“Deaths Will Continue to Occur”

Standfirst: "Deaths will continue to occur." That was a coroner's warning to NHS Wales in 2023, about mental-health records still kept on paper — and it was neither the first such warning nor the last. Since 2018, coroners in Wales have been naming absent, delayed and partly delivered digital systems among their concerns in reports written after inquests — statutory documents with a single purpose: preventing the next death. In 2023, another coroner said it in a sentence: "the time it is taking is putting patients' lives at risk." Two of the newest reports are addressed to the Chief Executive of Digital Health and Care Wales. This is the record of the coroners' courts — eight years of Prevention of Future Deaths reports.

That NHS Wales's digital failures reach the bedside is not, at this point, a controversial claim. Delayed, fragmented and unreliable digital services slow diagnosis, break the handover of care between clinicians, and leave critical information sitting where the people treating a patient cannot see it — and some of those failures end in death. How many? Nobody can say. There is no register of the patients who might have lived had Wales possessed the fully integrated, high-quality digital infrastructure its national digital bodies have struggled, and largely failed, to build for more than twenty years. Those bodies — Digital Health and Care Wales (DHCW), and the nationally criticised NHS Wales Informatics Service (NWIS) it replaced in April 2021 — share much of the same leadership: DHCW's founding Chief Executive, Helen Thomas, came to it from NWIS, where she was Director of Information and then interim Director and Chief Executive. The counterfactual is unmeasurable by design: you cannot count the deaths a working system would have prevented.

What exists instead is a narrow but unusually authoritative window. When a death is violent or unnatural, or its cause is unknown, the law requires an inquest — an official judicial investigation. Where that inquest leaves the coroner believing something must change to stop the next such death, the coroner writes a Prevention of Future Deaths report and sends it — on the record — to the people and bodies with the power to act. These are the formal findings of judicial officers, following official investigations into specific, named deaths.

The record they form is sparse — coroners see only the fraction of deaths that reach an inquest, and fewer still produce a report that touches digital systems. But sparse is not the same as silent. What these reports do show casts the digital delivery of DHCW and NWIS in a starkly troubling light. Here is one entry in it.

Lyn

Lyn Maher was 79. On 3 January 2024 she was prescribed clarithromycin for a chest infection. On her repeat prescription, like millions of people her age, was a statin — simvastatin. Between those two drugs, in the coroner's words, "There is a well-known contraindication." The instruction that would have protected her was one sentence long: stop the statin while you take the antibiotic.

Nobody said it. Not her GP. Not the community pharmacist who dispensed the antibiotic. Not the different pharmacist who dispensed a second course a week later. Her family collected her tablets; nobody told them either. The pharmacists did not know she was taking simvastatin — because in Wales, community pharmacists cannot routinely see a patient's medication record.

In the Royal Glamorgan Hospital, where she was admitted on 15 January, the statin was still being given. The coroner records that Lyn "became so weak she could not use her legs and could barely lift a spoon to her mouth." She died on 23 January 2024 — twenty days after the first prescription.

At the inquest, coroner Rachel Knight heard "that access to such information is available routinely in English pharmacies, but only in exceptional circumstances in Wales." A judicial officer, weighing evidence about a national arrangement, recorded her view of it in a single sentence: "I have no understanding of why that is the case."

Then the finding that makes this case different. Had either pharmacist been able to see Lyn's drug history, they would have noted the contraindication and told her, told her family — "or written on the pharmacy bag that she was to stop the simvastatin. This likely would have changed the outcome for Lyn."

A sentence on a pharmacy bag. That, in the coroner's finding, is what would likely have saved her. What stood between the pharmacists and that sentence was access to a record that already exists — on national infrastructure run by DHCW. The report, issued on 3 February 2026, is addressed to the Chief Executive of DHCW.¹

The instrument

It matters what kind of document that finding sits in. A Prevention of Future Deaths report — a "Regulation 28 report" — is not journalism, not a campaign claim, not an advocate's characterisation. When an inquest leaves a coroner believing there is "a risk that future deaths will occur unless action is taken", reporting it is not a choice but a statutory duty, under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009. The named recipient is, in turn, under a statutory duty to reply to the coroner — in writing, on the record — within 56 days, setting out what they will do. The Chief Coroner's office publishes both the report and the reply.

Everything quoted here comes from those documents: the findings of judicial officers, and the formal answers of the public bodies required to respond to them. This is the same principle that runs through The Safety Case DHCW Made Against Itself — we are not the ones making the argument. We are quoting the people whose job it was to record it.

The machinery

Two things need setting out, because the same names recur through what follows. First, Wales's NHS is delivered through seven regional health boards — Betsi Cadwaladr in the north; Aneurin Bevan, Swansea Bay, Cwm Taf Morgannwg and Powys among those across the south and mid-Wales — and it is they, not DHCW, who run the hospitals and clinics, and who receive and answer most of these reports.

Second, the long national effort to give those boards joined-up electronic records is co-ordinated centrally, not built board by board. Its centrepiece is WCCIS — the Welsh Community Care Information System, a single health-and-social-care record meant to be shared across Wales, delivered through a software product called CareDirector; around it sit other national systems, such as the Welsh Clinical Communications Gateway (WCCG), through which every GP-to-hospital referral in Wales is meant to move, and the Welsh Clinical Portal, the shared viewer clinicians use to see a patient's record across care settings. So when a coroner writes of "this national strategy", or a health board of "the national system", this is the machinery they mean — and DHCW is the body that co-ordinates it.

The people in the record

CareNHS compiled every published Welsh Prevention of Future Deaths report we could locate that touches digital systems and records: 27 reports from 2018 to 2026, with 38 published responses — every document archived and quoted from source. (The set is what a systematic sweep finds; we do not claim it is complete.)

In the judiciary's database they are case numbers. In the files they are people.

Eric Thompson, 81, sat in an emergency department at Ysbyty Glan Clwyd with dangerously high potassium in his blood. The laboratory knew, and tried to telephone the department. "There was no answer." A second call got through; the results were "not initially documented or escalated". He went into cardiac arrest at 02:50 and died. Coroner Kate Robertson's concern: "There is no electronic or IT method or system by which the laboratory can send the results to the emergency department quickly and efficiently with an alert to indicate abnormal results." In a Welsh hospital in 2022, the safety net for a critical blood result was a telephone that might not be answered.²

Jennifer Campbell, 73, had gallstones, and a specialist who knew exactly which procedure she needed. The referral was a paper form, sent to the endoscopy department in November 2021. It was never seen again — "it is not clear why it was not received or what had occurred to it." She received a letter confirming she was on the waiting list. Sixteen weeks after the referral vanished, she died of an infection caused by the gallstones it was meant to deal with. Her coroner, Kate Robertson, did not stop at the health board — the local NHS organisation her report was sent to. She aimed one sentence at the pace of the national plan to put patient records online: "I am aware that this national strategy is ongoing but the time it is taking is putting patients' lives at risk."³

Eifion Huws's GP sent a "very urgent" mental-health referral, "extremely concerned" that Eifion was deteriorating after attempts to end his life. The referral went into "the hard copy set of notes held by the Psychiatric Liaison Team"; the staff who later saw him "were not aware of this 'very urgent' referral as they only had access to the electronic notes". His coroner, Kate Sutherland, found that any delay in making all notes available electronically "is potentially harmful to patients".⁴

Richard Griffiths, 53, moved to the Conwy area to live with his mother. His mental-health care was meant to transfer with him; "For reasons unknown the transfer of care did not occur." Five months after the move he took his own life. His notes were paper — in 2023, mental-health records "still not electronic" — and the coroner — Kate Robertson again, after the Thompson and Campbell reports above — noted she had "issued several Prevention of Future Death Reports specifically relating to this", that there had been "considerable delay" in moving those records off paper, and that without action "deaths will continue to occur".⁵

Isaac Ingle-Gillis went to his GP in December 2024 after trying to end his life. The GP referred him to the crisis team the same day. The team assessed him and discharged him without follow-up — and, coroner Caroline Saunders heard, "the CRHTT do not have access to the GP records." She could not find that the missing information would have changed the assessment. Her warning was for the next patient: "I am concerned that in future this information (or lack of it) may be vital."⁶

Five cases of twenty-seven. The rest repeat the pattern in different rooms: results that cannot travel, records that cannot be seen, referrals that cannot survive the journey from one desk to another.

Eight years in the future tense

The oldest report in the corpus is from 2018. Steven Welch was 45 when his father found him at home on Boxing Day 2017, "rousable" but immobile. He had a bleed on the brain. The specialists who could treat him were in Bristol — and the radiology software Wales had commissioned stopped at the border. Images could move between Welsh hospitals, but not to England: a "serious commissioning omission", the assistant coroner for South Wales, Sarah-Jane Richards, noted, given that image transfer between hospitals "nationally and internationally has been available for approximately 20 years" — a capability two decades old that Wales had simply not commissioned.

The fallback was to print the scans and fax them. "However the only printer available had run out of ink and there were no spare ink cartridges available." The images were eventually sent to another hospital in Merthyr Tydfil, printed there, and "dispatched by taxi" to Bristol — while, the report records, Mr Welch's condition further deteriorated. The 2018 coroner drew a line the following eight years kept crossing: "No patient transfer should be delayed and life put at risk as a result of a printer not having ink in its cartridge."⁷

What happened over those eight years is the most damning thread in the record — not any single defect, but a tense. Health boards, answering coroners under statutory duty, describe the same national programme again and again — and the description never leaves the future tense.

2019: the assistant coroner for South Wales, Rachel Knight, reporting after the death of 78-year-old Glenys Button, points NHS Wales at a working alternative across the bridge: "a cutting-edge system used in Bristol, in Southmead Hospital, called www.referapatient.org" — and asks, "Could this be a better system to be used widely across the NHS in Wales in the longer term?" The answer: a health board's IT team had already built its own — one that "appears to have better functionality compared with the currently available commercial system."⁸ Southmead, again. The hospital Wales could not send a brain scan to in 2017 is, by 2019, the hospital whose referral software a coroner is recommending. When Jennifer Campbell's specialist referred her in November 2021, the referral was still a paper form.

2022: Powys tells a coroner its inpatient staff are "only able to read information stored on the Welsh Community Care Information System" — they cannot write to it — so risk assessments live in a Word document uploaded by admin staff — and cites Audit Wales: the national rollout of WCCIS "is taking much longer and proving more costly than expected."⁹

2023: Betsi Cadwaladr tells a coroner WCCIS "will enable a single integrated health and social care record."⁴ Will. The same year, Swansea Bay reports the rollout is "currently on hold pending the approval by Welsh Government of recommendations made within a Ministerial Advice Paper."¹⁰ Months later, Betsi again: "We now know that following a decision made by WG the national system will not be progressing in the way that was previously expected" — and a division's digital transformation plans collapse with it.⁵

2024: Cwm Taf Morgannwg tells a coroner that "Care Director as a national solution will be withdrawn in January 2026."¹¹

Follow the sequence: a national system rolling out too slowly, then paused by the Government, then withdrawn — described to coroners throughout as the fix that was coming.

And while the programme slipped, the same files record what filled the gap: the Welsh Government "working with Cwm Taf Morgannwg University Health Board to accelerate the implementation of electronic patient records for mental health, ahead of the all-Wales system"¹¹ — the centre funding a bypass of its own programme. Endoscopy referrals "scanned into the endoscopy email inbox."³ Care plans placed on the "digital front page"¹² because there is nowhere better for them to live.

Steven Welch's coroner had called the missing capability twenty years old back in 2018. The newest reports in this record are from 2026 — and in them, clinicians still could not see the records they needed.

"We are chasing them on it"

DHCW is a named recipient of only two of the 27 reports. But look at who the fixes depend on.

Betsi Cadwaladr, to a coroner, on an electronic referral form being developed in the Welsh Clinical Portal, another national DHCW system: "It is not clear when this national work will be delivered and we are chasing them on it."³ Aneurin Bevan: record integration "is centrally co-ordinated by Digital Health and Care Wales", and "We are not aware of any immediate plans to allow full access."⁶ Aneurin Bevan and Velindre (the national cancer trust), on a shared record: "dependant on Digital Health & Care Wales support."¹³ The Welsh Government itself, answering a coroner about mental-health records: Digital Health and Care Wales "are developing an electronic patient record that will help."¹² Will, again.

Counting both roles, the national digital body appears in eleven of the twenty-seven cases: twice as an addressee, nine times in the remedial plans of others — mostly as a dependency without a date. The bodies legally required to answer coroners keep describing fixes they do not control, on timelines they cannot give.

The two letters

In October 2025, coroner Rachel Knight reported on two Cardiff-area patients "diagnosed with Barrett's, lost to follow-up" who "have gone on to die from oesophageal cancers" — one of them Milos Jankovic, whose surveillance lapsed when a bowel cancer took priority — noting that GP systems carry "no prompt" for the relevant red flags.¹⁴ She addressed the report to the Minister for Health and Social Services of Wales — and to the Chief Executive of Digital Health & Care Wales: the office Helen Thomas has held since the body was founded. In February 2026 coroner Knight addressed the Maher report the same way.¹ Twice in four months, a coroner used a power created to prevent deaths to write to the national digital body.

These are not ordinary letters: each is a formal document of a coroner's court, and the reply it requires is owed back to that court, within the same 56 days. On the judiciary's published pages, that reply has appeared from the Welsh Government, from Cardiff and Vale University Health Board, from the General Pharmaceutical Council — from every other recipient of those two reports. No reply from DHCW is published for either.

The necessary caveat, stated plainly: publication of responses is at the Chief Coroner's discretion, and deadlines can be extended. The absence of a published response is not proof that none was sent. But the asymmetry is on the record — the same pages are publishing everyone else's answers.

What this record does not say

Read fairly, the corpus also says things a critic of DHCW must sit with. In 25 of the 27 reports the addressees are health boards, the Welsh Government and others — until October 2025, the accountability was addressed locally. Nearly every health-board response is substantive: concerns accepted, owners named, dates given. Not every failure is a technology failure: in one case a national commissioning system existed, was contractually mandated — and a health board simply did not enter its patients into it. And Betsi Cadwaladr — the health board that appears most often in these reports — was also the first in Wales to implement a major new national radiology system: adoption capacity is not a simple story. Even the taxi carries a caveat, and the coroner stated it: "It is accepted that the delays in providing neurosurgery at UHW and the provision of CT images for review by Southmead Hospital did not cause the death of Mr. Welch and the extent to which they contributed to the death, if any, is unclear."⁷ Nor is every gap digital: the reason every such patient went to Bristol at all was that, "for reasons unknown to the inquest, UHW had received resignations of its interventionist radiologists". Only the Maher report approaches outcome language; the others are findings of future risk, not causation.

What the record does establish is narrower and harder: for eight years, coroners have named absent, delayed and partly delivered digital infrastructure among the circumstances of deaths and the risks of the next ones — and the bodies legally required to answer have, over and over, described the remedy as national, in progress, and undated.

The ledger

A delivery delay in a national digital programme looks administrative from the centre: a slipped milestone, a rebaselined plan, a business case awaiting approval. From the bedside it looks like a telephone ringing out in an emergency department, a brain scan in the back of a taxi, a sentence nobody was able to write on a pharmacy bag. The distance between those two views is where these twenty-seven reports live.

These twenty-seven reports are not, in our view, twenty-seven local accidents. They are the bedside signature of one national delivery system — one in which "in progress" has been allowed to stand in for "delivered" for eight years at a time. That is our opinion, and we state it as opinion; the record underneath it is not. It is the same failing delivery layer documented, from the inside of the institution's own board and audit record, in The Safety Case DHCW Made Against Itself, and traced programme by programme in The Trajectory of Failure. In April 2026 the Welsh Government escalated Digital Health and Care Wales to Level 4, Targeted Intervention, citing delivery, accountability and leadership. The coroners had been naming the same three things, in the same body's systems, for eight years before the label was applied.

The immediate question is smaller, and it is not rhetorical. When a coroner uses a statutory power created to prevent the next death to write to the national digital body — twice in four months — the public record should show what happened next. Today, for both letters, it does not.

Sources

Every quotation in this article is drawn from Prevention of Future Deaths reports and the formal responses to them, all published by the Courts and Tribunals Judiciary. Each link below opens the judiciary.uk page for that case, which carries the coroner's report and any published responses — so the pattern described in The two letters can be checked directly. Reports are numbered in the order they first appear above.

Cited in this article:

• [1] Lyn Maher — ref 2026-0053 — statin–antibiotic contraindication; community pharmacists unable to see the medication record. Addressed to the Chief Executive of DHCW. — judiciary.uk
• [2] Eric Thompson — ref 2024-0323 — no electronic system to send abnormal laboratory results to the emergency department. — judiciary.uk
• [3] Jennifer Campbell — ref 2023-0404 — lost paper endoscopy referral; coroner on the national strategy "putting patients' lives at risk"; BCUHB "chasing them on it" and referrals "scanned into the endoscopy email inbox". — judiciary.uk
• [4] Eifion Huws — ref 2023-0185 — "very urgent" referral held only in paper notes; BCUHB says WCCIS "will enable a single integrated ... record". — judiciary.uk
• [5] Richard Griffiths — ref 2023-0333 — mental-health records "still not electronic"; transfer of care failed; BCUHB "the national system will not be progressing". — judiciary.uk
• [6] Isaac Ingle-Gillis — ref 2025-0373 — crisis team without access to GP records; ABUHB integration "centrally co-ordinated by Digital Health and Care Wales". — judiciary.uk
• [7] Steven Welch — ref 2018-0267 — cross-border radiology image transfer; brain scan "dispatched by taxi"; printer with no ink; causation caveat. — judiciary.uk
• [8] Glenys Button — ref 2019-0192 — coroner recommends referapatient.org (Southmead); NHS Wales response cites an in-house system with "better functionality". — judiciary.uk
• [9] Samuel Gomm — ref 2022-0163 — Powys inpatient staff "only able to read" WCCIS; response cites Audit Wales, rollout "taking much longer and proving more costly than expected". — judiciary.uk
• [10] Samuel Morgan — ref 2023-0163 — Swansea Bay WCCIS rollout "on hold pending ... a Ministerial Advice Paper". — judiciary.uk
• [11] Isobel Stapleton — ref 2024-0341 — CTM "Care Director ... will be withdrawn in January 2026"; WG accelerating mental-health EPR "ahead of the all-Wales system". — judiciary.uk
• [12] Nicholas Harrison — ref 2024-0224 — Swansea Bay care plans on the "digital front page"; WG "developing an electronic patient record that will help". — judiciary.uk
• [13] Steven Turzynski — ref 2025-0492 — shared record "dependant on Digital Health & Care Wales support" (Aneurin Bevan / Velindre). — judiciary.uk
• [14] Milos Jankovic — ref 2025-0490 — Barrett's surveillance lost to follow-up; GP systems carry "no prompt". Addressed to the Chief Executive of DHCW. — judiciary.uk

The remaining reports in the reviewed 2018–2026 corpus (part of the set of 27, not quoted above):

• Ruth Edwards — 2018-0395 — judiciary.uk
• Robert Wright — 2021-0374 — judiciary.uk
• Lynsey Smalley — 2023-0322 — judiciary.uk
• Catherine Jones — 2023-0526 — judiciary.uk
• Philip Taylor — 2024-0051 — judiciary.uk
• Jennifer Trigger — 2024-0116 — judiciary.uk
• Maureen Owens — 2024-0177 — judiciary.uk
• Susan Williams — 2024-0461 — judiciary.uk
• Kay Simmonds — 2024-0463 — judiciary.uk
• Margaret Daly — 2024-0701 — judiciary.uk
• Ann Cotgrove — 2025-0103 — judiciary.uk
• Annette Lewis — 2025-0126 — judiciary.uk
• Joan Read — 2026-0055 — judiciary.uk

Related: The Safety Case DHCW Made Against Itself — the same failing digital layer, from DHCW's own board and audit record | The Trajectory of Failure — the pattern across every programme | DHCW Now at Level 4 — the government's targeted-intervention verdict | Celebrating the 5-Year Crash Against Reality — the founding promises against the record | Nine Programmes, Zero Results — the delivery ledger, programme by programme

CareNHS invites responses from DHCW and from anyone named or referenced in this article. If a response is received, we will publish it in full.

Correspondence: Rose Davies, CareNHS.