Betsi Cadwaladr University Health Board

PFD Addressee
Reports: 77 Earliest: Sep 2013 Latest: 27 Feb 2026

83% 2-year response rate (matches average). 38% of classified responses show concrete action taken.

Response Status (last 2 years, 12 reports)
Responded 10 No Response 1
AI Classification
Action Taken 38%
Action Planned 56%
Noted 5%
Disputed 2%
Based on 66 classified responses
PFD Reports Received by Quarter
PFD Reports
77 results
Summer Mant
No Identified Response
2026-0118 27 Feb 2026 South Wales Central
Child Death Wales prevention of future deaths reports
Concerns summary (AI summary) A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior doctors in a time-critical situation.
Rory Williams
All Responded
2026-0016 13 Jan 2026 North Wales (East and Central)
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 North Wales (East and Central)
Mental Health related deaths Wales prevention of future deaths reports
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 North Wales (East and Central)
Alcohol, drug and medication related deaths Emergency services related deaths Wales prevention of future deaths reports
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.
Etta-Lili Stockwell-Parry
All Responded
2025-0236 21 May 2025 North West Wales
Child Death Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
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.
Patricia Catterall
All Responded
2025-0189 11 Apr 2025 North Wales (East and Central)
Care Home Health related deaths Wales prevention of future deaths reports
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.
Leanne Carroll
All Responded
2025-0153 19 Mar 2025 North Wales (East and Central)
Mental Health related deaths Wales prevention of future deaths reports
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.
Ann Cotgrove
Partially Responded
2025-0103 21 Feb 2025 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) There was an absence of formal documented processes and record-keeping for inter-hospital referrals, discussions, and the subsequent advice and actions taken.
Action Planned (AI summary) The Health Board shared the issues with the clinical team involved and is developing a case summary presentation to share learning across services through clinical governance meetings. An Outline Business Case has been developed and is due for approval at their Board in June 2025, before submission to the Welsh Government in July 2025.
Margaret Daly
All Responded
2024-0701 28 Oct 2024 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
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.
Philips Evans
All Responded
2024-0387 22 Jul 2024 North Wales (East & Central)
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
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 North Wales (East & Central)
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Wales prevention of future deaths reports
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 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
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.
Maureen Owens
All Responded
2024-0177 27 Mar 2024 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
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 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
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.
Nesta Jones
All Responded
2024-0110 28 Feb 2024 North West Wales
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
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 North West Wales
Alcohol, drug and medication related deaths Wales prevention of future deaths reports
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.
Philip Taylor
All Responded
2024-0051 2 Feb 2024 North Wales (East and Central)
Suicide Wales prevention of future deaths reports
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 North Wales (East and Central)
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 North Wales East and Central
Emergency services related deaths 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.
Catherine Jones
All Responded
2023-0526 8 Dec 2023 North Wales East and Central
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 North Wales East and Central
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.
Jennifer Campbell
All Responded
2023-0404 24 Oct 2023 North West Wales
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
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).
Margaret Kelly
All Responded
2023-0375 9 Oct 2023 North Wales East and Central
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Unsustainable pressure on emergency department staff, stemming from insufficient strategic planning and support, is causing treatment delays and raises concerns about patient safety and increased mortality.
Action Planned (AI summary) Betsi Cadwaladr UHB acknowledges concerns about pressure on the Emergency Department at Ysbyty Glan Clwyd. They are undertaking a programme management approach organized into three phases to strengthen planning, leadership and governance across the Health Board and are working with operational and clinical teams.
Richard Griffiths
All Responded
2023-0333Deceased 14 Sep 2023 North Wales East and Central
Suicide Wales prevention of future deaths reports
Concerns summary (AI summary) The coroner raises concerns about deficiencies in the Health Board's investigation process, the lack of detail in the Transfer of Care document, and the continued use of paper-based patient notes for mental health.
Action Planned (AI summary) Betsi Cadwaladr University Health Board is undertaking an addendum investigation regarding the transfer of care, and a strategic outline case for an Electronic Patient Record system(s) is being developed on a Health Board wide level to address the issue of fragmented care records; the deadline for the strategic outline case is the end of January 2024.
James Jones
Historic (No Identified Response)
2023-0320 6 Sep 2023 North West Wales
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.