Vivienne Greener
18 Dec 2023 · Coroner David Pojur · North Wales East and Central
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. out of hours emergency endoscopy unavailable
“An out of hours emergency endoscopy is still not available at Clan Clwyd Hospital or in this area of North Wales as the provision has 'collapsed' at Wrexham Maelor Hospital, so no referrals can be made”
2. insufficient doctors nurses and space
“There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department”
3. ineffective triage and record
“There is an ineffective triage and record of triage of patients arriving at Glan Clwyd Emergency Department by ambulance”
4. unclear Emergency Treatment Team activation
“There is not a clear understanding of when the Emergency Treatment Team should be called”
5. unclear Major Haemorrhage Pathway activation
“There is not a clear understanding of when the Major Haemorrhage Pathway should be engaged”
6. outdated Upper GI Bleeding guidance
“The Health Board's Upper GI Bleeding Management and Principles of Care 2022 is no longer fit for purpose”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The Emergency department staff gave evidence that they regularly have too many patients in the department and cannot find space to safely allow ambulances to transfer patients into their care and then leave.”
This report
“There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department”