THE death of a man at Ysbyty Glan Clwyd “would probably not have occurred when it did” had opportunities to provide treatment in hospital to him not been “missed”, an inquest ruled.

Philip Martin Evans died at the Bodelwyddan hospital on July 26, 2023 at the age of 38.

Following a full inquest into his death, coroner Kate Robertson recorded a narrative conclusion, and has issued Betsi Cadwaladr University Health Board (BCUHB) with a Prevention of Future Deaths (PFD) report.

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On the date of his death, Mr Evans had been conveyed to Glan Clwyd by a police officer who had attended his home following reports of concern for his safety.

Mr Evans went into cardiac arrest at 3.07pm, and was transferred to the hospital’s intensive care unit, but died later that day.

BCUHB’s own investigation into his death, including a review of his previous mental health care and treatment, found no concerns regarding his care while in the hospital’s emergency department (ED).

But a second review of the ED’s care and treatment of Mr Evans, completed on July 10 (eight days prior to the inquest into Mr Evans’ death), did identify omissions in this regard.

In her PFD report, Ms Robertson, assistant coroner for North Wales (East and Central), expressed concern regarding the “quality, effectiveness and timeliness” of BCUHB’s investigations.

This, she said, “means that issues or concerns with care and treatment are not being identified, either at all or quickly enough, in order to put in place additional measures or learning to prevent deaths in similar circumstances”.

Ms Robertson added: “I have issued several reports pertaining to this very point over a long period, and yet the same concerns remain.

“At hospital, there were missed opportunities to provide treatment which would probably have afforded time to consider and initiate additional treatment options, to the extent that death would probably then have not occurred when it did.”

BCUHB has until September 16 to issue its response to Ms Robertson’s PFD report, detailing action taken or planned to be taken, as well as the timetable for proposed action.

Otherwise, the health board must explain why no action is proposed.