Gareth Idris Johnson · Prevention of Future Deaths report

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Issued 12 Sep 2025•South Wales Central

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns: 3
Recipients: 2
Responses found: 2
Stated actions: 15

Recipients and published responses

Cardiff & Vale University LHBResponse found Welsh GovernmentResponse found

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 18 October 2024 I commenced an investigation into the death of Gareth Idris Johnson. The investigation concluded at the end of the inquest on 01/09/2025.

I made the following determinations:

Gareth Idris Johnson, aged 41 died at University Hospital of Wales on the 16th of October 2024 due to complications following a catheter directed thrombolysis procedure.

I reached a narrative conclusion:

After undergoing uneventful catheter directed thrombolysis, Gareth's anti coagulation medication management was sub optimal for a number of reasons, the most significant of which was lack of clarity about the appropriate level of heparin to be administered. On the balance of probabilities, sub therapeutic anti coagulation medication more than minimally, negligibly or trivially contributed to Gareth's death and it is more likely than not that Gareth would have survived had his medication been delivered appropriately

The medical cause of death was:

1a Cardiac arrest

1b Pulmonary Embolus

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

Failure of safeguards for moving patients requiring critical care during times of pressure
Part of recurring concern: Unreliable healthcare patient transfer processes
Lack of adequate hospital building maintenance
Insufficient Critical Care capacity for patient volumes

Stated actions 15

Welsh Government
Work with Cardiff and Vale University Health Board to prioritise estate investment using the capital prioritisation exercise.
Welsh Government
Provide £0.750 million funding for a detailed condition survey of the University Hospital of Wales buildings.
Welsh Government
Write to Cardiff and Vale University Health Board to confirm clinical governance and safe clinical cover for future critical-care-unit maintenance.
Welsh Government
Develop a business case to refurbish the intensive therapy unit at the University Hospital of Wales.
Welsh Government
Discuss University Hospital of Wales infrastructure issues with Cardiff and Vale University Health Board and NHS Shared Services Partnership-Specialist Estate Services.
Welsh Government
Write to selected health boards, including Cardiff and Vale University Health Board, requesting responses to the critical care network estate census.
Welsh Government
Consider the critical care census report to inform Welsh Government capital investment plans and health board planning.
Cardiff & Vale University LHB
Deliver scheduled infrastructure upgrades, including UPS installations and electrical-supply improvements, through the Estates programme.
Cardiff & Vale University LHB
Regularly review and simulate critical-care escalation and major-incident plans.
Cardiff & Vale University LHB
Implemented a Critical Care Escalation Plan governing staffed bed capacity, patient prioritisation, delayed-transfer escalation, clinically led transfers and diversion arrangements.
Cardiff & Vale University LHB
Developed a Major Incident Plan framework defining emergency command, reporting, escalation, evacuation, triage, patient transfer, communications and critical-care staff responsibilities.
Cardiff & Vale University LHB
Operate governance processes for incident review and dissemination of learning.
Cardiff & Vale University LHB
Conduct annual stress testing and live major-incident exercises at least every three years, maintaining training records.
Cardiff & Vale University LHB
Developed an Electrical Failure Emergency Action Card covering power-failure response, vulnerable-patient evacuation, emergency decanting and business-continuity arrangements.
Cardiff & Vale University LHB
Provide ongoing staff training in major-incident response and escalation procedures.

Respondent positions 2

Welsh Government
The existing estate was not the primary cause of the death, although estate improvements and resulting patient relocation contributed to it.
Disputes the concern
Welsh Government
Day-to-day operation and management of the hospital site and services remain the statutory responsibility of Cardiff and Vale University Health Board.
Redirects responsibility

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised3

Failure of safeguards for moving patients requiring critical care during times of pressure

Lack of adequate hospital building maintenance

Insufficient Critical Care capacity for patient volumes

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.15

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

Stated actions 15

Respondent positions 2