Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of strategic governance hindering incident identification
The earlier warning
Lynsey Smalley · 8 Sept 2023 · Kate Robertson, North West Wales
“It is clear that there was no strategic plan or collaboration in governance processes.”
judiciary.uk/…/lynsey-smalley-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Lynsey Smalley (8 Sept 2023) · stated timescale: April 2024
“The Health Board is now fully reviewing the incident process to identify where it can be improved and strengthened. A workshop was held on the 23rd October 2023 to identify current issues and to begin the work of revising our process. The concerns you have identified in this notice, and in other notices, are being directly fed into this work.”
judiciary.uk/…/2023-0322-Response-from-Betsi-Cadwaladr-Universi…
What recurred
- 12 May 2025 · Kenneth Foster · Graeme Irvine · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Lynsey Smalley · 8 Sept 2023
“It is clear that there was no strategic plan or collaboration in governance processes.”
Later · Kenneth Foster · 12 May 2025
“A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework.”
What happened next
No web check of the stated actions has been published for this chain.