the debating chamber at the senedd
The debating chamber at The Senedd Credit: Senedd Cymru / Welsh Parliament)

Senedd members raised concerns about the above-average number of prevention of future death reports issued by coroners related to Betsi Cadwaladr University Health Board.

Darren Millar raised alarm about high numbers of prevention of future death reports, which can be issued after inquests, questioning whether lessons are being learned in north Wales.

The Conservative MS for Clwyd West pointed to the case of Jennifer Trigger, a 71-year-old constituent, who died after suffering an acute stroke in January 2020.

Mr Millar said a coroner issued a Regulation 28 prevention of future death report last week.

He told the Senedd: “Due to a misunderstanding caused by the alert system in the Wrexham Maelor Hospital, the time-critical treatment that she was prescribed was not given until 11 hours after it should have been administered.”


Mr Millar called for a statement from the Welsh Government on what action is being taken by the health board, which has been in and out of special measures for a decade.

He said: “Now, clearly, we have to make sure that our NHS learns when issues like this occur and when reports of this nature are published.

During the Senedd’s business statement on March 12, Llŷr Gruffydd echoed calls for an update from the health minister on preventable death reports. 

The Plaid Cymru MS, who represents North Wales, said: “They are there, of course, to help prevent future deaths and they clearly require urgent action by health boards.

“But, despite that statutory duty, there are worrying trends in north Wales.”

‘Very serious’

Mr Gruffydd told the chamber Betsi Cadwaladr accounted for 41% of all preventable death coroner reports in Wales, rising to 50% in 2021-22.

He said: “In the past nine months, Betsi Cadwaladr health board accounts for 80% of all of these preventable death reports in Wales – that’s 21 out of a total of 25.

“Now that to me points to a very serious ongoing problem in the north.”

Lesley Griffiths, who is Trefnydd, the Welsh Government’s business manager, similar to the leader of the house at Westminster, agreed that lessons have to be learned.

Ms Griffiths said she would ask Eluned Morgan, Wales’ health minister, to bring forward a written statement on prevention of future death reports.

‘Profoundly sorry’

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.”