Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0016, written 13 Jan 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Jan 2026 |
|---|---|
| Reference | 2026-0016 |
| Deceased | Rory Williams |
| Coroner | Kate Robertson |
| Coroner area | North Wales (East and Central) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Kate Robertson Assistant Coroner for North Wales (East and Central) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive, Betsi Cadwaladr University Health Board 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 16 August 2024 an investigation was commenced into the death of Rory Colin Williams (DOB 18/7/1979) who died on 10 August 2024. The investigation concluded at the end of the inquest on 7 January 2025. The conclusion of the inquest was that death was due to natural causes. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are as follows :- Rory Colin Williams was referred to the Gastroenterology service at Ysbyty Glan Clwyd (part of the Betsi Cadwaladr University Local Health Board) on 22nd May 2023 by his General Practitioner under an urgent suspected cancer pathway due to suffering with symptoms of dysphagia and weight loss. Despite multiple attempts by the service to contact Mr Williams via telephone and written communications, Mr Williams did not attend an outpatient appointment scheduled for 17th August 2023. Mr Williams attended an initial endoscopy on 1st October 2023. This revealed severe oesophagitis. Mr Williams found it difficult to tolerate the procedure, however, and in view of this and the noted severe oesophagitis, it was recommended that the procedure be repeated on 18th November 2023. However, Mr Williams did not attend this appointment. A follow-up letter in December 2023 informed Mr Williams that due to his non-attendance he was being discharged back to his General Practitioner, but advised Mr Williams to arrange the repeated endoscopy if he wished to proceed with this. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | On 17th April 2024, Mr Williams re-engaged with healthcare services after presenting to the Emergency Department at Ysbyty Glan Clwyd with chest pain. Mr Williams was referred for an outpatient endoscopy. The endoscopy, conducted on 30th July 2024, identified adenocarcinoma. On 8th August 2024, Mr Williams was admitted to Ysbyty Glan Clwyd with severe abdominal pain and passed away on 10th August 2024, whilst still being cared for in hospital. 5 CORONER’S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern. 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 – It was accepted by the Health Board that there had been a delay between April 2024 and July 2024 in undertaking the endoscopy. Whilst this did not impact on the outcome for Rory Williams it did highlight a number of ongoing concerns with the gastroenterology / endoscopy service:- a. Staffing – the evidence at Inquest was that the Health Board was struggling to maintain this most basic service at Ysbyty Glan Clwyd due to staffing issues which included lack of consultants, endoscopists and other essential healthcare staff. There is currently only one full time equivalent consultant and 3 locums. The service is currently considered to be ‘absolutely dependent on locums’. It was noted that recruitment into gastroenterology is a challenge yet these issues have been ongoing for many considerable years, potentially since 2018. b. Infrastructure – evidence was heard that this requires significant investment and improvement within the service, and despite business cases having been made there have not been significant steps to improve this. It is not known why. c. The Health Board’s target for urgent suspected cancer referrals to endoscopy (that is from GP referral to endoscopy) is 21 days. Today, this stands at 8 weeks. d. The Health Board’s current wait time for urgent referrals (non-suspected cancer) to endoscopy is currently 89 weeks. This figure has increased since 2023. e. The Health Board’s current wait time for routine referrals to endoscopy is currently 148 weeks. This figure has increased since 2023. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | f. I am concerned that there is no fully networked service for endoscopy / gastroenterology where this and the above concerns do not appear on the corporate risk register. Whilst they appear on the local risk register it is extremely concerning that corporately it does not appear as a risk. Evidence was heard that at one point the risk score for the service was reduced from 25 to 20. The reason is not known. g. The overall impression is that the service is not fit for purpose and that all of these concerns, many of which have existed for several years, signify a risk of harm and death of patients into the future as a result. 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 10 March 2026. I, Kate Robertson, 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, Cabinet Secretary for Health and Social Care, 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 13 January 2026 Signature Assistant Coroner for North Wales (East and Central) Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 |
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Block 5, Carlton Court, St Asaph Business Park, St Asaph LL17 0JG ---------------------------------- Bloc 5 Llys Carlton Parc Busnes Llanelwy Llanelwy LL17 0JG Ms. Kate Robertson HM Assistant Coroner North Wales (East & Central) County Hall Wynnstay Road Ruthin LL15 1YN Dyddiad / Date: 5th March 2026 Dear Ms. Robertson, Inquest into the death of Rory Colin Williams I write on behalf of the Health Board in response to your Regulation 28 Report to Prevent Future Deaths, dated 13 January 2026, issued following the inquest touching the death of Mr Rory Colin Williams. At the outset, the Health Board wishes to express its sincere condolences to Mr Williams’ family and loved ones. We recognise the distress caused by his death and acknowledge the importance of the inquest process in providing answers, assurance and learning for families and organisations alike. The Health Board notes the conclusion of the inquest that Mr Williams’ death was due to natural causes, and that the matters identified during the course of the evidence did not impact upon the outcome for Mr Williams. Notwithstanding this, the Health Board recognises the significance of the wider systemic issues highlighted during the inquest and welcomes the opportunity to set out the actions taken and planned to reduce the risk of future harm to patients. Overview of Gastroenterology and Endoscopy Services Gastroenterology and endoscopy services across the Health Board operate within a challenging national and regional context, characterised by increasing demand, workforce shortages and infrastructure constraints. These pressures have been recognised within the organisation for some time and have been subject to ongoing clinical and executive oversight. In light of the concerns raised during the inquest, the Health Board has taken steps to ensure that these risks are reviewed collectively, at executive level, and addressed through a combination of immediate mitigation and longer‑term service development. 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 Workforce Capacity and Resilience The Health Board acknowledges the challenges associated with recruiting and retaining gastroenterology consultants and endoscopists, an issue experienced across the UK. In our Health Board, these challenges have affected service resilience, particularly at Ysbyty Glan Clwyd, where staffing gaps have necessitated reliance on locum support. Active recruitment to substantive posts continues across the Health Board with advertisements now being for the whole Health Board rather than individual sites to help strengthen resilience. In parallel, work is underway to develop more sustainable workforce models, including greater use of multidisciplinary roles, cross‑site working, and alternative pathways designed to reduce pressure on consultant capacity whilst maintaining patient safety. Capsule sponge endoscopy has been introduced at Wrexham Maelor; this is less invasive than endoscopy and can be used in certain diagnostic circumstances. This will be rolled out across the Health Board. Endoscopy Infrastructure and Diagnostic Capacity Infrastructure limitations within endoscopy services have been recognised as a contributing factor to prolonged waiting times for diagnostic procedures. As an immediate mitigating action, a temporary endoscopy unit has been established at Ysbyty Gwynedd, planned to be operational from mid-March 2026 for an anticipated period of approximately five months. This facility has been introduced to increase diagnostic capacity and is expected to enable the delivery of in excess of 1,500 additional endoscopy procedures, supporting patients who have been waiting longer than intended for investigation. We are also progressing whether further contracts for additional outsourcing activity are required for the new financial year. Alongside this, existing and previously submitted business cases relating to endoscopy and gastroenterology infrastructure are being reviewed collectively to ensure that future investment decisions are informed by current service risks and priorities. Waiting Times and Access to Care The Health Board recognises that current waiting times for endoscopy, including for urgent non‑suspected cancer and routine referrals, are longer than intended and have increased since 2023. The potential risks associated with prolonged waits are acknowledged, and reviewed within the Health Board quality governance processes. Actions underway to address this include the standardisation of referral and triage pathways across the Health Board, strengthened referral management (including the introduction of specialist nurse triage for all urgent cancer referrals) and prioritisation processes, whole‑system capacity and demand modelling, and interim capacity‑enhancing measures to improve access to care while longer‑term solutions are developed. The Health Board has been working closely with national colleagues over the last three months to ensure both clerical and clinical validation of those awaiting endoscopy. Over 1000 referrals have been reviewed and approx. 40% have been removed from the waiting list either because it is felt that scope was not clinically indicated or that a further review or test may help decide whether the scope, or a different form of treatment, was needed. This work will be continued and is pivotal in the design of effective referral pathways. Governance, Risk Management and Executive Oversight In response to a series of quality, performance and workforce concerns raised during 2024 and 2025, I convened a Rapid Quality Review of Gastroenterology Services on 13 February 2026. This review brought together executive leaders, hospital medical and operational directors, clinical directors and multidisciplinary representatives from across all three Integrated Health Communities. Its purpose was to identify current quality and safety risks, assess service resilience, and agree immediate and longer‑term actions to mitigate the risk of harm. As part of this work, the Health Board is reviewing the escalation and governance of gastroenterology‑related risks to ensure that they are appropriately reflected within local and corporate risk management arrangements and subject to ongoing executive oversight. Future Service Development The Health Board recognises that addressing the challenges within gastroenterology and endoscopy services requires a coordinated, Health Board‑wide approach. Work is therefore progressing on the development of an Integrated Digestive Disease Service, with shared clinical leadership, standardised pathways, coordinated workforce planning and strengthened governance. This programme of work is being taken forward under executive sponsorship, with follow‑up reviews scheduled to monitor progress and ensure delivery of agreed actions. Conclusion The Health Board remains committed to patient safety, learning and continuous improvement. The actions described in this response reflect the Health Board’s ongoing work to address the systemic risks highlighted during the inquest and to strengthen the resilience of gastroenterology and endoscopy services for the future. The Health Board recognises the importance of sustained collaboration between clinical teams, executive leaders and system partners in delivering these improvements, and remains committed to working openly and constructively to support safe, timely access to care for patients across North Wales. The Health Board hopes that this response provides assurance to the coroner, and to Mr Williams’ family, that the concerns identified have been carefully considered and are being addressed through clear governance, immediate mitigation and longer‑term service development. The Health Board remains willing to work with yourself and other partners should any further clarification, assurance or engagement be helpful. Yours sincerely Executive Medical Director Gyfarwyddwr Meddygol Gweithredol Cc , Chief Executive Director of Corporate Governance , Deputy Director for Legal Services
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