PFD report

Phillip Lawrence HOGGARTH · Prevention of Future Deaths report

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Issued 16 Dec 2025•Gwent

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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

Concerns raised1

  1. Lack of a consistent approach to pre-operative management and administration of iron
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Implement a standard operating pathway for surgical patients with anaemia or iron deficiency, incorporating the NHS Wales preoperative anaemia pathway and preoperative intravenous iron guidance.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
  2. Action

    Conduct a six-week post-infusion blood test, where surgery timing permits, to confirm improvement and inform whether further intravenous iron is required.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a consistent approach to pre-operative management and administration of iron

Wider context from the report

“The deceased died from a heart attack and I did not determine that any omission in the administration of the iron had more than minimally contributed to his death. However the lack of a consistent approach to pre-operative management and administration of iron to a chronically anaemic patient could put patients’ lives at risk in the future. Kindly address the issues raised, namely: 1. Whether there are clinical guidelines which determine the pre-operative administration of iron therapy. 2. Whether there is a process which supports these guidelines 3. Whether there is an agreement between Health Boards in these circumstances regarding funding to prevent potentially damaging delays in surgery. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement a standard operating pathway for surgical patients with anaemia or iron deficiency, incorporating the NHS Wales preoperative anaemia pathway and preoperative intravenous iron guidance.

Verbatim wording from the response

“Please find attached to this response the Health Board’s Standard Operating Pathway (SOP) for the management of surgical patients presenting to preassessment clinic with anaemia or iron deficiency.”

Source location

Response from Aneurin Bevan University Health Board
Page 1 · response
Published 19 December 2025

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct a six-week post-infusion blood test, where surgery timing permits, to confirm improvement and inform whether further intravenous iron is required.

Verbatim wording from the response

“Our standard IV iron pathway in preassessment includes a blood test at 6 weeks post iron transfusion (where sufficient time is available before surgery) to confirm improvement or inform decision making if a further iron transfusion is required.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 19 December 2025

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Fund the intravenous iron service through the Health Board regardless of patient residence or Health Board boundaries, with costs charged to the relevant clinical area or responsible clinician.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Existing Health Board funding arrangements apply regardless of patient residence or Health Board boundaries, addressing potential funding-related surgical delays.

    Stated by Aneurin Bevan University LHBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Fund the intravenous iron service through the Health Board regardless of patient residence or Health Board boundaries, with costs charged to the relevant clinical area or responsible clinician.

Verbatim wording from the response

“The Health Board confirms that the cost of IV iron is charged to the relevant clinical area or responsible clinician. When the IV iron service was set up, it was agreed that the drug cost of IV iron would be paid for by the surgical specialty the patient belonged to. The service has been running for over two years, with funding provided by the Health Board regardless of patient residence or Health Board boundaries.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 19 December 2025

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing Health Board funding arrangements apply regardless of patient residence or Health Board boundaries, addressing potential funding-related surgical delays.

Verbatim wording from the response

“The Health Board confirms that the cost of IV iron is charged to the relevant clinical area or responsible clinician. When the IV iron service was set up, it was agreed that the drug cost of IV iron would be paid for by the surgical specialty the patient belonged to. The service has been running for over two years, with funding provided by the Health Board regardless of patient residence or Health Board boundaries.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 19 December 2025

Open published response
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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