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recurance

Catherine Jones

8 Dec 2023 · Coroner John Gittins · North Wales East and Central

The coroner's concerns

  1. 1. lack of documented approved system of work for surgery

    “for many departments within the health board, surgery was conducted on the basis of "pooled lists" and although evidence was given that the common practice of one of the surgeons was to ensure that they had some form of communication with the patient's consultant prior to surgery (by phone and/or email), there was no evidence that this practice was part of an approved system of work which was documented within the health board's protocols”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Catherine Jones · Recurance