Health board failings exposed as bereaved families say 'our loved ones should still be alive'

North Wales' troubled health board is facing calls to be the subject of a public inquiry after 28 "prevention of future deaths reports" (PFD) were recorded over a 16-month period, more than the combined number handed to the other six Welsh health boards.

A special ITV Wales report reveals the scale of coroners' concerns about the care people received from Betsi Cadwaladr University Health Board (BCUHB) before their deaths, with a bereaved husband warning the recorded number of PFDs could be the "tip of the iceberg".

A PFD can be issued by a coroner if they have concerns about the circumstances in which someone died, and if it appears there is a risk of other deaths occurring.

Wales' seven health boards were handed a total of 46 PFDs from January 2023 to April this year, with Betsi Cadwaladr the recipient of 28 - four times the number of any other Welsh health board.

The Welsh Conservatives' Shadow North Wales Secretary has joined calls for the public inquiry.

Darren Millar MS said it would "build confidence back into the system" and help to make improvements to "long-standing issues that are not going away".

Pictures of Catherine Jones and Twm Bryn visible among 26 others whose deaths were subject to a prevention of future death notice. Credit: ITV Cymru Wales

Chief executive Carol Shillabeer has apologised to the families affected and admits they have been "let down", while the Welsh Government admits the high number is of "significant concern".

The troubled health board was placed into special measures in 2015, only to be controversially taken out in November 2020 by former health minister and current first minister, Vaughan Gething.

In February 2023, Mr Gething's successor in the health brief, Eluned Morgan, put the health board back into special measures following concerns being raised regarding the service delivery, quality and safety of care and organisational effectiveness.

Bereaved families have spoken exclusively to ITV Wales about their heartbreak at learning their loved ones' deaths were not inevitable and could have been prevented.

  • Catherine Jones

A coroner concluded that Catherine Jones' death was "avoidable" after she was wrongly given the all-clear from ovarian cancer. Credit: Family photo

Catherine Jones was a cardiology nurse for Betsi Cadwaladr University Health Board. Her career revolved around helping others.

In July 2013, she underwent surgery at Wrexham Maelor Hospital to remove an ovarian cyst.

A biopsy sample from the cyst should have been identified as borderline cancerous, which would have meant she would have been offered surgery to remove it and, together with other treatments, this should have been survivable.

Instead, she was wrongly given the all-clear.

In the summer of 2016, Catherine was rushed back to hospital. The cancer had spread and she died a few months later in November 2016 aged 35.

Coroner John Gittins concluded that her death was "avoidable".

Her widower David told ITV Wales: "Catherine worked as a nurse in the very board responsible for her wholly preventable death and failed her after her death in its conduct in the investigation into her death. That is inexcusable.

"It's profound. It's devastating. As I stepped through Catherine's medical records and came across information, a point where she'd been written up for an operation which never occurred, it was evident that, had that operation occurred, she would have been alive - words are not enough to describe the impact of that."

David Jones is calling for a public inquiry into the high number of preventable deaths in north Wales. Credit: ITV Cymru Wales

He continued: "Catherine was wonderful. It was a complete honour and privilege she chose to journey through her life with me.

"To see her suffer in the way that she suffered and to know that her death was avoidable has been horrendous for me and her family."

David says hearing his wife's death was preventable was "incredibly painful".

He said: "Although I expected it and believe that's the right finding based upon what I had to investigate for Catherine, when you actually hear it and it's spoken in a public arena it takes on a whole new dimension.

"It underlines the sheer gravity of the situation and how truly awful it is that Catherine lost her life unnecessarily."

  • Twm Bryn

Twm Bryn took his own life after being deemed a "mild risk of suicide, and no risk of harm to others" by mental health services. Credit: Family photo

Bethan Llwyd Jones remembers her late son Twm Bryn as a "cheeky" young man.

"He was always the little clown in the middle of everything," she remembers.

"He was always close to you but he would argue with his brother and sister because he wanted to be the boss.

"He was the life and soul of the family. Very sadly missed."

Twm presented to a GP in July 2021 having experienced low moods for a number of years, which escalated in the months leading up to his death after he was a victim of an unprovoked attack in the street.

He described the feeling of it "hitting him like a wall" when upset and angry, and at times, thoughts of wanting to harm himself and occasional suicidal thoughts.

He spoke with a GP over the phone and his appointment with the mental health team was not until 40 days after the initial referral, nearly two weeks after the target time of 28 days.

After being seen by local primary mental health support service (LPMHSS), he was deemed a "mild risk of suicide and no risk of harm to others" and was due to be offered counselling.

Twm took his own life on October 4, 2021 - days after his 21st birthday.

Twm's mother believes he was "let down" by Betsi Cadwaladr University Health Board. Credit: ITV Cymru Wales

Bethan said: "Twm had been struggling with his mental health for some time, not that we actually realised to what extent.

"In the last few months of his life he was attacked in Pwllheli and that did have a tremendous impact on him.

"As a family we were trying to get him help and because he was considered an adult he had to self-refer which he did eventually.

"The doctor referred him to the mental health team. Unfortunately he didn't get the right level of care and Twm lost his battle."

Bethan has decided to share her experience despite the fact she herself works for Betsi Cadwaldr University Health Board as a nurse in a minor injury unit. She believes Twm was "let down" by her health board colleagues.

She said: "Definitely, Twm was let down. There is so much research about young lads and depression and suicide. Surely that would have rung a bell in any referral.

"As nurses we are there to do the best for our patients. Every treatment should be a holistic one. It's not a tick-box exercise. Every patient should be given that time to be assessed and if needed reassessed.

"So I do feel one of my colleagues had let Twm down."

Following the inquest into Twm's death, coroner Sarah Riley raised concerns about the continued staffing pressures within mental health services, resulting in assessment delays and waiting lists for support.

At the time, the waiting list for LPMHSS was between four to six months. Coroner Riley said there was "no evidence" this would improve.

Twm's death was ruled to have been preventable and a PFD was issued.

"To be honest, I didn't quite grasp the implication of that," said Bethan. "I did know there had been so many mistakes in Twm's referral that it did have an impact on his care.

"But I didn't realise how many other people [this affected].

"I already knew [Twm's death was preventable], so for it to actually be confirmed it was such a shock that I was right, that Twm was not given the right level of care.

"I felt guilty because I pushed him and steered him towards getting professional help because as a family we felt like he needed it.

"I couldn't provide him with the right safety net and for me to push and steer him towards that help, only for him to be let down - it made me feel guilty."

  • 'The tip of the iceberg'

But Twm and Catherine's families are not alone. In fact, for many, their experiences are an all too familiar tale.

Twm Bryn, Catherine Jones, Thomas Ithell, Emily Corfield, Leonard Harmsworth, Nancy 'Lyn' Price, Effion Huws and Margret Kelly (L-R). Credit: Family Photos

Coroners in north Wales have raised concerns about the care someone has received from the health board before they died in 28 cases since the start of 2023.

The next highest number was handed to both Swansea Bay and Aneurin Bevan University Health Boards, with seven each.

Cardiff and Vale University Health Board have been given three over the last 16 months and Cwm Taf Morgannwg have received one.

Both Hywel Dda University Health Board and Powys Teaching Health Board haven’t received any in that timeframe.

Betsi Cadwaladr have been issued with more PDFs than all other Welsh health boards combined between January 2023 and April 2024. Credit: ITV Cymru Wales

Sitting in front of a photo of his late wife Catherine, along with 27 other pictures and silhouettes to represent all those who unnecessarily died in north Wales since early 2023, David Jones said: "To see Catherine amongst so many others who have lost their lives, and those deaths were wholly avoidable, is truly shocking.

"It's completely alarming and I think underlines why urgent action is required.

"The health board did not report any concerns to the coroner in relation to Catherine's death.

"It was the coroner, who kindly took a call from me when I wouldn't accept her death certificate and he then initiated an inquest. That is how we began the investigations into Catherine's care.

"Therefore, when I see the number of people along with Catherine who have lost their lives, there are potentially so many others affected.

"It's representative of a significant injustice which can't be tolerated any longer."

Having fought for an inquest into his wife's death, David believes the 28 PFDs represent just "the tip of the iceberg".

When asked how he feels hearing Betsi Cadwaladr have been issued with more PFDs than any other health board, David said he was "deeply concerned for the people of north Wales.

"Not only have they had more 'prevention of future death reports' but the issues raised about Betsi Cadwaladr University Health Board extend many, many years.

"We have a concern here about just how long this has been occurring for and how many 'prevention of future death reports' have been raised in north Wales.

"I'm very concerned this is only the tip of the iceberg."

Both David and Bethan say the health board has not been in touch with them since the conclusion of their loved ones' inquests.

  • What is a "prevention of future death report"?

Coroners can make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths.

The recipient must then reply within 56 days to say what action they plan to take.

It is not a coroner’s role to make recommendations. Instead they draw attention to the risk so others can consider how it should be addressed.

Any body issued with a PFD report has six months to respond to a coroner's concerns.

Both the reports and responses have been published online for more than a decade in an effort to ensure lessons are learned and steps are taken to reduce the risk of future harm.

However, once a coroner issues a PFD report their judicial role is at an end. They have no statutory authority to follow-up or otherwise enforce a PFD report.

  • Calls for a public inquiry

David Jones believes there are "critical" failings which allow the changes promised by health boards to go unchecked.

He is now calling for a public inquiry into the high number of preventable deaths in north Wales which he hopes will highlight mistakes which can be prevented.

He said: "There appears to be no closed loop check to see what has or hasn't happened. Once a response has been received [from the health board] that is the end of the matter. That doesn't seem good enough."

The Welsh Conservatives have joined calls for a public inquiry, with the Shadow Health Minister Darren Millar MS saying it would improve trust in the health board.

"The fact that they're such an outlier means there are some serious governance failings in the health board that need to be got to grips with", he told ITV Wales.

"Given that special measures aren't working, the answer is to have an independent public inquiry to shine a light on the problems in the health board and try to understand why it's not learning the lessons from what's been going wrong in order to make some clear recommendations to put those right in the future".

In a letter to Prime Minister Rishi Sunak, seen by ITV Wales, David Jones has also asked for the UK Government to take control of Betsi Cadwaladr University Health Board to eliminate preventable deaths.

He has also called on the prime minister to "implement a framework to compel and enforce healthcare policy and regulation in Wales".

He says he is yet to receive a reply from Downing Street.

  • What has the health board said?

We sat down with Carol Shillabeer, the chief executive of BCUHB, to put directly to her the concerns Catherine and Twm's families have shared with us.

She apologised for their experiences.

Speaking about the high number of PFD reports the health board has received, Ms Shillabeer said: "I can't make a comment on the different parts of Wales and the coroners' approach to that.

"What I can say is, when I spoke with coroners in north Wales, their drive to see improvement is really strong and that's a drive that we share.

"The key thing for me is what are we doing to overall improve the health board. Clearly, the health board is in special measures and it has been in and out of special measure for 10 years.

"There is an opportunity to make progress now but I do say there's a long way to go."

We also asked Ms Shillabeer why the families had not been contacted since the inquests, and about the internal investigations the health board had conducted.

She said: "We're trying to change the way we work going forward, that we work with people and not, what might be perceived as, some 'dark room over there'.

"We have to open ourselves up to talking about difficult circumstances with people who at times, let's be honest, we've let them down.

"It's a change of culture as well as a change of process. It's quite a big change for an organisation which has been so troubled."

  • What is the Welsh Government saying?

Eluned Morgan, the Welsh Government's health secretary, did not back calls for a public inquiry into the number of preventable deaths in north Wales, but did say she was "deeply worried" by the figures.

She said: "This is an issue I have discussed directly with the chair. Most of those were issued before they were placed into special measures but that's not an excuse.

"The key thing is you have to learn from [PFDs]. So, one of the things I've asked [the health board] to do is to make sure they are putting the learning in place from any recommendation from the coroners.

"If there was good reason to [have a public inquiry], of course I would consider that but at the moment I don't think it's reached that threshold."

A Welsh Government spokesperson said: "The number of prevention of future deaths reports received by Betsi Cadwaladr University Health Board is of significant concern.

"It must put robust systems and processes in place and show it both understands the root causes of the issues raised by the coroners and that it can address the systemic issues apparent in the reports.

"The health board has much to improve but work is underway. It is essential all services have quality and patient safety at their core."

Worried about mental health?


Mind is a mental health charity which promotes the views and needs of people with mental health issues.

It provides advice and support to empower anyone experiencing a mental health problem, and campaigns to improve services, raise awareness and promote understanding.

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CALM, or the Campaign Against Living Miserably, runs a free and confidential helpline and webchat – open from 5pm to midnight every day, for anyone who needs to talk about life’s problems.It also supports those bereaved by suicide, through the Support After Suicide Partnership (SASP).

  • Phone their helpline: 0800 585858 (Daily, 5pm to midnight)

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For practical, confidential suicide prevention help and advice you can contact PAPYRUS HOPELINEUK on 0800 068 4141, text 07860 039967 or email pat@papyrus-uk.org

Suicide is the biggest killer of young people in the UK. PAPYRUS aims to reduce the number of young people who take their own lives by breaking down the stigma around suicide and equipping people with the skills to recognise and respond to suicidal behaviour.

HOPELINEUK is the charity’s confidential helpline service providing practical advice and support to young people with thoughts of suicide and anyone concerned about a young person who may have thoughts of suicide.

HOPELINEUK is staffed by trained professionals, offering a telephone, text and email service.

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Samaritans is an organisation offering confidential support for people experiencing feelings of distress or despair.

  • Phone 116 123 (a free 24 hour helpline)

  • Email: jo@samaritans.org

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YoungMinds is a resource with information on child and adolescent mental health, but also offers services for parents and professionals.

It is the UK’s leading charity fighting for children and young people's mental health, and wants to make sure all young people can get the mental health support they need, when they need it

  • YoungMinds Textline - Text YM to 85258

  • Phone Parents' helpline 0808 802 5544 (Monday to Friday, 9.30am - 4pm)

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The Martin Gallier Project

The Martin Gallier Project are a Wirral-based charity dedicated to helping individuals and families across the North West of England.

They were the UK's first Suicide Prevention, Intervention and Postvention charity. The project offers non clinical suicide interventions on the high street, with no barriers to access, waiting list or criteria.

The service is open 7 days a week 9.30am-4.30pm - lines and emails are only monitored during these hours.

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