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
Clear 66 results
Pamela Conway
All Responded
2016-0309 26 Aug 2016
Betsi Cadwaladr University Health Board Welsh Ambulance Services NHS Trust
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for other calls, creating ongoing risks to public safety.
Action Planned (AI summary) The Welsh Ambulance Service NHS Trust has made progress against key actions identified in an attached action plan, with the most significant impact from the Welsh Health Circular regarding hospital handover guidance. Lessons learned from the case are being monitored through a Task and Finish Group. The University Health Board is scrutinizing two working action plans relating to the case, which will be monitored by the Quality and Safety Group.
Danielle Robinson
All Responded
2016-0205 31 May 2016
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)
Concerns summary (AI summary) Staff are not rigorously following the Therapeutic Engagement and Observation Policy, leading to missed opportunities for escalating patient observation levels during critical risk periods.
Action Taken (AI summary) The University Health Board has reviewed and updated its Therapeutic Engagement and Observation Policy to include the automatic escalation of observations following a serious attempt of self-harm until a full multi-disciplinary team review can take place; the policy will be formally re-launched at a learning event planned for September 2016.
John Rogers
All Responded
2016-0097 9 Mar 2016
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for their required work.
Action Taken (AI summary) The University Health Board has undertaken and completed a detailed action plan relating to Ysbyty Glan Clwyd with specific training requirements. They are strengthening systems to ensure training and qualifications remain up to date, introducing a more rigorous approach to monitoring and a supportive approach for staff training.
Peter Furness
All Responded
2015-0398 5 Oct 2015
Nant y Gaer Hall Nursing Home
Care Home Health related deaths
Concerns summary (AI summary) The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for reviewing vulnerable residents' risk assessments and care plans.
Action Taken (AI summary) Nant Y Gaer Hall has implemented a new alert system for changes in residents' conditions, with training and supervision for staff. The new system includes forms, flow charts, and posters, and is supported by red alert files.
Nancy Hughes
All Responded
2015-0221 12 Jun 2015
BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) No systematic medication review occurred as per medical practice, and a lack of cohesion between mental health and general medical treatment meant vulnerable patients' mental health information was disregarded in their physical care.
Action Taken (AI summary) The Health Board has implemented a system where patients have a named care coordinator responsible for maintaining contact and reviewing medication, including a prescribing guideline for review and discontinuation of medication at 6 or 12 weeks. The Mental Health Improvement Group is working to improve communication between transferring and receiving wards.
Sally Ellison
All Responded
2015-0163 27 Apr 2015
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and potentially delaying optimal treatment. A rapid testing and reporting service is urgently needed.
Action Planned (AI summary) NHS Wales, through the Pathology Clinical Programme Group, has reviewed the process for requesting urgent samples from primary care and is distributing a memorandum to GPs and Practice Managers with instructions on labeling and transportation to minimize delay, along with contact numbers for laboratories.
Anthony Williams
All Responded
2014-0523 2 Dec 2014
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Staff lacked clear guidance on psychiatric assessment pathways for 'exceptional cases', medical records were inaccessible out-of-hours, and there was insufficient engagement with family/carers on care plans.
Action Taken (AI summary) The health board now has a larger number of psychiatric nurses present on the Heddfan Adult Unit out of hours so socially anxious patients could be assessed at the Unit. The adoption of an electronic case record is currently being explored.
Clive Turner
All Responded
2014-0404 12 Sep 2014
Betsi Cadwaladr University Health Board
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital staff lacked knowledge of pre-hospital pain relief, there were no clear policies for overnight patient discharge, and senior clinical oversight was unavailable late at night.
Action Taken (AI summary) The Welsh Ambulance Service reviewed the delayed response, implemented a new clinical support desk for early triage of calls, staffed by paramedics and nurses, using the Manchester Triage System. This aims to provide clinical support for patients waiting longer than 8 minutes and improve the ambulance performance standard.
Gary Daltry
All Responded
2014-0295 2 Jul 2014
Denbighshire County Council
Other related deaths
Concerns summary (AI summary) An unmitigated tripping hazard poses a significant risk of falls and potential future deaths if not addressed.
Action Planned (AI summary) Denbighshire County Council will review the coastal risk assessment at Prestatyn, including the area near the Beaches Hotel, and carry out a joint boundary to boundary inspection of DCC coastal areas by the end of 2014.
Ronald Perry
All Responded
2014-0302 2 Jul 2014
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inconsistent criteria for requesting CT scans based on time of day or weekend leads to varying levels of care and risks missed diagnoses for patients 'out of hours'.
Noted (AI summary) The University Health Board states that its radiology service operates a full service during weekday hours, with emergency on-call service at all other times, and a CT scan would have been performed had a ruptured abdominal aortic aneurysm been indicated. They are working to develop increased access outside of normal office hours.
Alun Sheppard
All Responded
2014-0268 13 Jun 2014
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, potentially hindering patient well-being.
Noted (AI summary) The Health Board agrees that familial support improves patient recovery and routinely encourages service users to engage with their families. The policy of the Health Board is to use a confidentiality form.
Alfred Hodges
All Responded
2014-0033 24 Jan 2014
Conwy County Council
Community health care and emergency services related deaths
Concerns summary (AI summary) Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was not offered a free home fire safety check.
Action Taken (AI summary) The council has installed 105 linked smoke detectors, funded a full-time installation post, and received refresher training from NWFRS on smoke detector placement. They also prepared a briefing note for Social Services staff to identify and test smoke alarms during home visits.
Frederick Pring
All Responded
2014-0024 21 Jan 2014
Betsi Cadwaladr University Health Board
Community health care and emergency services related deaths
Concerns summary (AI summary) Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for other critical calls.
Action Planned (AI summary) The Welsh Ambulance Service NHS Trust and Betsi Cadwaladr University Health Board are working towards completing an All Wales Handover Policy for patient handover between clinical teams. The Health Board also proposed acting as a 'Demonstrator Site' to implement recommendations regarding overcrowding in Emergency Departments.
Kate Louise Pierce
All Responded
2013-0363 20 Dec 2013
General Medical Council
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A practicing GP failed to diagnose a patient and misled parents, with new evidence casting doubt on his fitness to practice. Previous GMC action stalled, posing a risk of future deaths.
Noted (AI summary) The GMC acknowledges the concerns but states that statutory rules preclude them from investigating events that are more than five years old and they have not received any further complaints since 2007.
Annie Jones
All Responded
2013-0306 20 Nov 2013
Abbeydale Residential Home, Princes Dri…
Care Home Health related deaths
Concerns summary (AI summary) An inadequate mobility assessment led to the unsafe use of a stand aid for a non-weight-bearing resident. Staff lacked awareness of limitations and proper training, posing a significant risk of injury to vulnerable patients.
Action Taken (AI summary) Abbey Dale House created an updated document providing a snapshot of each resident's needs, including a summary person handling plan, readily available to all staff. The care home adopted the All-Wales Manual Handling Passport, an intensive manual-handling training programme.
Gwilym Pugh Jones
All Responded
2013-0239 25 Sep 2013
Betsi Cadwaladr University Hospital Boa…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Clinician-requested tests were not conducted, resulting in a missed opportunity for diagnosis and treatment.
Action Taken (AI summary) • The Corporate Governance Team was tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. • Of the 120 Corporate Policies and Procedures currently in place , 117 are now in date. • Three policies are subject to fundamental review; this process will be completed by 31st March 2014.