Emily Corfield

Kate Robertson 
Assistant Coroner for North Wales (East and Central) 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO:   
Betsi Cadwaladr University Health Board (BCUHB) 

1 

CORONER 

I am Kate Robertson, Assistant Coroner for North Wales (East and Central)                     

2 

CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and INQUEST 

On 27 September 2021 an investigation was commenced into the death of Emily 
Corfield (DOB 30/12/79) who died on 19 September 2011. The investigation concluded 
at the end of the inquest on 11 July 2023.  The conclusion of the inquest was an alcohol 
related death. 

4 

CIRCUMSTANCES OF THE DEATH 

The circumstances of the death are as follows :- 

Emily Corfield was aged 41 at the time of her death. She had a past medical history of 
vitamin B12 deficiency, anxiety, depression and excess alcohol consumption. She had 
some support from alcohol liaison services to assist in her overuse of alcohol. On 20 
April 2021 she was admitted into hospital with coffee ground vomiting and chronic 
alcohol misuse. She was discharged on 26 April 2021 with outpatient OGD and was due 
for review by alcohol liaison as an outpatient. There was no evidence that she had had 
an inpatient assessment by the alcohol liaison team. On 30 May 2021 she was admitted 
into hospital again with coffee ground vomiting and alcohol withdrawal. There was no 
evidence of the alcohol liaison team involvement whilst an inpatient. Emily discharged 
herself against advice on 4 June 2021 having the capacity to do so. On 19 September 
2021 Emily was found deceased in her bed at her home 

.  

5 

CORONER’S CONCERNS 

During the course of the inquest, the evidence revealed matters giving rise to concern.   

Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN 

    |  

 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In my opinion there is a risk that future deaths will occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows  – 

Emily had two inpatient admissions in the year of her death. Whilst the clinician had 
noted that she was for referral to the alcohol liaison team there was no evidence that 
Emily had in fact received any input from them either as an inpatient or as an 
outpatient nor any referrals to external organisations. 

It is concerning that there appears to have been no evidence that Emily was receiving 
support from the Alcohol Liaison Team whilst an inpatient on either occasion despite 
her long history of alcohol misuse and need for support.  

In the event that clinicians advise referral to alcohol liaison team, either as an inpatient 
or as an outpatient there ought to be systems and processes to ensure that this occurs.  

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you have 
the power to take such action. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely 8 September 2023. I, Kate Sutherland, the Coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out 
the timetable for action. Otherwise, you must explain why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner.  

I am also under a duty to send the Chief Coroner a copy of your response.  

The Chief Coroner may publish either or both in a complete or redacted or summary 
form. He may send a copy of this report to any person who he believes may find it 
useful or of interest. You may make representations to me, the coroner, at the time of 
your response, about the release or the publication of your response by the Chief 
Coroner. 

9 

Dated 14 July 2023 

Signature   

Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN 

    |  

 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 Assistant Coroner for North Wales (East and Central) 

Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN 

    |

Meeting  the needs of 
Bodoli anghen ion pobl sy'n 
agored i niwed sy'n wynebu  vu lnerable  people facing 
complex life challenges 

heriau by.,vyd cymhleth 

Ty Dafydd Alun, 36 Rhodfa'r Tywysog, Bae Colwyn, LL29 8LA 
Ty Dafydd Alun, 36 Princes Drive, Colwyn Bay, LL29 8LA 

0 

  V 

To: 

HM Assistant Coroner, Kate Robinson 

North Wales (East and Central) Coroner 

Dear Madam, 

Response of Adferiad Recovery Ltd to the Regulation 28 Report to Prevent Future Deaths 

Inquest touching on the death of Emily Anne Corfield 

We write with reference to  your Regulation 28 Report to Prevent Future Deaths ("the Regulation 28 

Report") dated 14 July 2023 concerning the inquest touching on the death of Ms Emily Anne Corfield. 

On  behalf of Adferiad  Recovery  Ltd  ("Adferiad"),  may  J  express  our  deepest  condolences  to  Ms 

Corfield's family and friends. 

May we assure you and the family that the matters set out herein have been carefully and thoroughly 

considered  by Adferiad's senior management team which,  we trust,  reflects our commitment to  place 

the health and wellbeing of our patients at the heart of everything we do. 

Adferiad is a charity and we are funded through various projects by Betsi Cadwallader University Health 

Board ("the Health Board") and the Welsh  Government. We are a therapeutic support service and the 

service in question provides non clinical help and support for people with mental health, substance use, 

addiction and other complex needs. We  are  not a  crisis service.  Our Counselling  and  Motivation for 

Addiction Service provides free therapy for those requiring specialist substance misuse psychological 

M..ltJ Ad ftr~1d  R~co"cry yn 

Adfor,Jd Pe-:o· ..cry 1s 
).(cf:,dliad corlfott-diy  f.!lu~nno•  o c h,mt,:,bl~ inccrpor'l)t?'Q 
ac ,•,edy ccf re,i ru y ng  or43.,n1-;uttc n  , ~  1-.tcrcd •r, 
E.l"lglar,ct :-.,,d W.1lcs 

Nt3hymru  n Llocgr 

 
 interventions including: counselling; cognitive behaviour therapy;  and access to recovery groups.  Our 

therapists  are  qualified  counsellors  with  additional  training  in  substance  misuse  and  recovery. 

Individuals can be referred to us by other health and care providers/professionals and/or they can self-

refer. 

We set out below our Response to the Matters of Concern insofar as they relate to Adferiad. For ease 

of reference, the relevant Matters of Concern appear below in blue type and Adferiad's Response is in 

black type. 

1. 

Matter of Concern 1: 

Firstly,  evidence  was heard during  the  Inquest that Emily had self-referred on  a  number of 

occasions for support to Adferiad (formerly Cais).  It could not be established whether or not 

Emily had received written correspondence from them relating to appointments and/or offer of 

support as correspondence was not retained by Adferiad. Emily  was on occasion closed to the 

service  for  not  having  responded  to  correspondence.  The  system  at  the  time  was  that 

communicating with service users was in writing only. 

It appears that more recently,  policies and procedures have  been  established to  ensure that 

correspondence  relating  to  those  who  require  support and I or contact  the  service  is  now 

retained though  these  were  not provided at the  Inquest.  Without  clear and thorough policies 

and  procedures  relating  to  all  contact  with  service  users  or those  who  seek  support,  the 

organisation will not be able to adequately monitor the support processes. 

2. 

Response to Matter of Concern 1: 

Following a referral to Adferiad,  a patient will be placed on our waiting list for an assessment. 

Thereafter,  at the material time: 

2. 1 

Our practice was to send hard copy letters to our patients to confirm: 

2. 1. 1  They had been placing on the service's waiting list for an appointment; 

or 

2.1.2  They remained on the service's waiting list but an appointment was not 

as yet available  (letter sent 6  weeks post referral).  This  letter would 

M.1~ Adfor.tiU Ra-covery yn 
,-cfyd i:,,d c:orfforcd ig ~lu ~onnot 

Adfod,td RtC:::).\l~.:ry  ,,s 
.J ~h.JritJb!,:, incc•,::::o,,..t.,.U 
.sc wcdy coft(l'!.tftJ yng  c rg:.mis,1t1on re;wstcrc-:1 fr, 

N ghymru J  Uoegr 

EJ"lgla,.d and 

 also ask the patient to confirm within 10 days if they wished to remain 

on the service's waiting list; or 

2.1.3  The  time and date of their appointment. 

2.2 

A hard copy ofthese letters was not retained on the patient's file,  but the date 

on  which they were posted to  the patient was recorded electronically on the 

relevant electronic patient file. 

At the inquest, Adferiad's 

 gave evidence that a new,  better 

system and procedure is now in place,  whereby all correspondence is kept electronically on a 

database, and all calls are logged.  The system is the Adferiad Information Management System 

and is accompanied by the Aims User Guide. All staff have received training on this new system 

and are aware of Adferiad's requirements. Accordingly, Adferiad's current practice is that: every 

letter sent to  a patient is scanned and stored electronically on our IT system; and every call 

made  to/received  from  a  patient  is  recorded  electronically.  In  addition,  concerning  the 

monitoring ofsupport, the new system, amongst other things, allows a "red flag" to be displayed 

for those patients who are considered to be a risk to  themselves or others,  has the option to 

add viewable  risk management plans,  records  signposting  that has taken  place and has an 

internal referral system to refer patients directly to another service.  Further, if a patient leaves 

the service,  staff need to  input the exit date,  reason and other relevant information. Adferiad is 

updating  its  service  specification  to  incorporate  these  requirements.  The  updated  service 

specification will be implemented and rolled out to all staff by the end of September 2023. 

Adferiad had understood from correspondence received from the Coroner's Office on 23 March 

2023 that no further documentation was required,  and Adferiad was not an Interested Person. 

Nevertheless, Adferiad understands that matter can arise during the course of the inquest, and 

it is regrettable that the documentary evidence was not before the court.  Adferiad is committed 

to extending full co-operation to coronial investigations and inquests. 

3. 

Matter of Concern 2: 

Secondly, it was indicated that due  to resource restrictions  that communication cannot be by 

telephone with those requiring support I service users (in  writing only) and the waiting time for 

M.10- Adfcr.:,1d  Uf-<;.ov..:ry ~n 
scfydlind ,o:crfforcdig. clu~..,:nnc! 

A.dforiJd ~;JCO\IN~  1~ 
J  c.h:,rh.:,bl(- inc:orpor,>U•d 
,1c ·.r.-c d',I cofrc~tru. 't"Y  ')f9'Jnis..itu:.,n r'C9 1•~ter'Cd •f\ 

Nghymn,.1., LI 

n 1 

Eng!anr:i ;Jnd  h 

 support sessions I counselling is long. This will have a detrimental impact and deaths may occur 

if the treatment and support is not afforded in a timely manner. 

4. 

Response to Matter of Concern 2: 

At the material time, our administrators were responsible for sending out the abovementioned 

letters to patients. They did not, however, make routine calls to patients as this would require a 

different skill set given that in our experience, when  patients are spoken to on the telephone, 

they often  seek therapeutic engagement.  Our administrators are not therapists and using our 

therapists to make routine telephone calls would add pressure to the service in the context of 

current resources and consequently, add to service waiting times. 

Adferiad  is,  however,  currently  in  the  process  of  seeking  a  range  of updated  automated 

communication routes for the service (such as a text reminder service) and as we proceed with 

this  initiative,  we will,  of course,  continue  to  have  regard  to your concern.  However, we  are 

unable to guarantee that patients will  act on  appointments;  and/or respond  to  our telephone 

calls, messages, visits, or other forms of communication. 

We acknowledge your concerns regarding our service's waiting  times but , funding  decisions 

concerning the service are matters for the Health Board and/or Welsh Government. 

We trust that this Response provides assurance that action is being  taken by Adferiad to address the 

matters raised by HM Coroner. 

Yours sincerely 

Chief Executive 

M,1c A<jf•r~1id Re,co'l."P.1y yn 
.,d·rdliadeori-for~d ig t-luscnnot 

Adfcr1.Jd l::!e:.::,wcry i~ 
,) r. 1"111rit,1b1e incorpof•'~ 
.3c wedy cofre~tru )'ng  \ltg.Jnis-Jtion rcgl•,tcr<'ct  n 
En13land .,.nd V'l..il0::; 

Ng'1:,mru J  lit'C~ r

Bloc 5, Llys Carlton, Parc BusnesLlanelwy, 
Llanelwy, LL17 0JG 

---------------------------------- 

Block 5, Carlton Court, St Asaph Business 
Park, St Asaph, LL17 0JG 

Dyddiad / Date: 12th September 2023  

Kate Robertson 
Assistant Coroner 
North Wales (East and Central) 
Coroner's Office 
County Hall 
Wynnstay Road 
Ruthin LL15 1YN 

Dear Ms Robertson,  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 
Emily Corfield  

I write in response to the Regulation 28 Report to Prevent Future Deaths dated 16 July 
2023,  issued  by  yourself  to  Betsi  Cadwaladr  University  Health  Board,  following  the 
inquest into the death of Emily Corfield.  

I would like to begin by offering my deepest condolences to the family and friends of Ms 
Corfield for their loss, and to apologise to them for the failures that were identified during 
the inquest which led to your notice.  

In the notice, you highlighted your concerns that Ms Corfield had not received input from 
the alcohol liaison service when an inpatient nor in the community and that you were not 
assured of the Health Board processes to ensure that referrals to the service are acted 
upon.  

In response to the notice, I requested our Mental Health and Learning Disabilities Division 
(MHLD) consider your concerns and provide details of their plans to make our services 
as effective as possible, taking into account the learning from the inquest.  

Firstly, I can confirm there is a Mental Health and Learning Disabilities Liaison Psychiatry 
Services in Acute Hospitals Delivery Framework (MHLD AC001) that is within date and 
available on the Intranet for all Health Board staff to access. This document outlines the 
services provided by Liaison from a multidisciplinary group of staff and includes alcohol 
liaison staff. The referral process to liaison services is detailed within the framework.  

During consideration of your concerns, it was identified that the liaison service did not 
receive  a  referral  from  the  treating  team  located  in  our  Integrated  Health  Community 
(East).  In response to this, a communication has been produced that outlines the referral 
process to liaison services that will be shared with clinical teams across the Health Board 
to ensure there is clarity and consistency across all areas. This communication has now 
been issued.  

Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: 
Swyddfa'r Gweithredwyr / Executives’ Office 
Ysbyty Gwynedd, Penrhosgarnedd 
Bangor, Gwynedd LL57 2PW 

Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
 Although  in  date  and  operational,  the  MHLD  Liaison  Psychiatry  Services  in  Acute 
Hospitals Delivery Framework will be reviewed by a working group of stakeholders, to 
include liaison team managers and key clinicians, led by a senior manager to ensure the 
referral process is clear and unambiguous.  

Once  the  review  is  complete,  the  revised  framework  will  be  subject  to  a  period  of 
consultation  and  will  then  proceed  through  the  ratification  process.  Progress  on  the 
review and ratification process will be monitored by the Divisional Policy and Procedure 
Development Subgroup and any potential delays will be escalated to the Divisional Senior 
Leadership Team.  

I hope this letter sets out for you the actions we have taken to ensure the concerns raised 
by yourself are being addressed.  

We  would  be  happy  to  meet  with  you  further  and  discuss  our  plans  in  more  detail,  or 
provide further information and assurance should that be helpful.  

Once again, I offer my deepest condolences to the family and friends of Ms Corfield for 
their loss and I reiterate my sincere apologies to them for the concerns identified at the 
inquest.  

Yours sincerely, 

______________ 

Prif Weithredwr Dros Dro 
Interim Chief Executive 

c.c.  

, Interim Deputy Chief Executive and Executive Medical Director 
, Executive Director of Public Health (Executive Lead for Mental Health)  

, Deputy Director of Quality