North West Wales

Coroner Area
Reports: 23 Earliest: Jul 2014 Latest: 21 May 2025

91% response rate (above 63% average).

Response Status
Responded 21 Historic 2
AI Classification
Action Taken 27%
Action Planned 46%
Noted 23%
Disputed 4%
Based on 26 classified responses
Top Categories
Wales prevention of future deaths … (12) Other related deaths (7) Hospital Death (Clinical Procedure… (6) Suicide (from 2015) (3) Alcohol, drug and medication relat… (2)
Quarterly Trend
Category Breakdown
How does this area compare?
vs Wales average: -55 reports · +28pp response rate
vs national average: -61 reports · +28pp response rate
23 results
Etta-Lili Stockwell-Parry
All Responded
2025-0236 21 May 2025
Betsi Cadwaladr University Health Board…
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete records. Learning from the investigation was poorly shared and lacked context, hindering genuine organizational change.
Action Taken (AI summary) Betsi Cadwaladr University Health Board has made immediate safety changes including that investigations across women's and neonatal services will have a single investigation officer and use the framework and templates within the Integrated Concerns Policy, and appointed a new quality governance officer into neonatal services.
Wilfred Fitchett, Jevon Hirst, Hugo Morris and Harvey Owen
All Responded
2024-0560 17 Oct 2024
Clough Williams-Ellis Trust Cyngor Gwynedd Council Landowner Department for Transport
Road (Highways Safety) related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The absence of legal restrictions on newly qualified and young drivers carrying multiple young passengers significantly increases collision risk, leading to concerns about future deaths.
Disputed (AI summary) Cyngor Gwynedd Council acknowledges the report but argues against installing a Road Restraint System at the collision site, citing costs, engineering constraints, and potential hazards. It emphasizes the role of motorists in road safety. The Department of Transport acknowledges the concerns and is developing a road safety strategy, incorporating findings from the 'Driver 2020' project to improve road safety for young drivers. The Trust disputes responsibility for the fence, stating it was likely erected by Cyngor Gwynedd and that stock fencing is not intended for highway safety. They assert that highway safety is the responsibility of the relevant Authority, not the landowner.
Jane Walker
All Responded
2024-0137 13 Mar 2024
Home Office
Alcohol, drug and medication related deaths Other related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Paramedics are unable to administer rapid-acting analgesics like mucosal fentanyl lozenge due to controlled drug legislation, potentially delaying critical pain relief and extrication.
Noted (AI summary) The NHS England Task & Finish Group on Analgesia is considering recommendations from the Manchester Arena Inquiry regarding paramedics administering mucosal fentanyl lozenges. The group has been provided with a copy of the coroner's letter for reference, and any recommendations will be considered by a future government.
Nesta Jones
All Responded
2024-0110 28 Feb 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) Junior doctors may not feel able to challenge consultant opinions, risking missed diagnoses. The Health Board also lacked adequate systems for urgent complaints and failed to conduct a full, timely investigation into the death.
Action Planned (AI summary) The Health Board is issuing a Safety Alert by the end of April 2024 to share learning from the case and improve the process of listening to professional views and concerns. The Chief Executive is driving work for a new framework covering incidents, complaints, and mortality, aiming for significant process improvement.
Teresa Bennett
All Responded
2024-0081 14 Feb 2024
Betsi Cadwaladr University Health Board
Alcohol, drug and medication related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Widespread non-compliance with medication review targets and a lack of standardised review practices led to insufficient patient advice, increasing the risk of inadvertent overdose from combined medications.
Action Planned (AI summary) Betsi Cadwaladr UHB has commenced benchmarking work to identify patients on regular repeat medication without a documented medication review in the last 12-15 months. They will add the Faculty of Pain Medicine opioid leaflet onto the clinical system and share learning with independent contractor GP practices.
Jennifer Campbell
All Responded
2023-0404 24 Oct 2023
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 crucial ERCP referral was lost, with no investigation or learning by the Health Board, compounded by delays in electronic referral implementation, risking patient safety.
Action Taken (AI summary) The Health Board implemented a new standing operating procedure for endoscopy referrals in November 2023 and scans all paper referrals into the endoscopy email inbox. Referrals are also recorded onto the Welsh Patient Administration System (WPAS) as soon as they are received. They are also working with Digital Health and Care Wales (DHCW) on developing an electronic form as part of the Welsh Clinical Portal (WCP).
Lynsey Smalley
All Responded
2023-0322 8 Sep 2023
Barts Health NHS Foundation Trust
Other related deaths
Concerns summary (AI summary) Fragmented governance processes and significant delays in acting on investigation findings impede learning. The lack of electronic medical records across mental health teams risks lost notes and poor continuity of patient care.
Action Planned (AI summary) The Health Board is developing a Strategic Outline Case for a Health Board wide Electronic Patient Record system to address fragmented care records with a deadline of end of January 2024, and will undertake a significant piece of work to make long term, substantial changes regarding investigations.
James Jones
Historic (No Identified Response)
2023-0320 6 Sep 2023
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Persistent pressures and insufficient staffing in the A&E department lead to review delays, risking missed opportunities and potential future deaths in life-threatening situations.
Mary Jones
All Responded
2023-0236 10 Jul 2023
Betsi Cadwaladr University Health Board…
Emergency services related deaths (2019 onwards) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Persistent and unacceptable ambulance delays, compounded by patient offload issues at emergency departments, are linked to a lack of local authority involvement in addressing social care deficiencies affecting patient flow.
Noted (AI summary) The Welsh Ambulance Service NHS Trust acknowledges concerns about ambulance delays and inability to offload patients. They state they have robust plans in place and liaise with Health Boards but do not believe they are the authority with the power to take such actions.
Eifion Huws
All Responded
2023-0185 8 Jun 2023
Betsi Cadwaladr University Health Board
Suicide (from 2015)
Concerns summary (AI summary) Inadequate access to comprehensive patient records (due to electronic vs. hard copy discrepancies) hindered emergency staff decision-making. The Health Board's investigation also failed to address this critical information-sharing flaw or improve overall investigation timeliness.
Action Taken (AI summary) The Health Board is implementing the Welsh Community Care Information System (WCCIS) for integrated health and social care records and has reviewed its incident process, implemented rapid learning panels, and prioritized completion of overdue investigations and action plans.
Twm Bryn
All Responded
2023-0064Deceased 17 Feb 2023
Betsi Cadwaladr University Health Board
Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Persistent staffing shortages lead to extensive waiting lists and assessment delays in mental health services, while interim support for low-risk patients is inadequate and lacks proactive monitoring.
Action Planned (AI summary) The Health Board is redesigning Local Primary Mental Health Support Services (LPMHSS) as part of ministerial priorities for 2024/2025, including a review of referral processes and interim support for low-risk patients; they will report on progress in 3 months.
Glendys Roberts
All Responded
2022-0333 24 Oct 2022
Betsi Cadwaladr University Local Health… Welsh Ambulance Service Trust
Emergency services related deaths (2019 onwards) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Ambulance availability is critically low for inter-hospital transfers due to bed blocking and a lack of community care. Implementation of crucial reviews for intra-hospital transfers, vascular emergency pathways, and an ambulance handover plan has been unacceptably slow.
Action Planned (AI summary) The Trust is working with Betsi Cadwaladr University Health Board and the National Collaborative Commissioning Unit to improve intra-hospital transfer resources, including developing a proposal for dedicated transfer resources, and is considering actions to address issues in the Regulation 28 report, including changes to Standard Operating Procedures. Betsi Cadwaladr University Health Board is reviewing intra-hospital transfer processes with support from the National Collaborative Commissioning Unit and modeling service demand. They are also working with WAST on ambulance performance and handover delays, and have an Integrated Commissioning Action Plan.
Eirlys Roberts
All Responded
2022-0034 31 Jan 2022
Minister for Health and Social Services…
Care Home Health related deaths Other related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) A critical shortage of residential and nursing placements in Gwynedd prevents elderly patients from accessing appropriate care as their needs evolve, posing a risk to their well-being.
Noted (AI summary) The Welsh Government describes plans for an Expert Group to support a National Care Service for Wales and states that the Minister for Health and Social Services will write to Regional Partnership Boards, Health Boards and Directors of Social Services requesting a review of provision for older peoples residential care and robust exploration of sufficiency of provision. Gwynedd Council explains the challenges it faces in providing care placements, particularly due to COVID-19 and staffing capacity, but states that the link between the incident and placement availability is not entirely clear.
Jonathan Bayliss
All Responded
2021-0413 7 Dec 2021
Ministry of Defence
Accident at Work and Health and Safety related deaths Product related deaths Service Personnel related deaths Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) Urgent investigations into an artificial stall warning for the Hawk Mk 1 aircraft, which can stall without warning, are stalled. The training simulator also inaccurately models the aircraft with a smoke pod.
Action Planned (AI summary) The MOD is undertaking investigations into incorporating an artificial stall warning capability in the Hawk T Mk1, with a decision expected in summer 2022. The RAF is developing options for a RAFAT-focused Hawk Synthetic Training Facility, expected to be in place by 2025, and will update the current Hawk Synthetic Training Facility software to reflect a RAFAT aircraft by 2023.
Mared Foulkes
All Responded
2021-0378 10 Nov 2021
Cardiff University
Other related deaths Suicide (from 2015) Wales prevention of future deaths reports (2019 onwards)
Concerns summary (AI summary) The university's examination results system is complex and misleading, with provisional passes and pending marks causing confusion. There is also no system for personal tutors to proactively contact vulnerable students before releasing failed results.
Action Taken (AI summary) The University has reviewed its process for releasing in-year resit results to ensure all available results are ratified at the Main Examining Board in June. The practice of using notional marks where a student has not met a competency standard has been stopped.
Elijah Shotade
All Responded
2018-0290 10 Sep 2018
North & Mid Wales Trunk Road Agency
Road (Highways Safety) related deaths
Concerns summary (AI summary) Dangerous road layout design and misleading sat nav directions encourage westbound motorists to remain or enter the eastbound lane after overtaking, significantly increasing collision risk.
Action Taken (AI summary) The Department for Economy and Infrastructure has extended double white lines and lane arrows on Britannia Bridge. Further improvements to signage are planned before the end of the financial year, and road safety audits are being conducted.
Simon Willans
Historic (No Identified Response)
2017-0280 5 Oct 2017
Betsi Cadwaladr University Health Board
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The ambulatory care unit lacked effective scrutiny and the consultant failed to document patient care. Discharge by an uninvolved nurse practitioner, insufficient safety netting, and failure to commence heparin despite a DVT/PE differential posed significant risks.
Jasmine Lapsley
All Responded
2016-0022 15 Jan 2016
EMERGENCY AMBULANCE SERVICE COMMIT-TEE … Welsh Ambulance NHS Trust Welsh Assembly Government
Community health care and emergency services related deaths
Concerns summary (AI summary) Emergency services in rural NW Wales suffer from a lack of nighttime air support, ineffective rostering and communication for Community First Responders, and inadequate resource planning for seasonal population increases.
Noted (AI summary) This response is not classifiable due to being unreadable. The Welsh Air Ambulance is expanding by an additional helicopter in July 2016 and has funding for three more in early 2017. The Welsh Ambulance Services NHS Trust has piloted hand-held devices to improve communications for community first responders.
Alexander Hadley
All Responded
2015-0433 11 Nov 2015
Gwynedd Council
Other related deaths
Concerns summary (AI summary) The absence of warning signs at a public waterfall meant people were unaware of dangerous currents, creating a risk of further accidental deaths.
Action Planned (AI summary) Gwynedd Council is arranging to install safety warning signs near the pool at Rhaeadr Afon Arddu, Llanberis, to warn visitors of the danger of underwater currents, with installation expected by the end of January 2016 pending suitable weather.
Barry Wilson
All Responded
2015-0167 29 Apr 2015
Glan Clwyd Hospital
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A defective surgical anastomosis, made with staples, was not detected prior to the patient's hospital discharge, directly contributing to their death.
Action Planned (AI summary) The University Health Board will implement a pre-discharge checklist, provide patients with information leaflets outlining symptoms of concern and contact numbers, ensure care aligns with planned surgery, and have patients report by telephone to the ward daily until contacted by a Colo-Rectal Nurse Specialist.
Isaac Nash
All Responded
2015-0028 30 Jan 2015
Ynys Mon County Council
Child Death (from 2015) Other related deaths
Concerns summary (AI summary) Strong and unpredictable currents in Aberffraw beach's river estuary pose a danger, as visitors lack local knowledge and there are no warning signs to inform them.
Action Taken (AI summary) The Council has held meetings with the local community and undertaken a risk assessment. A new warning sign is to be placed in the car park drawing particular attention to the potential dangers at Trwyn Du.
Dylan Rattray
All Responded
2014-0371 12 Aug 2014
Snowdonia National Park Authority
Other related deaths
Concerns summary (AI summary) The Snowdonia National Park Authority's failure to follow mountain rescue advice regarding misleading paths at the summit created a dangerous illusion of safety, leading walkers into perilous situations.
Noted (AI summary) The Snowdonia National Park Authority explains its purposes and duties and argues that its accident rate is lower than other activities. Signage and re-routing of the Watkin Path will hopefully ensure walkers are provided with more information and a clearer route.
Hywel Hughes
Partially Responded
2014-0311 2 Jul 2014
Home Office North Wales Constabulary Security Industry Authority
Police related deaths
Concerns summary (AI summary) Police training on positional asphyxia is inadequate, and vehicle designs hinder monitoring detainees. The SIA also fails to review restraint-related deaths by door supervisors.
Action Taken (AI summary) North Wales Police amended their training materials on positional asphyxia to include snoring as a symptom and added an exercise to demonstrate the dangers of medical emergencies. They also designed and are testing a single cell compartment bubble car and considering auditory improvements.