“An out of hours emergency endoscopy is still not available at Clan Clwyd Hospital or in…”
Dated 18 Dec 2023, from the coroner for North Wales (East and Central). Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 12 Feb 2024. A reply may have been sent and not yet published.
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.
- Report dated18 Dec 2023
- Deadline12 Feb 2024
- Published on judiciary.uk28 Dec 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social Care | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Betsi Cadwaladr University Health Board | Response publishedPublished on judiciary.uk in December 2023. |
The coroner’s concerns
– 1. An out of hours emergency endoscopy is still not available at Clan Clwyd Hospital or in this area of North Wales as the provision has ‘collapsed’ at Wrexham Maelor Hospital, so no referrals can be made; 2. There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department; 3. There is an ineffective triage and record of triage of patients arriving at Glan Clwyd Emergency Department by ambulance; 4. There is not a clear understanding of when the Emergency Treatment Team should be called; 5. There is not a clear understanding of when the Major Haemorrhage Pathway should be engaged; 6. The Health Board’s Upper GI Bleeding Management and Principles of Care 2022 is no longer fit for purpose; 7. Any learning from the Health Board’s Investigation Report is not adequately shared with its practitioners; 8. A part of the Health Board’s Investigation Report changed in different versions and obscured the reason why the provision of blood products was delayed meaning issues are not sufficiently identified and actioned; 9. Ambulances and paramedics are being kept at the Emergency Department as an extension of the hospital and its staff, due to WAST being unable to get their patients admitted into the Emergency Department and back on active duty.
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, 2023-0531
- 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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