Delays in investigating adverse incidents and implementing actions
Betsi Cadwaladr University Health Board received 2 coroners' reports about this hazard between 14 Jul 2021 and 8 Jun 2023.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“I am concerned that the continual delays in investigating adverse incidents, sharing learning and implementing actions following the same, create risks to patient safety.”
Original on judiciary.uk ↗ Betsi Cadwaladr University Health Board responded, stating 3 specific actions.Response (PDF) ↗
“On arrival at ICU the clerking-in doctor requested a toxicology screen to include paracetamol and salicylate levels (notwithstanding that blood tests to include this were already in hand) and there was no evidence available at the inquest to establish whether or not the toxicology screen requested by the doctor was undertaken and if not why not.”
“An internal investigation by the health board following Mrs [name redacted]' death rightly established that action needed to be taken to update or modify the SOP for communicating of life-threatening blood results directly with clinical areas and an action plan indicated that this would be completed by the 30th of June 2021.”
Stated timescale: 20 July 2021
1 more stated action in the Promises tab.
- 1 year 11 months laterClosely relatedConfidence 0.90 · higha different coroner
“I am concerned that deaths will occur when the actions arising are not acted upon in a timely manner.”
Original on judiciary.uk ↗ Repeated from the earlier report:concernedactions
Betsi Cadwaladr University Health Board responded.Response (PDF) ↗
- All reports to Betsi Cadwaladr University Health Board
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2021 → 2023Eifion Huws1 year 11 months after Rhian Roberts · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight delays in acting on investigation findings or adverse incident reviews as a risk to patient safety. The earlier report focuses on delays in investigating incidents and implementing actions, while the later report stresses that untimely action on arising findings could lead to deaths.
Rhian Roberts · 14 Jul 2021
“I am concerned that the continual delays in investigating adverse incidents, sharing learning and implementing actions following the same, create risks to patient safety.”
Original on judiciary.uk ↗ Eifion Huws · 8 Jun 2023
“I am concerned that deaths will occur when the actions arising are not acted upon in a timely manner.”
Original on judiciary.uk ↗
Stated action
“On arrival at ICU the clerking-in doctor requested a toxicology screen to include paracetamol and salicylate levels (notwithstanding that blood tests to include this were already in hand) and there was no evidence available at the inquest to establish whether or not the toxicology screen requested by the doctor was undertaken and if not why not.”
Stated action · timescale: 20 July 2021
“An internal investigation by the health board following Mrs [name redacted]' death rightly established that action needed to be taken to update or modify the SOP for communicating of life-threatening blood results directly with clinical areas and an action plan indicated that this would be completed by the 30th of June 2021.”
Stated action · timescale: April 2021
“A new process to support the services to deliver timely investigations was commenced in April 2021.”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Betsi Cadwaladr University Health Board at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2021 → 2023 | 0.76 | 0.07 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Betsi Cadwaladr University Health Board
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.