Joan Read

I am Rachel Knight H M Coroner, for the coroner area of South Wales Central.

On 20 March 2025 I commenced an investigation into the death of Joan Marilyn READ . The investigation concluded at the end of the inquest on 03/02/2026 . The conclusion of the inquest was a narrative. The medical cause of death was recorded as follows: 1a  Bronchopneumonia 1b  Frailty due to B12 deficiency 1c  Pernicious anaemia II   COVID 19 infection, hypothryoidism, delirium

These were recorded as :-  Joan Marilyn Read was aged 91 when on 18th March 2025 she died at the University Hospital of Wales, Cardiff. Joan had been an inpatient in August 2023, and was discharged home whilst a blood  test  result  was  pending.  There  was  a  missed  opportunity  to  communicate  a  severely deranged B12 result, and as a consequence, it was not treated in hospital, nor in the community. Joan was admitted to the same hospital in January 2025 with a significant deterioration in her physiological reserves, she was frail and had been less compliant with her medication. Sadly, despite all treatment available, Joan did not recover and continued to decline to her death.   Joan was treated at the UHW from mid-January until her death on March 18th 2025. It is more likely than not, that the failure to address her B12 deficiency more than minimally contributed to her death.   The Inquest focused upon:-    – the processes surrounding deranged test results and their onward communication for action

During the course of 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. (1)  Evidence revealed that a single medical consultant is responsible for geriatric perioperative  care (POPS). There is no cross-cover during periods of expected and unexpected absence. There is a risk that deranged test results or other urgent results will be missed when that doctor is absent; (2) Without a robust system for cross-cover 52 weeks per year recognised within another doctor’s job plan, this risk will likely continue, despite huge positive strides in communicating test results  within the Trust.

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.