Gareth Johnson
12 Sept 2025 · Coroner Kerrie Burge · South Wales Central
The coroner's concerns
1. critical care patient transfer during building maintenance
“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.”
2. suboptimal postoperative medication management
“[the deceased]'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”
3. failure of transfer safeguards under pressure
“there remained fears that these systems would fail during times of pressure”