“Despite the deceased passing away just shy of 2 years ago, there have been inadequate…”
Dated 24 Nov 2023, from the coroner for North Wales (East and Central). 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 Jan 2024.
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 Nov 2023
- Deadline19 Jan 2024
- Published on judiciary.uk29 Nov 2023
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| Betsi Cadwaladr University Health Board | Response publishedPublished on judiciary.uk in November 2023. |
The coroner’s concerns
– 1. Despite the deceased passing away just shy of 2 years ago, there have been inadequate improvements to manage patients with food intolerances and allergies. The Health Board has been working with other organisations in Wales to create an e-learning module and implement the use of red wrist bands for food intolerances / allergies, but this has taken far too long. The e-learning training module was uploaded to BCUHB system the day prior to the Inquest. It is strongly suspected that this was due to the impending Inquest. 2. The Health Board has not investigated the incident at all. A Medical Examiner Report was prepared following the death in November 2021 highlighting the ingestion of gluten in a coeliac patient. I have raised and continue to raise a number of concerns around the inadequacy of governance and poor investigation processes. 3. There were other incidences of gluten ingestion at Ysbyty Maelor and Deeside Community Hospital. On the at least 4 occasions at Deeside Community Hospital there were no Datix reports completed at the time. I was provided with no evidence that additional training, refresher training or induction training deals with when such reports should be made. I cannot be satisfied and reassured that all staff are aware of when to make a Datix report and how to complete this.
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, 2023-0471
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use