Lisa Townsend

I am Patricia Morgan Area Coroner , for the coroner area of South Wales Central.

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

Your response must contain details of action taken or proposed to be taken, setting out  the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any  representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations  received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for  sensitive information prior to publication, as the information is already online . The names of those who do not respond to PFD reports are regularly published on the  Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports -Courts and Tribunals Judiciary .

SUMMARY OF CORONER’S CONCERN During the inquest touching the death of Lisa Jayne Townsend, the Coroner heard evidence in respect of the absence of clear guidance and protocol for when a referral  should be made by the local hospital (Princess of Wales, Bridgend) to the tertiary  centre (University Hospital of Wales) in respect of Hepato-Pancreato-Biliary (HPB)  related matters. There was a delay in advice being sought from and transfer to the  tertiary centre taking place. There remains no established protocol to assist Clinicians with when they should escalate and seek further specialist advice from their tertiary  centre to ensure timely consideration of the patient’s issue.