The debating chamber at The Senedd
The debating chamber at The Senedd Credit: Senedd Cymru / Welsh Parliament

One in five of the preventable death reports issued by coroners across Wales and England last year related to Betsi Cadwaladr University Health Board, the Senedd heard.

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: “Last year some 21% of all prevention of future death reports issued by coroners across the whole of England and Wales were in respect of Betsi Cadwaladr.

“That is an astonishing statistic.”

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

“I cannot accept that it is appropriate that 21% of all of those reports which are being issued have been in respect of one single health board.”


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.”

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.