Recurring concern

Unreliable patient whiteboard information systems

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First reported 18 Nov 2013•Latest report 17 Dec 2013

Definition

What this concern includes

Includes failures of patient whiteboard systems involving inconsistent content standards, omission of safety-critical patient information, inaccurate entries or unclear governance where the whiteboard is used to support clinical care.

Not included

Excludes general clinical record-keeping failures where no patient-whiteboard system is involved.
Excludes failures in the underlying observation, treatment or risk-management process when the whiteboard information system is not itself deficient.
Excludes generic documentation, communication or governance deficiencies not specifically tied to patient whiteboard information.
Excludes non-clinical whiteboards and neutral descriptions of whiteboard use without an identified safety deficiency.

Reports: 2
Individual concerns: 4
Date range: 2013–2013
Stated actions: 1

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Cardiff & Vale University LHB1

Cleveland Police1

Community Mental Health Services for Older People, Llandough Hospital1

South Tees Hospitals NHS Foundation Trust1

Tees, Esk and Wear Valleys NHS Foundation Trust1

Welsh Government1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

17 Dec2013
Cardiff & the Vale of Glamorgan
Concerns raised3
1. Failure to ensure accurate information on whiteboards
2. Lack of standardisation in information put on whiteboards
3. Reliance on whiteboard information instead of patients’ notes
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Request Chief Medical and Nursing Officers to remind Welsh Health Boards and Trusts to maintain robust PSAG safety systems.
  Stated by Mark Drakeford AC / AMStated completed
AI-generated summary

John Elvet Morgan · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

John Elvet Morgan, who had Alzheimer’s dementia, was admitted for respite care and collapsed on 30 August 2013. Staff did not resuscitate him because they relied on an erroneous red DNR star left on the ward whiteboard, although no DNR agreement or form existed; the post-mortem report showed pulmonary embolism. The concerns identified included reliance on whiteboard information instead of patient notes, human error in recording information, and the possible use of similar DNR systems elsewhere in Wales.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure accurate information on whiteboards
Wider context from the report
“(1) The Whiteboard (or PSAG) is in use throughout Wales as a quick reference guide to the patients on the ward. It was introduced as part of the “Transforming Care at the bedside “TCAB” programme. Dr ███████ Clinical Director for the University Hospital for Wales Board, confirmed that the information which is put on the whiteboard is a matter for local discretion. While the red “DNR” star system has been removed from the whiteboards in use in Cardiff and the Vale Local Health Board he could not say whether similar systems are not in use elsewhere in Wales. (2) The whiteboard system is a useful reference point for patient care but there is a danger that the information held on the whiteboard is relied upon instead of the patient’s notes. (3) Human error may mean that erroneous information is held on the whiteboard to the detriment of patient care. (4) A similar DNR “red star” system may be in use on whiteboards in other Health Board areas in Wales with the possibility that a similar chain of events may occur elsewhere in Wales. ”
Source location
John Elvet Morgan · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of standardisation in information put on whiteboards
Wider context from the report
“(1) The Whiteboard (or PSAG) is in use throughout Wales as a quick reference guide to the patients on the ward. It was introduced as part of the “Transforming Care at the bedside “TCAB” programme. Dr ███████ Clinical Director for the University Hospital for Wales Board, confirmed that the information which is put on the whiteboard is a matter for local discretion. While the red “DNR” star system has been removed from the whiteboards in use in Cardiff and the Vale Local Health Board he could not say whether similar systems are not in use elsewhere in Wales. (2) The whiteboard system is a useful reference point for patient care but there is a danger that the information held on the whiteboard is relied upon instead of the patient’s notes. (3) Human error may mean that erroneous information is held on the whiteboard to the detriment of patient care. (4) A similar DNR “red star” system may be in use on whiteboards in other Health Board areas in Wales with the possibility that a similar chain of events may occur elsewhere in Wales. ”
Source location
John Elvet Morgan · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Reliance on whiteboard information instead of patients’ notes
Wider context from the report
“(1) The Whiteboard (or PSAG) is in use throughout Wales as a quick reference guide to the patients on the ward. It was introduced as part of the “Transforming Care at the bedside “TCAB” programme. Dr ███████ Clinical Director for the University Hospital for Wales Board, confirmed that the information which is put on the whiteboard is a matter for local discretion. While the red “DNR” star system has been removed from the whiteboards in use in Cardiff and the Vale Local Health Board he could not say whether similar systems are not in use elsewhere in Wales. (2) The whiteboard system is a useful reference point for patient care but there is a danger that the information held on the whiteboard is relied upon instead of the patient’s notes. (3) Human error may mean that erroneous information is held on the whiteboard to the detriment of patient care. (4) A similar DNR “red star” system may be in use on whiteboards in other Health Board areas in Wales with the possibility that a similar chain of events may occur elsewhere in Wales. ”
Source location
John Elvet Morgan · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Request Chief Medical and Nursing Officers to remind Welsh Health Boards and Trusts to maintain robust PSAG safety systems.

Verbatim wording from the response
“I have further requested the Chief Medical Officer and Chief Nursing Officer write to all Health Boards and Trusts in Wales to remind them, where PSAG boards are in use, robust systems must be in place to safeguard patient safety and prevent a similar incident from happening again.”

Source location
2013-0372-Response-by-Welsh-Government
Page 1 · response
Published 17 December 2013
Open published response
18 Nov2013
Teesside
Concerns raised1
1. Failure to record nursing-observation frequency on the A&E whiteboard
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

STUART ARRON COLLINS · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Stuart Arron Collins was taken to hospital while intoxicated and fully conscious, but was discharged several hours later with a reduced level of consciousness. After arriving at an address, he became unconscious and suffered cardiorespiratory arrest before being returned to hospital, where he died later that day. Concerns included uncertainty about his assessment on arrival, the absence of required hourly nursing observations, incomplete nursing records, and the possible accessibility of alcohol hand sanitiser gel.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record nursing-observation frequency on the A&E whiteboard
Wider context from the report
“3. Evidence was given that Mr Collins was added to the whiteboard in the A&E dept but that the information regarding the frequency of his nursing observations was not. It was stated that this led to no nursing observations being taken during his first time at A&E on 9.10.12 ”
Source location
STUART ARRON COLLINS · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Failure to ensure accurate information on whiteboards

Lack of standardisation in information put on whiteboards

Reliance on whiteboard information instead of patients’ notes

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to record nursing-observation frequency on the A&E whiteboard

Actions described in response 1