Prevent of Future Deaths report: Gareth Johnson (12 September 2025)

Summary

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.

After undergoing an uneventful catheter directed thrombolysis, Gareth’s anti-coagulation medication management was suboptimal 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.

Content

Gareth Idris Johnson attended The Grange hospital on 12 December.2024 and was diagnosed with a moderate to large volume bilateral pulmonary embolism with acute right heart strain. It was the weekend and therefore Gareth was transferred to University Hospital of Wales for catheter directed thrombolysis. Following the procedure, Gareth was one of a small number of patients transferred out of the Critical Care Unit to PACU due to planned building maintenance works. Gareth’s post operative medication management was sub optimal for a number of reasons, including the impact of being cared for outside the main Critical Care Unit.

Matters of concern

Due to the age of the hospital building, maintenance is a constant battle. There are also capacity issues in Critical Care due to patient volumes. Building infrastructure had been a constant feature on the corporate risk register and was now scored at its highest level. Whilst measures have been put in place to safeguard against moving patients who require critical care from the Critical Care Unit, there remained fears that these systems would fail during times of pressure.