“An investigation by the Health Board has identified that there were failings in relation…”
Dated 18 Jul 2024, 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 12 Sep 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 dated18 Jul 2024
- Deadline12 Sep 2024
- Published on judiciary.uk31 Jul 2024
- 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 July 2024. |
The coroner’s concerns
– An investigation by the Health Board has identified that there were failings in relation to the care afforded to Mr Roberts both following the February mental health referral and at ED on the 14th of August, however the evidence at inquest indicated that the persons with responsibility for these issues had not been spoken to, nor played a part in the investigation process (respectively Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | being the team manager of LPMHSS and the nurse in charge of ED). Furthermore an action plan provided by the health board advised that by the end of May 2024 a leaflet would be available and would be given to patients attending ED with mental health issues and would be provided to them at the time of triage to provide advice, support and an indication of likely waiting times before any psychiatric assessment took place. My concerns are therefore as follows : 1. There do not appear to be any consequences for staff members whose actions or omissions result in a failure to adhere to the policies and procedures which the health board impose for the safe care and treatment of patients and in my opinion this lack of accountability perpetuates future risk to patients. 2. The failure to act in a timely manner when learning and actions have been identified (especially when the timetable has been set by the organisation itself) is incomprehensible and as a result there is a failure to mitigate the risk to patients.
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, 2024-0383
- Added to Minute Book
- 8 Oct 2026
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- 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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