“The Health Board conducted an investigation into Philip’s death to include a review of…”
Dated 22 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 16 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 dated22 Jul 2024
- Deadline16 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
– The Health Board conducted an investigation into Philip’s death to include a review of his previous mental health care and treatment as well as Emergency Department (ED) care and treatment. This did not identify any concerns from an ED perspective (conducted by a Head of Nursing). The report had been reviewed and approved by the Director or Nursing for the Mental Health and Learning Division and the Integrated Health Council Director. A request for a Statement as part of my investigation from an ED perspective prompted a second review of the ED care and treatment which was completed only on 10 July 2024. This was undertaken by an Emergency Department matron, approved by the Divisional Director, reviewed at an Incident Learning Panel and had Executive Approval which was completed on 10 July 2024, 8 days prior to the already listed Inquest. This identified omissions in the care and treatment. At the Inquest an ED Consultant gave evidence to the Investigation Report with this evidence differing in parts to the second investigation report. I am concerned that the quality, effectiveness and timeliness of the Health Board’s investigations means that issues or concerns with care and treatment are not being identified either at all or quickly enough in order to put in place additional measures or learning to prevent deaths in similar circumstances. I have issued several Reports pertaining to this very point over a long period and yet the same concerns remain. 6
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, 2024-0387
- Added to Minute Book
- 8 Oct 2026
- Reuse
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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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