Betsi Cadwaladr: North Wales healthcare a 'national scandal' amid calls for UK Government to step in

The parents of a nine-month old baby from Flint who died when his meningitis was misdiagnosed as tonsillitis at Ysbyty Glan Clwyd says they fear Betsi Cadwaladr Health Board (BCUHB) are not learning from their mistakes.

It comes as Conservative MPs in north Wales have written a letter, seen exclusively by ITV Cymru Wales, to the health secretary in Westminster describing healthcare in the region as "third world" and "a national scandal".

Carol Shillabeer, Chief Executive of Betsi Cadwaladr University Health Board, has apologised to the Munslow family and offered to meet with them to discuss their concerns.

The Welsh Government says it "will continue to support the health board and all its dedicated NHS staff as it works to improve care and services for people across north Wales."

Last month, ITV Wales revealed BCUHB were 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 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.

Calls for a independent inquiry have grown since our initial report, with the Prime Minister, the Secretary of State for Health and the Welsh Conservatives joining bereaved family's voices who want the health board to be investigated.

  • Lucas Munslow

On the evening of May 17 2019, Kim and Nathan Munslow, from Flint, took their nine month old son, Lucas, to the A+E at Ysbyty Glan Clwyd after he developed a high temperature and a squint in his eyes.

After a four hour wait at the paediatric ward and having been seen by a nurse, who observed Lucas having a "vacant episode", he was discharged by doctors who diagnosed tonsillitis and prescribed a sore throat spray.

But he was actually suffering from bacterial meningitis, an infection of the protective membranes that surround the brain and spinal cord.

The NHS website states that "meningitis can be very serious if not treated quickly. It can cause life-threatening sepsis and result in permanent damage to the brain or nerves."

The following evening, Lucas suffered a seizure. He died in his mother's arms.

It's been nearly five years since the traumatic loss of their son but Kim says the pain never goes away.

A senior north Wales coroner did not issue a prevention of future death notice in Lucas' case but did say it was "probable" his death could have been prevented.

"A Godsend", Kim says when asked to describe her son.

"A joy to everyone, whoever met him. He's with us no matter what.", Nathan agrees.

ITV Wales' Rob Shelley asked them if they believe BCUHB are are learning from their mistakes.

Lucas Munslow was described as a "Godsend" by mum Kim and dad Nathan. Credit: Family photo

"No", Kim replied. "Because it keeps happening again and again. Obviously they are not learning their lessons if it's reoccurring."

Kim and Nathan say the health board have never directly apologised to them, only sending statements to the press and speaking through their solicitor at the inquest.

BCUHB have since told us they will make contact with the Munslows.

Carol Shillabeer, Chief Executive at Betsi Cadwaladr University Health Board, said: “I would like to offer my sincere and heartfelt condolences to Lucas’ parents and wider family.

“I can only imagine how heart-breaking this experience has been and I am very sorry if the health board has added to the distress through its subsequent handling and communication with the family.

“I would like to reach out to the family to hear directly about their experience and to share with them the work that is underway to improve the services and care the health board provides.”

  • 'A national scandal'

In a letter seen by ITV Cymru Wales written to the Secretary of State for Health and Social Care, Victoria Atkins MP, Conservative Party MPs in north Wales say healthcare in the BCUHB area "constitutes a national scandal" and described it as "a third world service".

Signatories Sarah Atherton, Virginia Crosbie, David Jones, Simon Baynes, Dr James Davies, and Robin Millar said they had "extreme concern over the safety of NHS services in our region."

A section of the letter reads: "It is difficult to express quite how awful in nature the stories that we receive can be, but we believe it is no exaggeration to liken them to those that might emerge from a third world service."

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

It continues: "It is our strong view that what has been taking place within the NHS in North Wales for over a decade constitutes a national scandal at least as significant as others previously exposed within the NHS elsewhere in Britain."

Ms Atkins responded to the letter, saying: "I know that my colleague, the Secretary of State for Wales, previously called for an independent inquiry into Betsi Cadwaladr University Health Board so that the well-known and significant issues in North Wales can be rectified and people can access the healthcare that they expect and deserve. I support this call."

Three of the MPs, Dr James Davies, David Jones and Robin Millar, have met with Health Secretary Victoria Aktins in Westminster to discuss their concerns today.

Health is a devolved portfolio, meaning the Welsh Government is responsible for the NHS in Wales.

Speaking after the meeting, Dr James Davies, who represents the Vale of Clwyd in Westminster as well as being a GP, told ITV Wales: "Health has been devolved in Wales for 25 years but when I hear from my constituents with really quite appalling stories they say that they are British citizens and [ask] 'what it is the UK Government going to do?'

"At the moment we are seeing people who are being let down and waiting times that are quite awful in so many places.

"You see the consequences of that broken system when look at the prevention of future death reports."

BCUHB CEO, Carol Shillabeer, told ITV Wales that she does not think the MPs comments in their letter are "a fair overall assessment" of the health board.

  • Rishi Sunak responds

Our original investigation featured the story of David Jones, whose wife Catherine died after wrongly being given the all-clear from cancer.

In the summer of 2016, Catherine, who was a nurse at BCUHB, was rushed back to hospital. The cancer had spread and she died a few months later in November 2016 aged 35. A coroner concluded that her death was "avoidable".

Since Catherine's death, David has been desperate to get answers as to how her care went so wrong to ensure other families don't have to endure the same pain.

David told ITV Wales he fears the 28 prevention of future death notices represent "the tip of the iceberg" of the health board's failings.

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

He wrote to the Prime minister asking for an inquiry into Betsi Cadwaladr University Health Board and for the UK Government to take control of the organisation to eliminate preventable deaths.

David also called on the PM to "implement a framework to compel and enforce healthcare policy and regulation in Wales".

Responding to David's concerns, Rishi Sunak said: "I am aware of ongoing concerns about the Betsi Cadwaladr University Health Board.

"It is deeply worrying that it has been placed under special measures so frequently and I have expressed my support for a proper investigation into what has gone wrong. Too many families... have sadly been impacted."

Previously, Eluned Morgan, the Welsh Government's health secretary, did not back calls for a public inquiry into the number of prevention of future death notices in north Wales, saying it had not "reached that threshold".

She said: "[PFDs] 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."

  • Carol Shillabeer: MPs letter "not a fair assessment"

ITV Wales' Joanne Gallacher put the content of the letter from Conservative MPs to the CEO of BCUHB when we sat down with her on April 18.

Ms Shillabeer said: "I don't think it's a fair overall assessment at all. I'm still relatively new here but I get out and about to learn about the services that are provided day in, day out.

"For example, the most fantastic prehab centre in Wrexham for people about to undergo some really high intensity surgery. The outcomes there are better, the care is really positive.

"The services we provide to the people who have mobility and posture issues, I met some of those service users more recently. The groundbreaking work we're doing with artificial intelligence to diagnose cancers in urology and breast services and soon to be gastrointestinal.

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

"It's really important to get across that there are some excellent services here. Some of them are leading Wales and in the UK.

"But there have been cases, of course. We talk about the 23 prevention of future death notices [in 2013] and the years preceding that, where things have not gone well and the standard hasn't been met.

"That is something that is pushing us forward. Improvements have to be made and that is what we're getting on and doing. We can see the early signs of the organisation starting to improve.

"But they are early signs. There is some way to go yet."

A Welsh Government spokesperson said: “The Health Secretary has expressed her deep concern about the number of prevention of future deaths notices issued to Betsi Cadwaladr University Health Board.

“She has made it clear to the health board that it must address the systemic issues raised in these reports.

"We will continue to support the health board and all its dedicated NHS staff as it works to improve care and services for people across north Wales."

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