diet. In evidence his GP (Dr of the Richmond clinic in Newport) stated that he thought Brian should have remained in hospital, that he was not fit to be at home. Dr r stated that he did not understand the relationship between Brian's gastroenterology problems and his newly diagnosed lung cancer, specifically whether he was for active treatment or whether the approach was to be palliative. Given the GPs considerable concerns which he voiced with frustration and disdain, I questioned why he made no effort to try to address these problems by directly contacting the medical team in Nevill Hall Hospital responsible for Mr Wareham and who had in fact written to the GP practice at the time of his discharge. When these questions were put to Dr he stated that he thought this would be futile and it appeared that there was a significant breakdown in communication, trust and respect between primary and secondary care. The current situation appears to leave vulnerable patients without appropriate information and support due to a breakdown in the relationship between clinicians.
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, 2022-0010
- Added to Minute Book
- 8 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
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