Betsi Cadwaladr University Health Board
Coroner Kate Robertson · North Wales East and Central
No published response from this organisation found.
Coroner Kate Robertson · North West Wales · in 5 recurrence links
No published response from this organisation found.
Coroner John Gittins · North Wales East and Central · in 1 recurrence link
No published response from this organisation found.
Coroner Kate Sutherland · North Wales East and Central · in 2 recurrence links
No published response from this organisation found.
Coroner Kate Sutherland · North Wales East and Central · in 2 recurrence links
No published response from this organisation found.
Coroner Kate Sutherland · North West Wales · in 1 recurrence link
No published response from this organisation found.
Coroner John Gittins · North Wales East and Central
No published response from this organisation found.
Coroner Kate Sutherland · North Wales East and Central
No published response from this organisation found.
Coroner Kate Sutherland · North Wales (East and Central) · in 2 recurrence links
No published response from this organisation found.
- Twn Bryn: Prevention of future deaths report17 Feb 2023
Coroner Sarah Riley · North West Wales
No published response from this organisation found.
Coroner John Gittins · North Wales (East and Central)
No published response from this organisation found.
Coroner John Gittins · North Wales (East and Central)
No published response from this organisation found.
Coroner John Gittins · North Wales (East and Central)
No published response from this organisation found.
Coroner John Gittins · North Wales (East and Central)
Response · 1 stated action
2021-0359-Response-from-BCUHB_Published.pdf ↗“therefore intend to take executive decision to approve this procedure outside of the normal governance process and this will be completed no later than the 31 January 2022”
Coroner John Gittins · North Wales (East and Central) · in 1 recurrence link
Response · 3 stated actions
2021-0242-Betsi-Cadwaladr-University-Health-Board_Published.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.”
“A new process to support the services to deliver timely investigations was commenced in April 2021.”
- Arthur Hughes9 Mar 2020
Coroner John Gittins · North Wales (East and Central)
No published response from this organisation found.
- Peter Connelly7 Nov 2019
Coroner John Gittins · North Wales (East and Central) · in 6 recurrence links
No published response from this organisation found.
- Madeline Staples11 Feb 2019
Coroner John Gittins · North Wales (East and Central) · in 7 recurrence links
No published response from this organisation found.
- Gladys Williams10 Sept 2018
Coroner John Gittins · North Wales (East and Central) · in 6 recurrence links
No published response from this organisation found.
- Neville Welton17 May 2018
Coroner John Gittins · North Wales (East & Central)
Response · 1 stated action
2018-0150-Response-by-University-Health-Board.pdf ↗“The Health Board is revising the model for the investigation of serious incidents to support the divisions to investigate all incidents including catastrophic incidents. This will create capacity within the Corporate Concerns Teams in order for them to support and train staff in incident management. Each investigating officer for a catastrophic incident would have a member of the Corporate Concerns Team working alongside them to ensure a timely and robust investigation, that addresses qualifying”
- Daniel Watson18 Dec 2017
Coroner John Gittins · North Wales (East and Central)
No published response from this organisation found.
Coroner David Lewis · North Wales (East & Central)
No published response from this organisation found.
- Simon Willans5 Oct 2017
Coroner Nicola Jones · North West Wales
No published response from this organisation found.
- Catherine Roberts7 Jul 2017
Coroner Nicola Jones · North Wales (East and Central) · in 2 recurrence links
No published response from this organisation found.
- Daphne Williams25 May 2017
Coroner John Gittins · North Wales (East and Central) · in 4 recurrence links
Response · 1 stated action
2017-0167-Response-by-University-Health-Board.pdf ↗“In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs.”