Betsi Cadwaladr: Critical report issued following patient death

A prevention of future deaths notice has been issued to Betsi Cadwaladr health board

A critical report has been issued to a health board amid concerns it did not address failings after a patient died.

North Wales coroner Kate Sutherland issued a prevention of future deaths notice to Betsi Cadwaladr health aboard ahead of a full inquest into the death of Ben Harrison.

Such reports are normally issued at the conclusion of a full inquest.

But Ms Sutherland said she was concerned there was "a risk that deaths will continue in the interim".

Mr Harrison, 37, died in Ysbyty Glan Clwyd's Ablett unit, in Denbighshire, on 18 December, 2020, having apparently hanged himself.

Ms Sutherland's report expressed concerns an investigation after Mr Harrison's death had led to an action plan that had not been sufficiently carried out.

Medical director Nick Lyons said the coroner's findings would be treated seriously

It said: "Ben died over two years ago. It is particularly concerning that learning and actions arising therefrom are not more quickly addressed.

"If the learning, actions and changes are taking so long then there is a risk that deaths will continue in the interim."

The report said there was "an evident lack of overall strategic direction to investigations and learning".

At a pre-inquest hearing this week, Ms Sutherland accused senior hospital medics of being disrespectful by dragging their feet over submitting essential documents for Mr Harrison's inquest.

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At a previous hearing in May 2022, Ms Sutherland expressed concerns about the board's investigation into the death, having received a report just minutes before the hearing.

On Tuesday, she said there were still documents outstanding.

"It is an unusual and unacceptably long time," she said.

It follows the death of Ben Harrison at Glan Clwyd Hospital

"I do find there has been a complete lack of respect not only for the process and proceedings but also for Ben's family."

She said she had received 750 pages of documents on Monday but had not had time to read them.

Betsi Cadwaladr's medical director, Nick Lyons, said: "We treat the coroner's findings very seriously, and we will be providing a detailed response to the concerns raised, which will include information on the range of actions we have taken and have planned to reduce the likelihood of such a tragic event from reoccurring."