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Critical report issued following 'serious concerns' after Betsi Cadwaladr patient death


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 University Health Board 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, an admin worker from Denbigh, died at Ysbyty Glan Clwyd's Ablett unit, Denbighshire, on 18 December, 2020, having apparently hanged himself.

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

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

At a pre-inquest hearing this week, Ms Sutherland also accused senior hospital medics of being disrespectful by dragging their feet about submitting essential documents for Mr Harrison's inquest, having received a report only minutes before the hearing.

She added that there were still documents outstanding and added: "It is an unusual and unacceptably long time. I do find that 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 a few days before the inquest but had not had time to read them.

Two of the board’s most senior medics, executive medical director, Dr Nick Lyons, and interim director of nursing for the mental health division, Dr Paul Lumsdon, apologised for the delay and outlined what changes had taken place and how the action plan which followed the investigation was being implemented. Dr Lyons said that when he learned of the length of the delay he was also very concerned.

Ms Sutherland said she would be taking the unusual step of issuing a Section 5 order calling on the board to produce certain documents within 28 days or face a financial penalty in default. She also issued the Regulation 28 Prevention of Future Deaths report.

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. This 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."