Betsi Cadwaladr University Health Board
NHS / Health Body
Action Planned
Betsi Cadwaladr University Health Board is progressing work on developing an Integrated Digestive Disease Service, with shared clinical leadership, standardised pathways, coordinated workforce planning and strengthened governance, under executive sponsorship. (AI summary)
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Dear Ms. Robertson,
Inquest into the death of Rory Colin Williams
I write on behalf of the Health Board in response to your Regulation 28 Report to Prevent Future Deaths, dated 13 January 2026, issued following the inquest touching the death of Mr Rory Colin Williams.
At the outset, the Health Board wishes to express its sincere condolences to Mr Williams’ family and loved ones. We recognise the distress caused by his death and acknowledge the importance of the inquest process in providing answers, assurance and learning for families and organisations alike.
The Health Board notes the conclusion of the inquest that Mr Williams’ death was due to natural causes, and that the matters identified during the course of the evidence did not impact upon the outcome for Mr Williams. Notwithstanding this, the Health Board recognises the significance of the wider systemic issues highlighted during the inquest and welcomes the opportunity to set out the actions taken and planned to reduce the risk of future harm to patients.
Overview of Gastroenterology and Endoscopy Services
Gastroenterology and endoscopy services across the Health Board operate within a challenging national and regional context, characterised by increasing demand, workforce shortages and infrastructure constraints. These pressures have been recognised within the organisation for some time and have been subject to ongoing clinical and executive oversight.
In light of the concerns raised during the inquest, the Health Board has taken steps to ensure that these risks are reviewed collectively, at executive level, and addressed through a combination of immediate mitigation and longer‑term service development.
Dyddiad / Date: 5th March 2026 Ms. Kate Robertson HM Assistant Coroner North Wales (East & Central) County Hall Wynnstay Road Ruthin LL15 1YN Block 5, Carlton Court, St Asaph Business Park, St Asaph LL17 0JG
---------------------------------- Bloc 5 Llys Carlton Parc Busnes Llanelwy Llanelwy LL17 0JG
Workforce Capacity and Resilience
The Health Board acknowledges the challenges associated with recruiting and retaining gastroenterology consultants and endoscopists, an issue experienced across the UK. In our Health Board, these challenges have affected service resilience, particularly at Ysbyty Glan Clwyd, where staffing gaps have necessitated reliance on locum support.
Active recruitment to substantive posts continues across the Health Board with advertisements now being for the whole Health Board rather than individual sites to help strengthen resilience. In parallel, work is underway to develop more sustainable workforce models, including greater use of multidisciplinary roles, cross‑site working, and alternative pathways designed to reduce pressure on consultant capacity whilst maintaining patient safety. Capsule sponge endoscopy has been introduced at Wrexham Maelor; this is less invasive than endoscopy and can be used in certain diagnostic circumstances. This will be rolled out across the Health Board.
Endoscopy Infrastructure and Diagnostic Capacity
Infrastructure limitations within endoscopy services have been recognised as a contributing factor to prolonged waiting times for diagnostic procedures.
As an immediate mitigating action, a temporary endoscopy unit has been established at Ysbyty Gwynedd, planned to be operational from mid-March 2026 for an anticipated period of approximately five months. This facility has been introduced to increase diagnostic capacity and is expected to enable the delivery of in excess of 1,500 additional endoscopy procedures, supporting patients who have been waiting longer than intended for investigation. We are also progressing whether further contracts for additional outsourcing activity are required for the new financial year.
Alongside this, existing and previously submitted business cases relating to endoscopy and gastroenterology infrastructure are being reviewed collectively to ensure that future investment decisions are informed by current service risks and priorities.
Waiting Times and Access to Care
The Health Board recognises that current waiting times for endoscopy, including for urgent non‑suspected cancer and routine referrals, are longer than intended and have increased since 2023. The potential risks associated with prolonged waits are acknowledged, and reviewed within the Health Board quality governance processes.
Actions underway to address this include the standardisation of referral and triage pathways across the Health Board, strengthened referral management (including the introduction of specialist nurse triage for all urgent cancer referrals) and prioritisation processes, whole‑system capacity and demand modelling, and interim capacity‑enhancing measures to improve access to care while longer‑term solutions are developed.
The Health Board has been working closely with national colleagues over the last three months to ensure both clerical and clinical validation of those awaiting endoscopy. Over 1000 referrals have been reviewed and approx. 40% have been removed from the waiting list either because it is felt that scope was not clinically indicated or that a further review or test may help decide whether the scope, or a different form of treatment, was needed. This work will be continued and is pivotal in the design of effective referral pathways.
Governance, Risk Management and Executive Oversight
In response to a series of quality, performance and workforce concerns raised during 2024 and 2025, I convened a Rapid Quality Review of Gastroenterology Services on 13 February
2026.
This review brought together executive leaders, hospital medical and operational directors, clinical directors and multidisciplinary representatives from across all three Integrated Health Communities. Its purpose was to identify current quality and safety risks, assess service resilience, and agree immediate and longer‑term actions to mitigate the risk of harm.
As part of this work, the Health Board is reviewing the escalation and governance of gastroenterology‑related risks to ensure that they are appropriately reflected within local and corporate risk management arrangements and subject to ongoing executive oversight.
Future Service Development
The Health Board recognises that addressing the challenges within gastroenterology and endoscopy services requires a coordinated, Health Board‑wide approach.
Work is therefore progressing on the development of an Integrated Digestive Disease Service, with shared clinical leadership, standardised pathways, coordinated workforce planning and strengthened governance. This programme of work is being taken forward under executive sponsorship, with follow‑up reviews scheduled to monitor progress and ensure delivery of agreed actions.
Conclusion
The Health Board remains committed to patient safety, learning and continuous improvement. The actions described in this response reflect the Health Board’s ongoing work to address the systemic risks highlighted during the inquest and to strengthen the resilience of gastroenterology and endoscopy services for the future.
The Health Board recognises the importance of sustained collaboration between clinical teams, executive leaders and system partners in delivering these improvements, and remains committed to working openly and constructively to support safe, timely access to care for patients across North Wales.
The Health Board hopes that this response provides assurance to the coroner, and to Mr Williams’ family, that the concerns identified have been carefully considered and are being addressed through clear governance, immediate mitigation and longer‑term service development.
The Health Board remains willing to work with yourself and other partners should any further clarification, assurance or engagement be helpful.
Inquest into the death of Rory Colin Williams
I write on behalf of the Health Board in response to your Regulation 28 Report to Prevent Future Deaths, dated 13 January 2026, issued following the inquest touching the death of Mr Rory Colin Williams.
At the outset, the Health Board wishes to express its sincere condolences to Mr Williams’ family and loved ones. We recognise the distress caused by his death and acknowledge the importance of the inquest process in providing answers, assurance and learning for families and organisations alike.
The Health Board notes the conclusion of the inquest that Mr Williams’ death was due to natural causes, and that the matters identified during the course of the evidence did not impact upon the outcome for Mr Williams. Notwithstanding this, the Health Board recognises the significance of the wider systemic issues highlighted during the inquest and welcomes the opportunity to set out the actions taken and planned to reduce the risk of future harm to patients.
Overview of Gastroenterology and Endoscopy Services
Gastroenterology and endoscopy services across the Health Board operate within a challenging national and regional context, characterised by increasing demand, workforce shortages and infrastructure constraints. These pressures have been recognised within the organisation for some time and have been subject to ongoing clinical and executive oversight.
In light of the concerns raised during the inquest, the Health Board has taken steps to ensure that these risks are reviewed collectively, at executive level, and addressed through a combination of immediate mitigation and longer‑term service development.
Dyddiad / Date: 5th March 2026 Ms. Kate Robertson HM Assistant Coroner North Wales (East & Central) County Hall Wynnstay Road Ruthin LL15 1YN Block 5, Carlton Court, St Asaph Business Park, St Asaph LL17 0JG
---------------------------------- Bloc 5 Llys Carlton Parc Busnes Llanelwy Llanelwy LL17 0JG
Workforce Capacity and Resilience
The Health Board acknowledges the challenges associated with recruiting and retaining gastroenterology consultants and endoscopists, an issue experienced across the UK. In our Health Board, these challenges have affected service resilience, particularly at Ysbyty Glan Clwyd, where staffing gaps have necessitated reliance on locum support.
Active recruitment to substantive posts continues across the Health Board with advertisements now being for the whole Health Board rather than individual sites to help strengthen resilience. In parallel, work is underway to develop more sustainable workforce models, including greater use of multidisciplinary roles, cross‑site working, and alternative pathways designed to reduce pressure on consultant capacity whilst maintaining patient safety. Capsule sponge endoscopy has been introduced at Wrexham Maelor; this is less invasive than endoscopy and can be used in certain diagnostic circumstances. This will be rolled out across the Health Board.
Endoscopy Infrastructure and Diagnostic Capacity
Infrastructure limitations within endoscopy services have been recognised as a contributing factor to prolonged waiting times for diagnostic procedures.
As an immediate mitigating action, a temporary endoscopy unit has been established at Ysbyty Gwynedd, planned to be operational from mid-March 2026 for an anticipated period of approximately five months. This facility has been introduced to increase diagnostic capacity and is expected to enable the delivery of in excess of 1,500 additional endoscopy procedures, supporting patients who have been waiting longer than intended for investigation. We are also progressing whether further contracts for additional outsourcing activity are required for the new financial year.
Alongside this, existing and previously submitted business cases relating to endoscopy and gastroenterology infrastructure are being reviewed collectively to ensure that future investment decisions are informed by current service risks and priorities.
Waiting Times and Access to Care
The Health Board recognises that current waiting times for endoscopy, including for urgent non‑suspected cancer and routine referrals, are longer than intended and have increased since 2023. The potential risks associated with prolonged waits are acknowledged, and reviewed within the Health Board quality governance processes.
Actions underway to address this include the standardisation of referral and triage pathways across the Health Board, strengthened referral management (including the introduction of specialist nurse triage for all urgent cancer referrals) and prioritisation processes, whole‑system capacity and demand modelling, and interim capacity‑enhancing measures to improve access to care while longer‑term solutions are developed.
The Health Board has been working closely with national colleagues over the last three months to ensure both clerical and clinical validation of those awaiting endoscopy. Over 1000 referrals have been reviewed and approx. 40% have been removed from the waiting list either because it is felt that scope was not clinically indicated or that a further review or test may help decide whether the scope, or a different form of treatment, was needed. This work will be continued and is pivotal in the design of effective referral pathways.
Governance, Risk Management and Executive Oversight
In response to a series of quality, performance and workforce concerns raised during 2024 and 2025, I convened a Rapid Quality Review of Gastroenterology Services on 13 February
2026.
This review brought together executive leaders, hospital medical and operational directors, clinical directors and multidisciplinary representatives from across all three Integrated Health Communities. Its purpose was to identify current quality and safety risks, assess service resilience, and agree immediate and longer‑term actions to mitigate the risk of harm.
As part of this work, the Health Board is reviewing the escalation and governance of gastroenterology‑related risks to ensure that they are appropriately reflected within local and corporate risk management arrangements and subject to ongoing executive oversight.
Future Service Development
The Health Board recognises that addressing the challenges within gastroenterology and endoscopy services requires a coordinated, Health Board‑wide approach.
Work is therefore progressing on the development of an Integrated Digestive Disease Service, with shared clinical leadership, standardised pathways, coordinated workforce planning and strengthened governance. This programme of work is being taken forward under executive sponsorship, with follow‑up reviews scheduled to monitor progress and ensure delivery of agreed actions.
Conclusion
The Health Board remains committed to patient safety, learning and continuous improvement. The actions described in this response reflect the Health Board’s ongoing work to address the systemic risks highlighted during the inquest and to strengthen the resilience of gastroenterology and endoscopy services for the future.
The Health Board recognises the importance of sustained collaboration between clinical teams, executive leaders and system partners in delivering these improvements, and remains committed to working openly and constructively to support safe, timely access to care for patients across North Wales.
The Health Board hopes that this response provides assurance to the coroner, and to Mr Williams’ family, that the concerns identified have been carefully considered and are being addressed through clear governance, immediate mitigation and longer‑term service development.
The Health Board remains willing to work with yourself and other partners should any further clarification, assurance or engagement be helpful.