Gareth Wynne Tatchell · Prevention of Future Deaths report

On the 19th of June 2024 I commenced an investigation into the death of Gareth Wynne Tatchell. The investigation concluded at the end of the inquest on the 26th June 2025.

The medical cause of death is
1a) pneumonia
2 squamous cell carcinoma

The conclusion of the inquest as to how Mr Tatchell came to his death was a narrative conclusion and is as follows:-

the deceased died from the natural cause of pneumonia having undergone treatment for squamous cell carcinoma which had returned at the time of death. The delay in providing treatment more than minimally contributed to the deceased’s death.

The deceased was Gareth Wynne Tatchell and he was pronounced dead on the 9th April 2024 at Princess of Wales Hospital, Swansea. The cause of death was pneumonia. Squamous cell carcinoma was a contributing factor in his death.

Gareth was referred to the maxillo-facial team at Morriston Hospital on the 12th of April 2023 by his dentist following the discovery of an ulcer in the lower left mandible. The referral was classed as an urgent suspected cancer (USC) and Gareth was seen in outpatients clinic on the 28th of April 2023. Cancer was suspected at that point, specifically a squamous cell carcinoma but it needed to be confirmed by a biopsy. That biopsy took place on 18 May and the result came back on 30 May as a moderately differentiated squamous cell carcinoma. Gareth was seen again on the 19th of June and further tests consisting of a CT of the thorax, a CT angiogram of the legs and an MRI and ultrasound of the neck were undertaken on the 28th. Care was then transferred to the treating consultant maxillofacial surgeon who first saw Gareth on the 6th of July, and then on the 27 July to discuss treatment, which would consist of surgery and radiotherapy. Due to theatre capacity, the earliest date being 13 September. By the week prior to surgery Gareth had developed a lump both inside and out, meaning that the lump was visible on the outside but it would also have spread to the blood vessels in the neck.
The surgery was able to remove the tumour macroscopically i.e all that was visible to the naked eye, but as it was encasing the carotid it would not be possible to remove it all.

In February 2024 the treating consultant saw Gareth in hospital after he had gone in to have the AAA repaired. It was then that Gareth complained of a pain in the neck which prompted the CT scan showing an enlargement and a biopsy then confirmed that the cancer had returned. Gareth was discharged from hospital following the AAA repair but was readmitted to hospital on the 8th of March 2024. He subsequently passed away in hospital on the above date.

1. There was a delay in both the diagnostic and staging phase and treatment phase contrary to the timescales in the Suspected Cancer Pathway.
2. Part of the delays resolve around the time taken to undertake staging scans for the purpose of the diagnostic and staging phase.
3. Two Associate Medical Directors have communicated that delays in undertaking staging scans are ongoing and are having an impact on survivability rates and prognoses by making treatable cancers irreversible.