An inquest has heard that an agency nurse made "bad decisions" and "panicked" after finding a patient cold and unresponsive, failing to follow resuscitation guidelines. Joseph Kamangire, the nurse involved, admitted to making poor choices in a state of panic after discovering Mohammed Jaafri at Glan Clwyd hospital on April 21, 2025.
Betsi Cadwaladr University Health Board acknowledged that resuscitation should have been attempted and that opportunities for further observation were missed. The inquest was told that Kamangire had checked on Jaafri, who was described as cold and not breathing at 6:30 a.m. Jaafri's death was confirmed at 7:25 a.m.
Coroner John Gittens stated that Jaafri's death was unexpected and that there was no "do not attempt CPR" order in place. No overnight tests or observations had been conducted. Gittens noted a "significant deviation" from expected care standards and "missed opportunities." Despite these failings, the hospital and medical examiner provided bronchopneumonia due to flu and frailty as the probable cause of death. The coroner also highlighted that the death was not reported to him or the medical examiner by the hospital doctors.
Gittens is considering whether a Prevention of Future Deaths report is necessary following the inquest. He recorded a narrative conclusion for the case.