North Wales (East and Central)

Coroner Area
Reports: 111 Earliest: Aug 2013 Latest: 5 Feb 2026

75% response rate (above 63% average).

Response Status
Responded 83 Historic 27
AI Classification
Action Taken 42%
Action Planned 45%
Noted 13%
Disputed 1%
Based on 101 classified responses
Top Categories
Hospital Death (Clinical Procedure… (55) Wales prevention of future deaths … (45) Emergency services related deaths … (12) Community health care and emergenc… (11) Care Home Health related deaths (10)
Quarterly Trend
Category Breakdown
How does this area compare?
vs Wales average: +33 reports · +12pp response rate
vs national average: +27 reports · +12pp response rate
111 results
Albert Rowlands
All Responded
2021-0253 26 Jul 2021
Gwern Alyn House Residential Home
Care Home Health related deaths
Concerns summary (AI summary) Falls prevention measures were inconsistently implemented, and staffing pressures led to errors in care. The resident's room placement also increased the risk of falls during toilet access.
Action Planned (AI summary) Pendine Park will introduce a programme of testing door pressures where mobile residents encounter doors and will continue to work with GPs and other health professionals to support any resident that has a history of falls using the North Wales Prevention and Management of Falls in Care Homes Pathway. They also aim to continue to be suitably staffed.
Rhian Roberts
Historic (No Identified Response)
2021-0242 14 Jul 2021
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) A toxicology screen requested on arrival at ICU may not have been undertaken; an updated SOP for communicating life-threatening blood results was still in draft form; and there are concerns about continual delays in investigating adverse incidents, sharing learning and implementing actions.
Hannah Browning
Partially Responded
2021-0106 13 Apr 2021
Betsi Cadwaladr University Health Board Wrexham County Borough Council
Community health care and emergency services related deaths Mental Health related deaths Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Mental Health Services failed to adequately protect a patient with an immediate self-harm plan, making no attempt to contact her or reinforce available crisis options.
Action Taken (AI summary) Wrexham County Borough Council has developed a social work checklist for mental health social work teams and duty cases, implemented in May 2021, to ensure clear guidance and process adherence regarding risk identification and escalation.
Arthur Hughes
Partially Responded
2020-0057 9 Mar 2020
Betsi Cadwaladr University Health Board Ysbyty Gwynedd
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) A lack of protocol for assessing locum staff's practical skills and managerial reluctance to thoroughly check references created risks that locums might perform tasks beyond their capabilities.
Action Planned (AI summary) The Health Board is revising and implementing a SOP for locum appointments, including additional pre-employment checks and reviews of practice. Implementation was delayed due to COVID-19 but is intended from 01 June 2020.
Benjamin Leonard
All Responded
2020-0032 7 Feb 2020
Scout Association
Child Death (from 2015) Other related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The Scout Association failed to implement or ensure understanding of critical safety policies, including risk assessments and leadership oversight, for an organised trip, directly endangering young people.
Action Taken (AI summary) The Scout Association has made further changes and improvements to guidance, rules and systems described in a previous response, as a result of their ongoing review of safety in Scouting. They have also committed to considering all evidence from the inquest and conducting a Safety Incident Learning Inquiry.
Samantha Brousas
All Responded
2019-0443 20 Dec 2019
Welsh Ambulance Service NHS Trust
Emergency services related deaths (2019 onwards) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Paramedics failed to pre-alert the hospital about suspected sepsis due to discretionary policy. They also could not administer vital antibiotics, and did not escalate concerns about patient condition or admission delays.
Action Taken (AI summary) The Trust implemented pre-alert guidance in Dec 2018 developed with clinical directors and the Royal College of Emergency Medicine, reinforced sepsis guidelines in mandatory training, and is designing an escalation process for ambulance crews when concerns aren't addressed in the Emergency Department.
Luke Jones
Partially Responded
2019-0409 3 Dec 2019
Government Legal Department HMP Berwyn MOJ
Alcohol, drug and medication related deaths State Custody related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Concerns exist regarding the continuing accessibility and use of novel psychoactive substances (NPS) within HMP Berwyn, posing significant health risks and a high probability of future deaths.
Action Taken (AI summary) HMP Berwyn has implemented various measures to tackle psychoactive substances, including improved gate searching, changes in the supervision of domestic visits, safe detoxification on reception, and extended mandatory drug testing. A Rapiscan machine is also in place to improve detection of contraband items.
Peter Connelly
Historic (No Identified Response)
2019-0376 7 Nov 2019
Betsi Cadwaladr University Health Board Ysbyty Gwynedd
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Persistent, unacceptable delays in patient handover at emergency departments and prolonged ambulance waits continue to put patients' lives at risk by delaying timely medical intervention, despite previous assurances.
Edna Evans
Historic (No Identified Response)
2019-0318 27 Sep 2019
Emral House Nursery Home
Care Home Health related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a policy for reassessment following multiple falls.
Carl Sargeant
All Responded
2019-0236 11 Jul 2019
Welsh Government
Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The report highlights a need to provide appropriate support channels for high-profile individuals removed from government roles, regardless of mental vulnerabilities or the reason for their removal.
Action Planned (AI summary) The First Minister of Wales has consulted with current and former ministers and the family of the deceased to make changes to the process for ministers leaving the Cabinet. A new section will be added to the Welsh Government Ministerial Code to ensure the well-being of ministers is taken into account during reshuffles and that they are aware of available support services.
Kathleen Smith
All Responded
2019-0184 3 Jun 2019
Coed Duon Care Home
Care Home Health related deaths
Concerns summary (AI summary) Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for those with swallowing difficulties, compounded by inadequate management oversight.
Action Taken (AI summary) Coed Duon Care Home has implemented several changes, including SALT training for staff, designation of two Dysphagia champions, creation of a diets and fluids consistency file for each resident in the kitchen, and clearer documentation of meals served.
Kristopher McDowell
All Responded
2019-0083 7 Mar 2019
Canal and River Trust
Other related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The report raises concerns about the wide spacing on the aqueduct parapet, posing a fall risk, and the subjective nature of the testing process for upright embedment, potentially leading to inconsistent assessments of deterioration.
Action Planned (AI summary) The Trust has started an investigation of physical options to address gaps in the parapet and will submit a final design for approval after an informal public consultation.
Madeline Staples
Historic (No Identified Response)
2019-0041 11 Feb 2019
Betsi Cadwaladr University Health Board Welsh Ambulance Services NHS Trust Ysbyty Gwynedd
Emergency services related deaths (2019 onwards) Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Persistent, unacceptable delays in patient handovers at emergency departments continue to result in long ambulance waits and unavailable resources, despite previous warnings, placing patients' lives at ongoing risk.
Austin Thomas
Historic (No Identified Response)
2018-0360 20 Nov 2018
Haulage Contractors Limited
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) Drivers of heavy machinery could be distracted by high-volume music, lacking a specific policy. The drug policy was inadequate, with no random testing despite evidence of an employee's drug use.
Gladys Williams
Historic (No Identified Response)
2018-0292 10 Sep 2018
Betsi Cadwaladr University Health Board Welsh Ambulance Services
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Ongoing, multifactorial problems with ambulance delays, emergency department overcrowding, and patient flow continue to risk lives, despite previous warnings and reported mitigation efforts.
Margaret Evans
Historic (No Identified Response)
2018-0197 26 Jun 2018
BCUHB HM Stanley Site Welsh Ambulance Services NHS Trust +1 more
Community health care and emergency services related deaths
Concerns summary (AI summary) Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient safety.
Ester Wood
Historic (No Identified Response)
2018-0176 6 Jun 2018
BCUHB HM Stanley Site Welsh Ambulance Services NHS Trust +1 more
Community health care and emergency services related deaths
Concerns summary (AI summary) Ongoing, systemic problems with ambulance delays, emergency department access, and patient flow continue to place lives at risk, despite repeated prior warnings.
Neville Welton
Partially Responded
2018-0150 17 May 2018
Betsi Cadwaladr University Health Board Ysbyty Gwynedd
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures outstanding for too long.
Action Planned (AI summary) The Health Board is establishing weekly meetings for senior staff to review incidents, track progress of investigations, and ensure timely action plan implementation, commencing July 12th, 2018. They will also use a project management approach with milestones for comprehensive investigations, to be implemented as part of the revised model.
Daniel Watson
Partially Responded
2017-0370 18 Dec 2017
Betsi Cadwaladr University Health Board Wrexham County Council Ysbyty Gwynedd
Community health care and emergency services related deaths Mental Health related deaths
Concerns summary (AI summary) A root cause analysis identified numerous care and service delivery problems, missed opportunities, and a lack of staff understanding. Significant improvements are needed in mental health teams' risk assessment and escalation training.
Action Planned (AI summary) The University Health Board will provide further debriefing and supervision for the Community Psychiatric Nurse (CPN), hold a focused session for the wider team on empathy and transparency, continue to make available the WARRN Accredited Programme for Care Coordinators, and update the MHLD Supervision Guidance for Nurses and Support Workers Policy by the end of February 2018. Wrexham Adult Social Care will provide feedback and management supervision to the social worker involved, implement the Mental Health and Learning Disability Supervision Guidance for Nurses and Support Workers Policy, and include relevant staff in the Wales Applied Risk Research Network (WARRN) training and specific training on assessment of suicide.
Joshua Hamill
All Responded
2017-0351 5 Dec 2017
North Wales Police
Mental Health related deaths Police related deaths
Concerns summary (AI summary) Police training was ineffective in identifying mental health issues, and 'concern for safety' incidents were closed without ensuring the individual's welfare.
Action Taken (AI summary) North Wales Police provide a list of mental health resources including webinars, powerpoints, business cards, posters, and modules that are delivered to officers as part of training.
Kate Pierce
All Responded
2017-0312 31 Oct 2017
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is a lack of clarity on when a sick child needs senior paediatrician review before discharge, especially with parental concerns. Additionally, the system for identifying and acting on learning opportunities from readmissions lacks clear, consistently applied criteria.
Action Taken (AI summary) The University Health Board confirms that it has a formal policy about discharging children from the children's assessment unit, and has altered the parent discharge information to explicitly state parents may escalate their desire to have a second opinion.
Douglas McTavish
All Responded
2017-0311 31 Oct 2017
Whirlpool (UK) Appliances
Product related deaths
Concerns summary (AI summary) Whirlpool's risk assessment processes may not fully appreciate the extent of fire risk with its appliances, and the company may be too reluctant to rely on 'soft data' such as reported fires. Additionally, public awareness of the risk of spontaneous combustion may be insufficient.
Action Taken (AI summary) Whirlpool will support initiatives to raise consumer awareness of risks such as spontaneous combustion and has added relevant usage instructions to the 'Register my appliance' website.
Bernard Hender
All Responded
2017-0311-wp25922 31 Oct 2017
Whirlpool (UK) Appliances
Product related deaths
Concerns summary (AI summary) Whirlpool's risk assessments for appliance fires were inadequate, with a dismissive approach to field data like reported fires. This prevents timely learning and proactive measures to enhance product safety and save lives.
1 response from Whirlpool UK Appliances Limited
Catherine Roberts
Historic (No Identified Response)
2017-0076 7 Jul 2017
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Problems with admission to the Emergency Department, resource availability, and patient flow continue despite previous reports to the Health Board, placing patients' lives at risk.
Daphne Williams
Partially Responded
2017-0167 25 May 2017
Betsi Cadwaladr University Health Board HM Stanley Site Welsh Ambulance Services NHS Trust +1 more
Community health care and emergency services related deaths
Concerns summary (AI summary) Persistent issues with ambulance delays, emergency department admissions, resource availability, and patient flow continue to place patients' lives at risk despite previous reports.
Action Planned (AI summary) The University Health Board and Welsh Ambulance Services NHS Trust are collaborating on several actions to improve patient flow, including implementing SAFER patient flow bundles, developing integrated discharge hubs, and working with local authorities to reduce delayed transfers of care.