Glyn Pressley

I am Frazer STUART, Assistant Coroner, for the coroner area of Gwent.

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online.   The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary.

SUMMARY OF CORONER’S CONCERN 1 am concerned that clinicians in secondary care are not aware of how their correspondence to primary care is handled upon receipt. If correspondence from secondary to primary care does not contain a specific instruction for further action, it is not viewed by a clinician but categorised by administrative staff, and uploaded to a patients file with no action being taken. It became apparent during the course of the inquest hearing that secondary care clinicians are not aware of this process and believed that every letter sent to a GP surgery would be passed to a GP or other medically qualified person for review. The inquest heard how this is the position across Wales, and was not limited to the ABUHB area. 1 am concerned that these circumstances create a risk that the need for a referral to a specialist could be missed, resulting in a risk of death following delayed or missed diagnosis and treatment.