Nesta Jones

“junior doctors may not reach a different opinion to their consultant colleagues where the consultants have seen patients prior, and that this opinion is then followed through the patient's journey”

“family wrote a detailed urgently marked letter to the Chief Executive on 3 May 2017 whilst [the deceased] was still in hospital. This requested consideration by him of her care as 'a matter of life or death”

“no full investigation undertaken by the Health Board into [the deceased]'s death other than a desktop report, the quality of which was questionable”