“It was accepted by the Health Board that there had been a delay between April 2024 and…”

The coroner’s concerns

– It was accepted by the Health Board that there had been a delay between April 2024 and July 2024 in undertaking the endoscopy. Whilst this did not impact on the outcome for Rory Williams it did highlight a number of ongoing concerns with the gastroenterology / endoscopy service:a. Staffing – the evidence at Inquest was that the Health Board was struggling to maintain this most basic service at Ysbyty Glan Clwyd due to staffing issues which included lack of consultants, endoscopists and other essential healthcare staff. There is currently only one full time equivalent consultant and 3 locums. The service is currently considered to be ‘absolutely dependent on locums’. It was noted that recruitment into gastroenterology is a challenge yet these issues have been ongoing for many considerable years, potentially since 2018. b. Infrastructure – evidence was heard that this requires significant investment and improvement within the service, and despite business cases having been made there have not been significant steps to improve this. It is not known why. c. The Health Board’s target for urgent suspected cancer referrals to endoscopy (that is from GP referral to endoscopy) is 21 days. Today, this stands at 8 weeks. d. The Health Board’s current wait time for urgent referrals (non-suspected cancer) to endoscopy is currently 89 weeks. This figure has increased since 2023. e. The Health Board’s current wait time for routine referrals to endoscopy is currently 148 weeks. This figure has increased since 2023. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | f. I am concerned that there is no fully networked service for endoscopy / gastroenterology where this and the above concerns do not appear on the corporate risk register. Whilst they appear on the local risk register it is extremely concerning that corporately it does not appear as a risk. Evidence was heard that at one point the risk score for the service was reduced from 25 to 20. The reason is not known. g. The overall impression is that the service is not fit for purpose and that all of these concerns, many of which have existed for several years, signify a risk of harm and death of patients into the future as a result.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0016

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0