“2 Although the Cwm Taf Morgannwg University Health Board did not provide direct care to…”

The coroner’s concerns

– 2 Although the Cwm Taf Morgannwg University Health Board did not provide direct care to Jackson Yeow during the period within scope, it provided the evidence of a consultant in emergency medicine to the inquest on the issue of delays in ambulance handovers at the Princess of Wales Hospital, Bridgend. That evidence directly identified the following matters of concern: (1) Care for patients in the emergency department is frequently provided in the corridor and other non clinical spaces, which: (a) Impedes efficient clinical assessment, causing clinicians to take longer performing tasks and rendering clinical care more difficult; (b) Impedes the ability of staff to recognize a patient’s deteriorating condition; (c) Increases patient morbidity through environmental factors compromising a patient’s ability to sleep, hygiene and nutrition. (d) May slow the process of ambulance handovers. (2) Care in corridors and other non clinical spaces has been normalized, which in the opinion of the consultant who gave evidence is unsafe. (3) When conducted routinely, care in corridors and other non clinical spaces reduces the capacity of the Emergency Department so that should acuity escalate, it is likely to cause delays to the release of ambulances. (4) The underling obstacle to improving flow through the hospital and relieving pressure on the Emergency Department is the significant number of patients who are medically fit to be discharged but whose discharge is delayed due to non medical reasons.

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, 2025-0032

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0