“5 Annette should have been referred for surgical review rather than being discharged”
Dated 6 Mar 2025, 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
All responses publishedReplies were due by 1 May 2025.
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 dated6 Mar 2025
- Deadline1 May 2025
- Published on judiciary.uk7 Mar 2025
- Today21 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Cwm Taf Morgannwg University Health Board | Response publishedPublished on judiciary.uk in March 2025. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
5 Annette should have been referred for surgical review rather than being discharged. Work on a “Failed Discharge” policy has been ongoing for some time. When implemented, patients re-attending Emergency Departments in similar circumstances would be automatically and swiftly filtered to the appropriate specialist team, which would reduce the risks for those individual patients and reduce pressures and the consequent risk of errors within Emergency Departments. Progress with this policy has been difficult and there is no definitive timescale for implementation.
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, 2025-0126
- 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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