North Wales (East and Central)
Coroner Area
Reports: 111
Earliest: Aug 2013
Latest: 5 Feb 2026
75% response rate (above 63% average).
Angela Darlow
All Responded
2026-0107
5 Feb 2026
Cabinet Secretary for Health and Social…
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critically long ambulance delays, exacerbated by hospital handover issues, led to patients missing crucial time-sensitive treatments like thrombectomy for stroke.
Noted
(AI summary)
The Welsh Government acknowledges the serious ambulance delays and systemic issues in North Wales, detailing ongoing efforts like providing additional financial and expert support to Betsi Cadwaladr University Health Board. An expert team has been announced to focus on reducing ambulance handover delays, improving patient flow, and strengthening governance.
Heather Parkhill
All Responded
2026-0050
2 Feb 2026
Welsh Ambulance Services University NHS…
Alcohol, drug and medication related deaths
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary)
Persistent ambulance delays and resource unavailability continue to put lives at risk, despite ongoing multi-agency efforts to address these long-standing issues.
Action Taken
(AI summary)
• All staff responsible for admissions have received one-to-one supervision regarding Ms George’s case, ensuring learning is embedded.
• Information has been disseminated to all junior staff for awareness training, emphasising the importance of correctly processing admission and discharge documentation.
• All hospital discharge summaries are now scanned directly into residents’ care plans upon receipt. • WAST is increasing its remote clinical support to ensure prioritization of available resources based on patient needs and to improve safety netting.
• WAST is working to minimize the number of patients being transported to busy hospitals by enhancing staff knowledge, skills, and competencies and the alternatives available to them.
• WAST is increasing resources available for use, completing roster changes to increase resource availability and improving levels of attendance levels.
Rory Williams
All Responded
2026-0016
13 Jan 2026
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The gastroenterology/endoscopy service suffers from critical staffing shortages, inadequate infrastructure, and excessively long waiting times. These systemic failures are not adequately reflected on the corporate risk register.
Action Planned
(AI summary)
Betsi Cadwaladr University Health Board is progressing work on developing an Integrated Digestive Disease Service, with shared clinical leadership, standardised pathways, coordinated workforce planning and strengthened governance, under executive sponsorship.
Caitlin Imber
All Responded
2025-0538
24 Oct 2025
BCUHB
Mental Health related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing a significant and potentially dangerous delay in support.
Action Taken
(AI summary)
CAMHS has changed its standard operating procedure to offer appointments even when contact numbers are missing from referrals, and is undertaking an audit to confirm these changes are embedded in practice. The learning from the inquest is planned to be shared via the Regional CAMHS Forum.
Jeanette Sidlow Beech
All Responded
2025-0279
29 May 2025
Betsi Cadwaladr University Local Health…
Local Authorities within this jurisdict…
Welsh Ambulance Service Trust
+1 more
Alcohol, drug and medication related deaths
Emergency services related deaths (2019 onwards)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Critical ambulance delays, exacerbated by significant hospital handover issues and a lack of social care, lead to patients awaiting discharge, blocking emergency departments and severely jeopardizing lives.
Noted
(AI summary)
The Welsh Government outlines its role in setting the strategic context for health services and holding NHS organisations accountable, noting that all health boards are in escalation for urgent and emergency care. They mention providing additional funding to Betsi Cadwaladr University Health Board and supporting improvement programs, but do not commit to specific changes in response to the report.
Patricia Catterall
All Responded
2025-0189
11 Apr 2025
Betsi Cadwaladr University Health Board
Pendine Park Care Organisation
Care Home Health related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in missed critical patient information.
Action Planned
(AI summary)
A task and finish group has been set up to review the current discharge form for suitability to ensure that frequency of observations and medication is clearly defined within the document. Changes to the form, once finalised and approved, will be shared with the North Wales Care Home Forum, with support from the Quality Development Team. Pendine Park Care Organisation now conducts all pre-admission assessments in person (except emergency admissions) and has updated the pre-admission assessment document to include prompts to ensure all information is requested prior to admission, including a section for diabetes.
Emma Hill
All Responded
2025-0180
9 Apr 2025
Wrexham County Borough Council
Road (Highways Safety) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Obstructed visibility at a road junction and high traffic speeds following a speed limit change create an ongoing risk of serious collisions and potential fatalities.
Action Taken
(AI summary)
Wrexham County Borough Council has raised a sign at the junction to improve visibility and is planning road marking alterations. They are committed to reducing the speed limit on the road in partnership with Cheshire West & Chester Council, subject to a formal Traffic Regulation Order consultation.
Leanne Carroll
All Responded
2025-0153
19 Mar 2025
Betsi Cadwaladr University Health Board
Mental Health related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
The Perinatal Mental Health Service suffers from insufficient awareness among health professionals, inadequate staffing levels, and a lack of documented decisions and discussions in patient records at the Single Point of Access.
Action Planned
(AI summary)
BCUHB is raising awareness of the Perinatal Mental Health Service, delivering mandatory training, and reviewing the 'SPOAA Referral Checklist' for consistency across the division, with implementation planned from 26th May 2025.
Carl Butler and Sean Brett
All Responded
2025-0035
21 Jan 2025
Cheshire Constabulary
Road (Highways Safety) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Cheshire Police had confused report management with no officer acknowledgement system and significant delays in delivering critical ANPR/Vehicle Finder system training to control room staff.
Action Taken
(AI summary)
Cheshire Constabulary has reviewed the way in which reports of dangerous driving / drivers are processed and all communications operators and operational officers will receive new guidance requiring clear and sustained attempts to confirm patrol acknowledgement of radio transmissions. All communications operators have attended a specific course which includes ANPR, Hotlist and Vehicle Finder.
Andrew Howat
All Responded
2024-0623
13 Nov 2024
Kingkabs
Road (Highways Safety) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
A taxi firm's training on driver duty of care and safety protocols for vulnerable passengers is inadequate, as a driver would repeat leaving a passenger in an unsafe location and police contact protocols were not followed.
Action Taken
(AI summary)
KingKabs updated their "DR18 Driver Information & Advice" document with clearer guidance on resolving confrontation and duty of care and created new 'Driver Incident Procedures' within "CC002 Call Centre Procedures" for call center staff, distributing both on January 3rd, 2025.
Margaret Daly
All Responded
2024-0701
28 Oct 2024
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 clinician prescribed a sedative without reviewing the patient's full medical records, leading to unawareness of her enhanced falls risk and demonstrating a risk of prescribing without adequate patient context.
Action Planned
(AI summary)
BCUHB is establishing a new process instructing doctors to only prescribe without reviewing patients in person if they have the patient's notes, with nursing staff required to relay falls risks, and is planning to roll out an Electronic Prescribing and Medication Administration System (ePMA) by March 2025.
Shirley Hughes
All Responded
2024-0584
28 Oct 2024
Welsh Ambulance Services University NHS…
Emergency services related deaths (2019 onwards)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
The Medical Priority Dispatch System (MPDS) for ambulance calls, designed years ago, is failing to meet current response targets due to resource issues, raising concerns that lives are being put at risk by outdated prioritization.
Noted
(AI summary)
The Welsh Ambulance Services University NHS Trust acknowledges concerns about ambulance delays and the MPDS system but states it is not the primary authority to take action, offering to meet to discuss the response in more detail and welcomes suggestions for actions they might take with partners.
Philips Evans
All Responded
2024-0387
22 Jul 2024
Betsi Cadwaladr University Health Board
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
The Health Board's investigations are consistently of poor quality, ineffective, and untimely, failing to identify and address care omissions or implement learning promptly, leading to recurring patient safety risks.
Action Taken
(AI summary)
BCUHB has implemented a new Integrated Concerns Policy and a Learning from Investigations Programme that reviewed 262 investigations against good practice standards. They have established clearer approval processes and are implementing a digital learning portal to cascade learning across the organization.
Paul Roberts
All Responded
2024-0383
18 Jul 2024
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
The Health Board's investigations into care failings lack accountability for staff and suffer from incomprehensible delays in implementing identified actions, perpetuating ongoing risks to patient safety.
Action Taken
(AI summary)
BCUHB has implemented a new Integrated Concerns Policy with a clear framework for reporting and investigating incidents, rolled out in September 2024. The MHLD Learning and Action Group will review action plan progression, and audits will ensure divisions upload Learning and Improvement Plans to Datix.
Eric Thompson
All Responded
2024-0323
14 Jun 2024
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)
Critical abnormal blood results were not promptly documented or actioned in the emergency department due to a lack of electronic alert systems and over-reliance on unreliable verbal communication.
Action Planned
(AI summary)
The Health Board will review and update processes for telephone alerts regarding abnormal lab results in EDs, ensuring a clear mechanism for receiving and acting upon them. They expect this work to be completed and evidence provided by the end of September 2024.
Ben Harrison
All Responded
2024-0256
10 May 2024
BOC Limited
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Oxygen cylinders with a confusing two-valve system led to delayed oxygen delivery during resuscitation. Despite repeated incidents and training, the design remains unsafe for high-pressure medical emergencies.
Noted
(AI summary)
BOC apologizes for the late response, explains the regulatory background, and requests an extension to provide further information. BOC claims they did not receive the report until late June.
Maureen Owens
All Responded
2024-0177
27 Mar 2024
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)
There is inadequate knowledge within the Health Board, including clinical and nursing staff, regarding the correct use and operation of the Adult Critical Care Service Cymru for urgent patient transfers.
Action Planned
(AI summary)
The Health Board will re-share the agreed transfer process with all Integrated Health Communities, acute sites will confirm site management teams as single point of contact for emergency transfers, and there will be a Health Board wide system focus on service provision required for intra-hospital transfers. Also, the Patient Transfer Procedure will be reviewed, and a monitoring process will be developed for transfers/repatriations.
Jennifer Trigger
All Responded
2024-0116
1 Mar 2024
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 miscommunication due to an inadequate bleep system caused critical delays in administering medication, leading to patient deterioration. The system's inability to electronically convey information risked proper task prioritization.
Action Taken
(AI summary)
The Health Board upgraded the critical messaging service at Ysbyty Glan Clwyd and Wrexham Maelor Hospital and plans to go live at Ysbyty Gwynedd in approximately 4 weeks; also restricted the use of the bleep system out of hours at Wrexham Maelor Hospital to four key areas and mandated 3pm ward huddles. A Safety Alert is being issued across the organisation.
Benjamin Leonard
All Responded
2024-0106
22 Feb 2024
Charity Commission for England and Wales
Children’s Commissioner for England
Children’s Commissioner for Wales
+6 more
Child Death (from 2015)
Other related deaths
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
The Scouts Association lacks a culture of candour and independent regulatory oversight for safety and safeguarding. A critical internal Fatal Accident Inquiry Panel Report was not completed in a timely manner, hindering learning.
Noted
(AI summary)
The Charity Commission acknowledges the report and states they are closely examining the concerns as part of their ongoing engagement with The Scout Association. They will be meeting with TSA again to discuss improvements and will take further regulatory action if needed. The Minister for Education and Welsh Language has noted the recommendations and passed them on to Welsh Government officials, noting that the UK Government is best placed to respond to the recommendation for a Public Inquiry into the Scout Association. The Children's Commissioner for Wales will seek updates from the Scouts Association and will share the PFD report with Estyn, who are expanding their inspections framework to include youth work. The Children's Commissioner will request updates from the Scouts Association by April 30th regarding actions to prevent future deaths/injuries. They have also called for Ofsted to play a larger role in assuring safety in youth work organisations. The Department for Education acknowledges the concerns raised, expresses condolences, and references existing guidance related to safeguarding and activity licensing but commits to no specific new actions. HSE will begin an investigation into Ben’s death and will also look at how they intervene generally with volunteering organisations that provide activities to young people such as the Scout Association to identify lessons for the future regulation of this sector. HSE will undertake a review to identify how this error occurred, and to ensure that it is not repeated and will be writing directly to Ben’s family to offer them an apology. The Scouts Association details actions taken including updating POR (Policy, Organisation and Rules), developing new training modules ('Growing Roots'), creating a new safety committee, and updating risk assessment processes. They also describe planned reviews and consultations. Unity Insurance Services acknowledges receipt of the report and expresses sympathy, noting they are working with insurers and The Scout Association to support customers, and clarifying a factual inaccuracy regarding the chair in 2018.
Philip Taylor
All Responded
2024-0051
2 Feb 2024
Betsi Cadwaladr University Health Board
Elysium Healthcare
Suicide (from 2015)
Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary)
Insufficient information sharing, poor discharge planning, and delayed documentation transfer between the Health Board and private out-of-area psychiatric units were identified. The absence of written agreements for minimum standards and communication protocols creates a significant risk of future deaths.
Disputed
(AI summary)
Following an inquest a memorandum/alert was shared with MHLD staff as an immediate “make safe” notice. A fully ratified Standard Operating Procedure (SoP) will be implemented to provide clear direction for health board staff and providers, ensuring a coordinated approach to out of area placement management and optimize communication. The Health Board is reviewing completed proportionate reviews and action plans to identify and address issues and expect this review to be fully completed towards the latter end of summer 2024. Elysium Healthcare disputes the coroner's concerns regarding information sharing and the existence of a standard operating procedure, stating that information was shared and a framework agreement with information sharing requirements was in place. They highlight Betsi's lack of attendance at MDT meetings and assert that there is no risk of future deaths if their processes are properly followed.
Thomas Ithell
All Responded
2024-0035
22 Jan 2024
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Health Board failed to raise incident reports or investigate a patient being lost to follow-up, citing time constraints and an un-user-friendly system, undermining patient safety governance.
Action Planned
(AI summary)
Betsi Cadwaladr University Health Board has raised an incident report and initiated a full investigation into a patient lost to follow-up; it also plans to survey staff experiences with the Datix system and consider building an alert in the electronic patient administration system for patients without a follow-up appointment.
Vivienne Greener
All Responded
2023-0531
18 Dec 2023
Betsi Cadwaladr University Health Board
Department of Health and Social Care
Emergency services related deaths (2019 onwards)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A lack of out-of-hours emergency endoscopy and insufficient Emergency Department staff contribute to ineffective triage and ambulance offloading delays. Unclear clinical protocols and inadequate sharing of investigation learning also pose risks.
Action Planned
(AI summary)
Betsi Cadwaladr UHB updated the Upper GI Bleeding – Management and Principles of Care pathway in July 2023 and will review it again in April 2024. A new incident process is being developed and will be implemented in April 2024, including a new report template to clarify the final version. The Welsh Government is holding health board chairs accountable for ambulance patient handover improvements and has incorporated this as a key objective for all chairs for 2023/2024. They have established national mechanisms for monitoring the quality, safety and effectiveness of services provided by health boards across Wales. Over £500,000 of additional funding was made available to Betsi Cadwaladr University Health Board in December 2023 to support upgrades and improvements in their emergency departments.
John Thomas
All Responded
2023-0527
15 Dec 2023
Denbigshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Known highway defects, including surface water and flooding, were not remedied by the local authority, posing a clear risk of future fatal road incidents.
Action Taken
(AI summary)
Denbighshire County Council has cleared drainage gullies and channels on the A539, erected warning signs alerting motorists to the possibility of water or ice and this culvert will now be added to a list of critical culverts which are known to require higher maintenance standards and this feature will now be added to it a monitored more closely.
Catherine Jones
All Responded
2023-0526
8 Dec 2023
Betsi Cadwaladr University Health Board
Welsh Government
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Undocumented surgical protocols led to a lack of cohesive care, as communication between surgeons and patient consultants was not a formal system, risking future harm.
Action Planned
(AI summary)
Betsi Cadwaladr University Health Board will develop a clear and consistent policy for surgical lists across the organisation, led by a task group meeting monthly starting in February 2024, with completion estimated within six months. The Welsh Government describes the implementation of the new Cancer Informatics Solution (CIS) which makes available a number of new clinical records that can be viewed through the Welsh Clinical Portal. It also includes functionality to notify the clinician of any new histopathology reports they have requested.
Hazel Pearson
All Responded
2023-0471
24 Nov 2023
Betsi Cadwaladr University Health Board
Care Home Health related deaths
Concerns summary (AI summary)
Inadequate management of food intolerances and allergies, including slow implementation of safety measures and a lack of proper incident investigation and Datix reporting, poses a serious risk.
Action Planned
(AI summary)
The Health Board is exploring how to access expert advice in relation to compliance. A revised training programme for incident reporting is in place for all staff with dates confirmed across North Wales for the next quarter alongside “how to” guides and videos for staff to access at any time via the BetsiNet intranet and a new incident process will be introduced in April 2024.