“although family and Yvonne were told that they could refer any concerns to various…”
Dated 13 Dec 2022, from the coroner for South Wales Central. 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 7 Feb 2023.
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 dated13 Dec 2022
- Deadline7 Feb 2023
- Published on judiciary.uk19 Dec 2022
- Today21 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Cardiff and Vale University Health BoardNamed in the report as “Cardiff and Vale University Health Board NHS Trust” | Response publishedPublished on judiciary.uk in December 2022. |
| Abbott Nutrition | Response publishedPublished on judiciary.uk in December 2022. |
The coroner’s concerns
– (1) although family and Yvonne were told that they could refer any concerns to various professionals including the Abbott nurse, they did not understand the specific signs of sepsis to watch out for; (2) had family understood the signs of sepsis, it is likely that they would have rung 1 999 much sooner; and (3) It may be that patient/carer information cards setting out the common signs of sepsis already exists. Would it be possible to give out such information cards to patients/carers with PEGs and/or those with a known risk of infection who are in the community?
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, 2022-0404
- 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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