Rory Williams
13 Jan 2026 · Coroner Kate Robertson · North Wales (East and Central)
The coroner's concerns
1. delay in undertaking endoscopy
“It was accepted by the Health Board that there had been a delay between April 2024 and July 2024 in undertaking the endoscopy. Whilst this did not impact on the outcome for [the deceased] it did highlight a number of ongoing concerns with the gastroenterology / endoscopy service:-”
2. insufficient gastroenterology staffing
“Staffing - the evidence at Inquest was that the Health Board was struggling to maintain this most basic service at Ysbyty Glan Clwyd due to staffing issues which included lack of consultants, endoscopists and other essential healthcare staff. There is currently only one full time equivalent consultant and 3 locums. The service is currently considered to be 'absolutely dependent on locums'”
3. inadequate endoscopy infrastructure
“Infrastructure - evidence was heard that this requires significant investment and improvement within the service, and despite business cases having been made there have not been significant steps to improve this”
4. missed urgent cancer referral targets
“The Health Board's target for urgent suspected cancer referrals to endoscopy (that is from GP referral to endoscopy) is 21 days. Today, this stands at 8 weeks”
5. excessive wait for non‑urgent endoscopy
“The Health Board's current wait time for urgent referrals (non-suspected cancer) to endoscopy is currently 89 weeks. This figure has increased since 2023”
6. excessive wait for routine endoscopy
“The Health Board's current wait time for routine referrals to endoscopy is currently 148 weeks. This figure has increased since 2023”
7. lack of corporate risk register inclusion for endoscopy issues
“I am concerned that there is no fully networked service for endoscopy / gastroenterology where this and the above concerns do not appear on the corporate risk register. Whilst they appear on the local risk register it is extremely concerning that corporately it does not appear as a risk”
8. service unfit for purpose leading to future patient harm
“The overall impression is that the service is not fit for purpose and that all of these concerns, many of which have existed for several years, signify a risk of harm and death of patients into the future as a result”