UK Inquiry Tracker

Joan Read Prevention of future deaths report

PFD Report Response Pending Ref: 2026-0055

Date of Report 4 February 2026

Coroner Rachel Knight

Coroner Area South Wales Central

Response Deadline ✓ from report 3 April 2026

Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)

Judiciary.uk Report PDF

6 days left · 0 of 2 responded

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Response Status

Responses 0 of 2

56-Day Deadline 3 Apr 2026

6 days left to respond

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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner’s Concerns

(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

Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 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.

Report Sections

Investigation and Inquest

On 20 March 2025 I commenced an investigation into the death of Joan Marilyn READ . The

Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 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

Circumstances of the Death

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

Copies Sent To

and the clinician concerned

Inquest Conclusion

1a Bronchopneumonia 1b Frailty due to B12 deficiency 1c Pernicious anaemia II COVID 19 infection, hypothryoidism, delirium