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
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.
Clive Clinton
Historic (No Identified Response)
2014-0238 23 May 2014
European Care
Care Home Health related deaths
Concerns summary (AI summary) A care home's complaints procedure failed, preventing family concerns about poor care (e.g., hygiene, medication) from reaching senior management and placing residents at risk of harm.
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.
Sadie Ann Jane McGrady
Partially Responded
2013-0189 16 Aug 2013
Driver and Vehicle Licensing Agency Association of British Insurers Vehicle and Operator Services Agency
Road (Highways Safety) related deaths
Concerns summary (AI summary) Substandard repairs to a Category D insurance write-off vehicle compromised its structural integrity, increasing injury risk in a collision, with no independent checks for repaired written-off vehicles.
Noted (AI summary) The Association of British Insurers provides context on the Code of Practice for the Disposal of Motor Vehicle Salvage and the categories used to classify damaged vehicles. The Department for Transport is reviewing the Vehicle Identity Check (VIC) scheme, analysing ideas from a consultation, with potential changes by 2015 subject to legal processes and government priorities.
Alan Smith
Historic (No Identified Response)
2013-0173 5 Aug 2013
Carrington Doors
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) A co-worker lacked specific training for working at height, and generic risk assessment forms and method statements were not routinely used by employees.