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
Lilly Baxandall
Partially Responded
2017-0160 17 May 2017
Betsi Cadwaladr University Health Board Conway County Council Denbighshire County Council +4 more
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Persistent, unresolved systemic issues, including ambulance handover delays, emergency department overcrowding, and bed blocking, continue to recur despite previous warnings, placing patients' lives at risk.
Action Planned (AI summary) Betsi Cadwaladr University Health Board, Welsh Ambulance Services NHS Trust, and the four Local Authorities are collaborating on actions to improve patient flow, including Innovation Unblocked event programmes and SAFER patient flow bundles.
Rebecca Evans
Partially Responded
2017-0077 14 Mar 2017
BCUHB HM Stanley Site Welsh Ambulance NHS Trust +1 more
Community health care and emergency services related deaths
Concerns summary (AI summary) Significant and recurring delays in patient handover at Emergency Departments led to late hospital admission and delayed medical treatment, tying up ambulance resources and risking future deaths.
Action Taken (AI summary) The University Health Board details a series of actions already taken, including improvements in performance indicators for ambulance handovers and emergency department waiting times, and implementation of patient navigators at YGC Emergency Department. They also mention an unscheduled care plan.
Carol Harvey
Partially Responded
2017-0059 10 Mar 2017
Betsi Cadwaladr University Health Board Ysbyty Gwynedd
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is no procedure to confirm district nurse referral receipt and action, and significant delays exist in developing and implementing a safe patient discharge procedure from acute hospitals.
Action Planned (AI summary) The University Health Board has provided a working action plan relating to the case which will be monitored at the Secondary Care QSE meeting in July 2017.
Raymond Edwards
All Responded
2017-0029 10 Feb 2017
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information was not promptly reviewed, posing a significant risk of delayed diagnosis and treatment in future cases.
Action Taken (AI summary) The University Health Board developed BCUHB Procedure MD23 to mitigate risks due to failure to act on diagnostic results, based on NPSA 16 guidance, and approved at the end of 2016. An electronic reporting system (CHAI Ping app) is being developed to provide alerts to clinicians when histology reports are authorised for viewing.
Sarah Tyler
All Responded
2017-0002 13 Jan 2017
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Pervasive hospital admission delays due to insufficient beds were exacerbated by increased 'bed blocking' on weekends, stemming from reduced patient discharges. This systemic issue poses a significant risk to timely patient care.
Action Planned (AI summary) The Health Board is implementing an Unscheduled Care Plan in 2017/18 to improve waiting times for hospital admissions and reduce bed occupancy. The plan includes targets for each section and will be overseen by a Health Board-wide Transformation Group, with progress monitored monthly and by Welsh Government.
Christopher Jones
All Responded
2016-0319 7 Sep 2016
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate mental health care planning resulted in patients being without consultant review for extended periods post-discharge. Increased demand on services also created staff cover deficiencies.
Action Taken (AI summary) The Division produced a multi-agency document which became operational in August 2013 and has been reviewed regularly. MHM administrators send a report to managers of all CTPs due for review, 3 months in advance with a view to avoiding any CTPs becoming out of date and patients have reviews in a timely manner.
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.
Kay Sheard
Historic (No Identified Response)
21 Dec 2015
BCUHB, Ysbyty Gwynedd
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Pulse oximeter alarm settings are fixed at a routine level rather than being adjusted to individual patient baselines, risking unnoticed significant oxygen desaturation.
Mary Hollands
Historic (No Identified Response)
21 Dec 2015
BCUHB, Ysbyty Gwynedd
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The system for providing radiologist reports to the Emergency Department is unreliable, creating a risk that subtle injuries may be missed and patient safety netting is ineffective.
Alan Walker
Historic (No Identified Response)
14 Dec 2015
BCUHB, Ysbyty Gwynedd
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical information was not consistently recorded in nursing notes, and handovers did not reference these records, risking significant patient details being missed by incoming staff.
Laura Newlands
Response Pending
Denbighshire County Council
Other related deaths
Concerns summary (AI summary) Incomplete safety plans, missed professional meetings, and an unreviewed case closure by Children's Social Services left a vulnerable young person without adequate support.
Vera Williams
Historic (No Identified Response)
2015-0428 6 Nov 2015
Betsi Cadwaladr University NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Emergency Department doctors and staff lack a digital system to support their work.
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.
Andrew Roberts
Historic (No Identified Response)
20 Aug 2015
North Wales Police BCUHB, Ysbyty Gwynedd
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inaccurate and delayed completion of the Transfer of Care Form by a doctor prevented critical patient information from being immediately available to custody nurses.
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.
Elouise Winship
Historic (No Identified Response)
2014-0431 7 Oct 2014
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is no documented standard practice for regular fetal heart auscultation after opiate administration or for further maternal examinations following a change in condition during labour.
Timothy Cowen
Historic (No Identified Response)
2014-0430 7 Oct 2014
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) New training on procedures is not mandatory for all staff, and the Acute Liaison Nurse role, crucial for patient support, lacks adequate cover during absences.
Christopher Davies
Historic (No Identified Response)
2014-0420 29 Sep 2014
Betsi Cadwaladr University Health Boar
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning signs of toxicity.
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.
Sybil Roberts
Historic (No Identified Response)
2014-0402 12 Sep 2014
Manor Park Residential Home
Care Home Health related deaths
Concerns summary (AI summary) A patient's declining condition and mobility were inadequately assessed for falls risk upon admission and after hospital discharge, leading to repeated falls due to unupdated care plans.
Esther Jones
Historic (No Identified Response)
2014-0296 2 Jul 2014
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further patient harm.