Coroner describes north Wales hospital service as ‘not fit for purpose’

Richard Evans, Local Democracy Reporter

A coroner highlighted serious concerns about a service based at a north Wales hospital after an inquest into a man’s death.

A prevention of future deaths report was sent to Betsi Cadwaladr University Health Board earlier this year following the death of Rory Colin Williams, aged 45.

The report, from assistant coroner for North Wales East and Central Kate Robertson, highlighted “severe workforce shortages” and “substantially extended waiting times” in gastroenterology and endoscopy services at Ysbyty Glan Clwyd.

The coroner said the service was “unfit for purpose”.

Betsi Cadwaladr University Health Board’s board members are set to meet tomorrow (Thursday) at Llandudno’s Venue Cymru for its quarterly meeting.

As part of the proceedings, the members will discuss an “integrated quality report”.

Listed under this report is a section on healthcare law, documenting concerns highlighted by the assistant coroner.

Mr Williams passed away in August 2024, having been referred urgently for suspected cancer by his GP in May 2023.

But a series of missed appointments and communication difficulties led to his discharge from the specialist service in late 2023.

After re-presenting to the emergency department with chest pain in April 2024, a delayed endoscopy finally confirmed he had cancer in July 2024.

But tragically, Mr Williams was admitted with severe abdominal pain just over a week later and died in the hospital shortly after his diagnosis.

While the coroner revealed the death was due to “natural causes”, the report has highlighted concerns at Glan Clwyd.

The NHS report stated: “A Prevention of Future Deaths report has been issued by the Assistant Coroner for North Wales (East and Central) following the inquest into the death of a patient who died in August 2024 from natural causes.

“While the Coroner concluded that delays in endoscopy between April and July 2024 did not affect the outcome for the deceased, the inquest identified significant and longstanding systemic concerns within the gastroenterology and endoscopy service at Ysbyty Glan Clwyd.”

‘Workforce shortages’

The report went on: “These include severe workforce shortages with heavy reliance on locum staff, inadequate infrastructure investment despite previous business cases, and substantially extended waiting times against national targets for urgent suspected cancer, urgent non‑cancer, and routine referrals.

“The coroner further expressed concern that these risks are not adequately reflected on the corporate risk register and concluded that the service is not currently fit for purpose, presenting an ongoing risk of harm to patients unless action is taken.”

The NHS report concluded that the Executive Medical Director has held a Health Board wide Gastroenterology Rapid Quality Review in February this year, to identify key areas of concerns and to prioritise actions.

The Health Board, which has been in special measures for over a decade, says it has submitted a formal response this month (5 March, 2026) to the Assistant Coroner, outlining actions it has taken.

Betsi Cadwaladr University Health Board board members will meet at Llandudno’s Venue Cymru tomorrow (Thursday, March 26).