An inquest has heard that an agency nurse made a series of poor decisions after discovering a patient cold and unresponsive at Glan Clwyd Hospital, failing to trigger emergency resuscitation procedures. Mohammed Jaafri, 90, from Dyserth near Rhyl, died at the hospital on 21 April 2025, with Ruthin Coroner's Court told that critical opportunities to save him were missed.
Nurse Joseph Kamangire told the court he had discovered Jaafri, a Moroccan-born former furniture dealer, cold and not breathing, and concluded that he had already died. Rather than issuing a cardiac arrest alert to summon medical staff in line with standard resuscitation protocol, he took no such action.
I was panicked and, in the panic, I made some bad decisions I was sorry for.
What went wrong on the ward?
According to evidence given on Tuesday, Kamangire had repeatedly entered and left Jaafri's room during the night of 21 April 2025 to check his oxygen mask. At 06:30 GMT he found the patient cold and not breathing, and death was formally confirmed roughly an hour later, at 07:25.
Coroner John Gittens told the court that Jaafri's death had not been anticipated, that no "do not attempt CPR" order was in place, and that no observations or tests had been carried out on him overnight. He described this as a "significant deviation" from expected standards of care, pointing to a string of "missed opportunities" to intervene.
Separately, according to the Daily Post, a ward manager told the inquest that the health board's internal investigation had identified a "breach of duty" in Jaafri's care, though it did not conclude that this breach had directly caused harm.
Why wasn't the death reported sooner?
The coroner said it remained unclear why, despite the clear failings identified in Jaafri's treatment, his death was never formally reported to him by hospital doctors or by the medical examiner responsible for reviewing such cases. Betsi Cadwaladr University Health Board, which runs the hospital, has since accepted that resuscitation efforts should have been attempted and that chances to carry out further checks on Jaafri were missed.
The hospital and medical examiner had listed the probable cause of death as bronchopneumonia linked to flu and frailty. Per the Daily Post, the coroner remarked that while the case might otherwise have been recorded as death by natural causes, doing so would not have adequately reflected the circumstances surrounding it.
What happens next?
Gittens, identified elsewhere as the senior coroner for North Wales (East and Central) per the Coroners' Society, recorded a narrative conclusion into Jaafri's death and said he was weighing up whether to issue a Prevention of Future Deaths report, according to the Daily Post. Court listings from Denbighshire Council show the inquest was scheduled to resume at Ruthin Coroner's Court on 17 August 2026.
Key Facts
- Mohammed Jaafri, 90, of Dyserth near Rhyl, died at Glan Clwyd Hospital on 21 April 2025.
- Agency nurse Joseph Kamangire found him cold and unresponsive but did not issue a cardiac arrest alert.
- Death was confirmed at 07:25 GMT, roughly an hour after he was found unresponsive at 06:30.
- Betsi Cadwaladr University Health Board accepted that resuscitation should have been attempted.
- The inquest is listed to continue at Ruthin Coroner's Court on 17 August 2026.
