Betsi Cadwaladr: Lessons not learned from preventable deaths

betsi-cadwaladr:-lessons-not-learned-from-preventable-deaths
Betsi Cadwaladr: Lessons not learned from preventable deaths

The health board responsible for providing healthcare in north Wales has not learned from previous incidents, causing concern from coroners. According to Wales’ health minister, Eluned Morgan, 27 of 41 “prevention of future deaths reports” were issued to Betsi Cadwaladr, the health board, since January 2023, before it re-entered special measures in February. To protect further incidents, coroners have identified systemic problems, including inappropriate investigations, inadequate electronic health records, and delays having adverse effects on ambulance response times. Inquests are frequently held well after a patient’s death, with the most recent report from 2016.

The health board has been chastised by coroners for providing minimal prevention efforts, highlighting its inability to improve past issues and readiness to address the gaps. Senior coroners expressed their displeasure at insufficient organisation learning and shallow inquest preparation during meetings between Morgan and the management team. The health board has not made substantial changes to its inquiries, with around 400 cases awaiting evaluation. According to Plaid Cymru, the responsible political party, Minister Vaughan Gething must justify why preventable deaths persisted after seizing special measures.

Betsi Cadwaladr received the most prevention notices, with Welsh Ambulance Service receiving ten, followed by Aneurin Bevan’s health board with six, two each to Swansea Bay and Cardiff and Vale and one to Health Education and Improvement Wales. They will each be scrutinised for similar violations. North Wales’ MS Llyr Gruffydd remarked that preventable deaths are a growing concern for the region, and the continuation of government officials to investigate the reason and steps to prevent another is necessary.

The reforms in the health board’s inquest procedure are expected to improve the quality of patient care and prevent further serious accidents in the future. The government aims to address the systemic issues identified by the coroners by integrating electronic health records and forming an efficient, comprehensive investigation process. Any other institution found to have contributed to preventable deaths will also be held accountable and prosecuted, adding that lives lost due to organisational negligence are unacceptable

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