Gareth Johnson

I am Kerrie Burge, H.M. Coroner for the coroner area of South Wales Central.

On 18 October 2024 I commenced an investigation into the death of Gareth Idris Johnson. The investigation concluded at the end of the inquest on 01/09/2025. I made the following determinations: Gareth Idris Johnson, aged 41 died at University Hospital of Wales on the 16th of October 2024 due to complications following a catheter directed thrombolysis procedure. I reached a narrative conclusion: After undergoing uneventful catheter directed thrombolysis, Gareth’s anti coagulation medication management was sub optimal for a number of reasons, the most significant of which was lack of clarity about the appropriate level of heparin to be administered. On the balance of probabilities, sub therapeutic anti coagulation medication more than minimally,  negligibly or trivially contributed to Gareth’s death and it is more likely than not that Gareth would have survived had his medication been delivered appropriately The medical cause of death was: 1a Cardiac arrest 1b Pulmonary Embolus

Gareth Idris Johnson attended The Grange hospital on 12.10.2024 and was diagnosed with a moderate to large volume bilateral pulmonary embolism with acute right heart strain. It was the weekend and therefore Gareth was transferred to University Hospital of Wales for catheter directed thrombolysis.   Following the procedure, Gareth was one of a small number of patients transferred out of the Critical Care Unit to PACU due to planned building maintenance works. Gareth’s post operative medication management was sub optimal for a number of reasons, including the impact of being cared for outside the main Critical Care Unit.

During the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Due to the age of the hospital building, maintenance is a constant battle. There are also capacity issues in Critical Care due to patient volumes. Building infrastructure had been a constant feature on the corporate risk register and was now scored at its highest level.   Whilst measures have been put in place to safeguard against moving patients who require critical care from the Critical Care Unit, there remained fears that these systems would fail during times of pressure.

In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.