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recurance

Paul Roberts

18 Jul 2024 · Coroner John Gittins · North Wales (East & Central)

The coroner's concerns

  1. 1. lack of accountability for staff failures

    “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. 2. failure to act timely on identified risks

    “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.”

Responses

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  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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