North Wales (East and Central)

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

73% response rate (above 62% average).

Response Status
Responded 81 Historic 23 Pending 2
AI Classification
Action Taken 62%
Action Planned 33%
Noted 5%
Disputed 0%
Based on 21 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 · +8pp response rate
vs national average: +28 reports · +11pp response rate
111 results
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 Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further patient harm.
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 The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, potentially hindering patient well-being.
Clive Clinton
Historic (No Identified Response)
2014-0238 23 May 2014
European Care
Care Home Health related deaths
Concerns 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 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 summary Conway Council has installed 105 linked smoke detectors, hired a full-time officer for a 6-month installation program, and provided refresher training for installers. They have also issued a briefing
Frederick Pring
All Responded
2014-0024 21 Jan 2014
Betsi Cadwaladr University Health Board
Community health care and emergency services related deaths
Concerns summary Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for other critical calls.
Action taken summary The Welsh Ambulance Services NHS Trust and Betsi Cadwaladr University Health Board are completing an All Wales Handover Policy and have proposed becoming a 'Demonstrator Site' for the RCP's 'Future …
Kate Louise Pierce
All Responded
2013-0363 20 Dec 2013
General Medical Council
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns 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.
Action taken summary The General Medical Council acknowledges the concerns but states no action is proposed as their previous investigation was closed due to the five-year rule and they have received no further …
Annie Jones
All Responded
2013-0306 20 Nov 2013
Care Home Health related deaths
Concerns 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 summary Abbey Dale House created an updated document with summary person handling plans for each resident, adopted the All-Wales Manual Handling Passport training programme, and improved documentation for sta
Gwilym Pugh Jones
All Responded
2013-0239-wp23941 25 Sep 2013
Betsi Cadwaladr University Hospital Boa…
Hospital Death (Clinical Procedures and medical management) related deaths
Sadie Ann Jane McGrady
Partially Responded
2013-0189 16 Aug 2013
Vehicle and Operator Services Agency Driver and Vehicle Licensing Agency Association of British Insurers
Road (Highways Safety) related deaths
Concerns 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.
Alan Smith
Historic (No Identified Response)
2013-0173 5 Aug 2013
Carrington Doors
Accident at Work and Health and Safety related deaths
Concerns 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.
Laura Newlands
Unknown
Other related deaths
Concerns 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.