Paul Roberts

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

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

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

Ein cyf / Our ref:  
Eichcyf / Your ref: 
: 
Gofynnwch am / Ask for: 
E-bost / Email: 
Dyddiad / Date: 09 September 2024 

John Gittins  
HM Senior Coroner 
North Wales (East and Central) 
Coroner's Office 
County Hall 
Wynnstay Road 
Ruthin LL15 1YN  

Dear Mr Gittins,  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 
Paul Anthony Roberts 

I write in response to the Regulation 28 Report to Prevent Future Deaths dated  18 July 
2024,  issued  by  yourself  to  Betsi  Cadwaladr  University  Health  Board,  following  the 
inquest touching upon the death of Mr Paul Roberts.   

I would like to begin by offering my deepest condolences to the family and friends of  Mr 
Roberts. 

In the notice, you highlighted your concerns that: 

1)  there does not appear to be any consequences for staff members whose actions 
or omissions result in a failure to adhere to the policies and procedures which the 
Health Board impose for the safe care and treatment of patients; and  

2)  that  the  failure  to  act  in  a  timely  manner  when  learning  and  actions  have  been 

identified leads to a failure to mitigate the risk to patients. 

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

Firstly, I would like to say that with the launch and implementation of the new Integrated 
Concerns Policy for the Health Board at the start of September 2024, we are rolling out 
a new approach to investigations. 

The new policy provides a clear and straightforward framework for all staff, detailing the 
expectations of the Health Board for reporting, investigating and learning from incidents, 
mortality and complaints.  

The  policy  was  developed  following  extensive  engagement  and  took  into  account  the 
findings  of  our  Learning  from  Investigations  Project.  As  you  know,  we  undertook  a 

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 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 retrospective review of 262 investigations. Significant learning was identified on how the 
Health  Board  approached  its  investigations  which  aligned  with  your  own  observations 
and that of Ms Robertson, Senior Coroner for North West Wales. The Chief Executive 
therefore  commissioned  a  further  programme  of  work  to  develop  this  new  Integrated 
Policy  covering  Incidents,  Complaints  and Mortality  Reviews.  As Executive  Director of 
Nursing and Midwifery, I oversaw this work along with the Acting Executive Director of 
Therapies and Health Sciences. The new policy was approved at the Board meeting in 
July 2024 and as mentioned above was implemented on 01 September 2024. 

As  part  of  the  new  policy,  there  is  new  guidance,  training  and  templates.  The  new 
template  includes  clear  guidance  for  the  investigator  that  directs  them  to  include  staff 
immediately involved in the care and treatment. This will ensure that staff delivering care 
are active contributors to learning investigations moving forward; it will also prompt the 
escalation of concerns about care and treatment to the managers of staff to ensure that 
any actions or omissions are addressed with staff appropriately. This template will be in 
use from 15 September 2024 as part of the new policy implementation.  

In addition to this, new training for investigating officers is being developed by the Health 
Board.  The  learning  from  Mr  Roberts’  inquest  will  be  incorporated  into  this  training, 
ensuring  that  investigators  are  aware  of  their  responsibility  to  escalate  concerns  in 
relation to action or omissions in care and treatment to the managers of staff. This will 
then  prompt  consideration  of  professional  and  workforce  processes.  This  training  is 
scheduled to be launched at the end of October 2024. 

The Health Board does have workforce policies that identify the action required in relation 
to staff whose practice falls below that of the standard expected. The Health Board strives 
to deal with capability issues in a fair and consistent manner, where the emphasis will not 
be  punitive,  but  will  help  employees  to  undertake  their  work  to  the  required  standard 
through training and support. However, there are disciplinary processes that are enacted 
where needed.  

With regard to your concerns about the failure to implement improvement actions in a 
timely manner, I can assure you that the outstanding Patient Information Leaflet is now 
in place within the Ysbyty Glan Clwyd Emergency Department and is given to patients at 
the point of triage. Adaptations are currently being made to launch the patient leaflet in 
both  Ysbyty  Wrexham  Maelor  and  Ysbyty  Gwynedd  Emergency  Departments. 
Completion of this will be monitored via the MHLD Learning and Action Group with an 
expected completion date of 25th September 2024.  

The MHLD Learning and Action Group is responsible for the dissemination of learning 
attained  via  multiple  routes  such  as  investigations,  inspections,  inquests  and  mortality 
reviews. Moving forward this group will review the progression of open action plans and 
provide timely escalation to facilitate completion.   

As part of the new policy, there are clear accountabilities now set on divisions to deliver 
the  improvement  and  action  plans.  The  Patient  Safety  Team,  Complaints  Team  and 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Clinical  Effectiveness  Team  will  conduct  rolling  audits  of  the  Datix  system  to  ensure 
divisions are uploading their Learning and Improvement Plans to Datix, that actions are 
being managed within date, and that evidence is being uploaded to support closure. This 
information  will  be  used  as  part  of  governance  and  accountability  processes  and 
meetings to ensure the Health Board is delivering on its improvement commitments. 

Later this year, we will also be launching a new Digital Learning Portal which is being 
designed  to  capture  and  cascade  learning.  Once  this  is  launched,  divisions  will  be 
responsible for ensuring information is entered into this system to enable learning to be 
recorded and cascaded across the organisation. This development is the first of a kind in 
Wales and is currently being actively developed by our IT department.   

I hope this letter sets out for you the actions that we are taking to address the concerns 
you raised.  

I would be happy to meet with you and discuss our work to improve patient safety 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  Mr Roberts for 
their loss. 

Yours sincerely 

Cyfarwyddwr Gweithredol Nyrsio a Bydwreigiaeth 
Executive Director of Nursing and Midwifery 

cc  

, Executive Director of Therapies and Health Sciences / Executive Lead for Mental Health  

, Deputy Director of Quality