Summer Mant
27 Feb 2026 · Coroner Rachel Knight · South Wales Central
The coroner's concerns
1. delay in obtaining adrenaline
“there was a delay in obtaining adrenaline”
2. no standardised crash trolley
“there is no standardised crash trolley”
3. confusion due to varying crash trolley set-ups
“junior doctors frequently rotate between hospitals and health boards and encounter different set-ups”
4. lack of standardised crash trolleys across settings
“it would be safer if there was a single standardised version of each type across every hospital setting in which junior doctors rotate”