Dear Ms Burge

Subject: Response to Regulation 28 Report to Prevent Future Deaths – Gareth Idris Johnson (2025-0464)

Thank you for your Regulation 28 Report concerning the death of Gareth Idris Johnson and for highlighting the critical issues regarding patient safety, critical care capacity, and infrastructure at University Hospital of Wales. On behalf of Cardiff & Vale University Health Board, I wish to extend our deepest condolences to Gareth’s family. We take the matters raised in your report with the utmost seriousness and are committed to taking robust action to prevent future deaths. This response sets out the actions taken and planned, with direct reference to our policies and procedures.

Infrastructure and Electrical Failure Mitigation

We acknowledge the risks associated with the ageing hospital infrastructure, particularly regarding electrical supply to critical care areas.

In response, we have developed the Electrical Failure Emergency Action Card (E1, draft October 2025), which outlines: Immediate actions to confirm and respond to power failures, including switching to unaffected supplies and declaring an ICU emergency if required.

Prioritisation of evacuation for the most vulnerable patients, with guidance on device battery backup and oxygen supply continuity.
• Identification of emergency decant areas, ensuring power supply is available before transfer.
• Activation of business continuity plans, including temporary ICU relocation and mutual aid arrangements.

Eich cyf/Your ref: Ein cyf/Our ref: SR-jb-1125-178 Welsh Health Telephone Network: Direct Line/Llinell uniongychol: 029 2183 6010 Executive Headquarters / Pencadlys Gweithredol

Woodland House

Ty Coedtir Maes-y-Coed Road

Ffordd Maes-y-Coed Cardiff

Caerdydd CF14 4HH

CF14 4HH

Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board

Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay

Whilst we record on the risk register the challenges that an ageing building poses, we attempt to mitigate risk as far as possible but acknowledge these are ongoing challenges.

Critical Care Capacity and Escalation

The Health Board recognises the challenges posed by patient volumes and infrastructure. To address these, we have implemented the Critical Care Escalation Plan (October 2024), which details:

• Maintaining a minimum of two level 3 staffed admitting beds at all times, with overnight plans for four beds.

Strategic Patient Flow Management and Standardised Escalation Procedures for Delayed Transfers of Care (DToC)

Prioritisation of the most acutely unwell patients for critical care beds, and use of recovery and PACU areas for lower-risk patients when necessary.

• Clinically led moves out of the Critical Care Unit, with thorough handover and up-to-date discharge summaries.
• Staged escalation, including internal optimisation, use of recovery/PACU, postponement of elective activity, and, if required, secondary transfers or tertiary diversion.

As part of ongoing recovery, refurbishment, and mitigation planning, several critical infrastructure issues have been identified that require clarification. These include challenges related to switching to the Uninterruptible Power Supply (UPS) system, particularly the absence of provisions for transferring equipment to essential power sockets if a UPS failure occurs.

Risk assessments conducted after multiple UPS failures have assumed that switching to essential sockets is possible. This capability is important to ensure operational continuity during the installation and transition to new UPS systems.

For reference, the draft Major Incident Plan has been attached, along with the newly developed Action Card detailing procedures for power failure scenarios within Critical Care.

Major Incident Preparedness

The Major Incident Plan v1.04 (DRAFT) provides a comprehensive framework for emergency preparedness, in line with the Civil Contingencies Act 2004. Key elements include.

• Clear command and control structures (Strategic/Gold, Tactical/Silver, Operational/Bronze) for incident management.
• Use of the METHANE model for incident reporting and situational awareness.
• Principles for escalation, evacuation, triage, and transfer of patients during major incidents.

Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board

Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay

• Action cards for critical care staff, ensuring roles and responsibilities are clear in emergencies.
• Communication protocols, including alternative channels (WhatsApp, Teams, VHF radio) to ensure effective coordination.
• Annual stress testing and live exercises at least every three years, with training records maintained by the Critical Care Directorate.

Ongoing Actions and Timetable

• Regular review and simulation of escalation and major incident plans.
• Infrastructure upgrades, including UPS installations and electrical supply improvements, scheduled as per the Estates programme.
• Ongoing staff training in major incident response and escalation procedures.
• Governance processes for incident review and dissemination of learning.

In conclusion the Health Board is committed to continuous improvement and transparency. We will continue to monitor, review, and strengthen our critical care capacity, infrastructure resilience, and emergency preparedness.

Should you require any further information or clarification, please do not hesitate to contact us.

Dear Kerrie,

Regulation 28 Report – Gareth Idris Johnson

I was sorry to hear about the sad circumstances that led to Gareth Idris Johnson’s death and want to take this opportunity to offer my condolences to his family and friends.

Below is the Welsh Government response to the Regulation 28 report following the death of Mr Johnson at the University Hospital of Wales (UHW). It is important lessons are identified and learnt from this tragedy and effectively shared across NHS Wales.

There are longer term plans being reviewed and considered by the health board for the redevelopment of the University Hospital of Wales site. This response focuses on the short and medium-term actions I will be seeking the health board to review at the site to address patient safety and ensure the continuity of healthcare services to the local population. The day-to-day operation and management of the site and the healthcare services provided remains the statutory responsibility of Cardiff and Vale University Health Board (UHB). There are also actions, which will be highlighted to other health boards in Wales.

Specific funding (£0.750m) has been made available to Cardiff and Vale UHB to complete a detailed condition survey of the main buildings on the UHW site to ensure future investment is appropriately targeted. This work will inform short-term investments and whether the buildings are suitable for significant refurbishment in the future.

It is recognised there are many areas of the UHW estate that require significant investment. My officials are working closely with colleagues from Cardiff and Vale UHB about the priority areas for investment informed by a recent capital prioritisation exercise.

The actions we are taking forward as a consequence of the Regulation 28 report are as follows:

1) Officials met Cardiff and Vale UHB on 15 October with NHS Shared Services Partnership-Specialist Estate Services (NWSSP-SES) to discuss the infrastructure issues at the ITU, critical care and theatres departments at the University Hospital of Wales. A business case is being developed to refurbish the ITU. Due to a lack of available space to relocate patients and the nature of the work involved, this work will likely take a number of years to complete.

2) To write to Cardiff and Vale UHB to confirm what clinical governance is in place to approve changes in the location of critical care and to ensure the appropriate clinical cover is in place to provide safe care during future planned maintenance of the critical care unit.

3) To write to selected health boards, including Cardiff and Vale UHB, to request them to respond to the NHS Performance and Improvement critical care network census. This includes questions about the estate, so Welsh Government can develop a national picture with expert context about the estate challenges for critical care across Wales. The census report will be considered by the Welsh Government to inform capital investment plans and health board planning.

There are plans being explored for further capital investment at the University Hospital of Wales. While the condition of the existing estate was not the primary cause of Mr Johnson’s death, the need to make estate improvements led to the relocation of patients, which was a contributory factor. I hope the actions I have set out above will result in robust measures being put in place to manage patient moves in the future.