“There was no evidence of any formal investigation having been undertaken into how the…”
Dated 24 Oct 2023, from the coroner for North West Wales. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 19 Dec 2023.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated24 Oct 2023
- Deadline19 Dec 2023
- Published on judiciary.uk1 Nov 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Betsi Cadwaladr University Health Board | Response publishedPublished on judiciary.uk in November 2023. |
The coroner’s concerns
– a. There was no evidence of any formal investigation having been undertaken into how the referral for ERCP became lost. It appears that only during the course of Inquest proceedings did the issue relating to the lost referral become known to the Health Board. Even once it became known to them in 2022 there was still no investigation undertaken. It is not understood at all which incidents that occur are to be investigated. I have issued a number of Prevention of Future Death Reports relating to investigations and governance and yet these concerns continue. I am not in any way satisfied that improvements have occurred. b. Given that no investigation was conducted to understand how the issue may have occurred there has been no learning, change or improvement to ensure it is not repeated. I have been provided with no assurances in this regard. c. There was no evidence that any audits had taken place to review whether any other patients’ referrals had become ‘lost’. d. Matters relating to the ERCP which did not take place were identified by the Medical Examiners in their report dated 4 days after the deceased’s death. There was no evidence as to whether the Health Board had been made aware of the concerns therein and if so, what action they had undertaken as a result. Coroner's Office, Shirehall Street, Caernarfon e. Evidence was heard relating to electronic notes and referrals. Such referrals remain paper based and there is no indication as yet when these will be fully electronic. I am aware that this national strategy is ongoing but the time it is taking is putting patients’ lives at risk.
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, 2023-0404
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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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
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