Welsh Secretary calls for public inquiry into preventable deaths in north Wales

• A special report from ITV Wales' Joanne Gallacher and Daniel Bevan.

The Secretary of State for Wales, David TC Davies MP, has called for a public inquiry into preventable deaths in north Wales.

In a letter to Welsh Government health secretary Elenud Morgan, seen by ITV Wales, Mr Davies said: "Too many families in north Wales are being needlessly bereaved."

It comes after an ITV Cymru Wales investigation found Betsi Cadwaldr University Health Board had been handed 28 "prevention of future deaths reports" (PFD) over a 16-month period up to April 2024, 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. A PFD report being issued in a case does not necessary mean the death itself was preventable.

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".

In response to our findings, Ms Morgan previously told us: "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 section of Mr Davies' letter said: "I note that previously you have not supported calls for a public inquiry on the number of preventable deaths in north Wales, citing the number of preventable death notices in north Wales having not reached that threshold.

"I disagree. Too many families in north Wales are being needlessly bereaved; their loved ones would still be alive were it not for the board’s failings.

"I do not know what threshold you have in mind for calling a public inquiry. But I believethat by any impartial judgment the case for a public inquiry has long been met.

"I urge you to take decisive action and announce immediately a public inquiry into preventable deaths in north Wales. I stand ready to do all that I can to support such an inquiry."

A Welsh Government spokesperson confirmed they have received the letter and will response in due course.

• A special report from ITV Wales' Hamish Auskerry and Daniel Bevan.

Since our initial report, ITV Wales has been contacted by families whose loved ones' deaths were also the subject of prevention of future death notices.

They have told us since our investigation, they had received a letter from Besti Cadwaldr University Health Board's chief executive apologising for their experience and offering to meet with them.

The health board has now confirmed to us that they are contacting the families affected.

In a statement, Ms Shillabeer said: "We are reaching out to families of loved ones who have had a prevention of future death notice issued following the inquest into their death over the last year in particular.

"We want to apologise and offer them the opportunity to meet with us to discuss their experience. This will also provide us with the opportunity to share with them the work that is underway to improve the services and care we provide."

Speaking to us previously, 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."

• Betsi Cadwaladr University Health Board chief executive Carol Shillabeer responds.

A Welsh Government spokesperson said: "The number of prevention of future deaths reports received by Betsi Cadwaladr University Health Board is of significant concern. This is an area of real concern that the health board must address at pace.

"It has been made clear to the health board that it needs to put in place systems and process that ensures that it understands the root causes of the points raised by the coroners and that is able to address the systemic issues that are apparent in the reports.

"We have received assurances that the health board is taking this matter extremely seriously and that work is ongoing to identify and respond to the key themes and points of learning that the reports contain.

"Work is also underway to make service improvements that will prevent these issues from arising in the future.

"The health board has much to improve on and it is essential that they provide services with quality and patient safety at the centre of everything it does."

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