Health board not learning from preventable deaths

Lessons have not been learned to prevent further deaths in north Wales, coroners have told the health secretary.

Over the past year, coroners in Wales wrote 41 "prevention of future deaths reports" and more than half were issued to Betsi Cadwaladr health board.

Eluned Morgan, who remains in her job as health secretary after new First Minister Vaughan Gething announced his new cabinet, said 27 reports issued since January 2023 was "of significant concern".

Betsi Cadwaladr health board said every report was taken very seriously and work was ongoing to respond to key themes.

Ms Morgan said all but three of the deaths happened before the health board was moved back into special measures in February 2023.

Inquests are often held some time after a death - sometimes many years after - with one of the deaths dating back to 2016.

The "systemic issues" that emerge as common themes from the coroners' reports include:

• the quality of investigations and effectiveness of actions

• a lack of integrated electronic health records impacting care

• the impact of delays in the system on ambulance response times

In a written statement earlier this week, Ms Morgan said the health board had given assurances that it was taking the matter "extremely seriously".

She said she had met with both north Wales senior coroners who "expressed their frustration about an historic lack of learning within the organisation and poor preparation for inquests".

The statement added improvements had been made to the health board’s inquest process, but there was still an estimated 350-400 cases waiting to be listed for inquest.

Dyfed Edwards, chair of Betsi Cadwaladr University Health Board, said: "I fully acknowledge the importance of the prevention of future death reports, and that the numbers being issued in north Wales are above the national average.

"We take every report very seriously as behind these statistics are people and families who have been affected, and we are profoundly sorry for their loss.

"Work is ongoing to identify and respond to the key themes and points of learning that the reports contain. We have much to improve on and ensure that we provide services with quality and patient safety at the heart."

Plaid Cymru has called on new First Minister Vaughan Gething to explain why so many preventable deaths took place after the health board was taken out of special measures in 2021.

North Wales MS Llyr Gruffydd said: "The level of preventable deaths is concerning enough for coroners to flag it up.

"It’s vital we understand why these deaths happened and what we can do to prevent them in future."

Darren Millar MS, Welsh Conservative spokesman for north Wales, said it was "scandalous" so many reports were related to a single Welsh health board.

"That such a volume appear to coincide with the period after Vaughan Gething took the Betsi Cadwaladr University Health Board out of special measures implies that the decision taken by the then Welsh government's health minister could have contributed to the failures that prevented learning from deaths."

In addition to the 27 reports issued to Betsi Cadwaladr, 10 were sent to the Welsh Ambulance Service, six to Aneurin Bevan health board, two to Swansea Bay health board, one to Cardiff and Vale health board and one to Health Education and Improvement Wales.

The minister was also issued with six "relating to a range of NHS Wales services and public health concerns".