24 Jun 2026 Nola-Reign Morgan · Prevention of Future Deaths report Gwent
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Concerns raised 6 Delays in transferring patients between antenatal and HDU wards View source Failure to identify causes of transfer delays and take steps to avoid unnecessary delay recurring View source Insufficient training to enable obstetric and midwifery teams to identify the risk of chorioamnionitis and ensure adequate monitoring View source Lack of specific guidance for identifying and treating chorioamnionitis in pre-term mothers View source Lack of national antenatal guidance establishing when and in what circumstances fetal monitoring should be used, especially when chorioamnionitis is suspected View source Failure of local antenatal monitoring guidance to address chorioamnionitis, transfer times and consideration of continuous fetal monitoring View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Nola-Reign 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
Nola-Reign Morgan was born prematurely on 5 February 2024 after her mother developed suspected chorioamnionitis, and died three days later despite resuscitation and neonatal care. The report identified delays in transferring her mother to the labour ward and high dependency unit, a period without fetal monitoring, and gaps in national and local guidance and staff training on monitoring and managing suspected chorioamnionitis in pre-term pregnancies.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients between antenatal and HDU wards
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to identify causes of transfer delays and take steps to avoid unnecessary delay recurring
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient training to enable obstetric and midwifery teams to identify the risk of chorioamnionitis and ensure adequate monitoring
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of specific guidance for identifying and treating chorioamnionitis in pre-term mothers
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of national antenatal guidance establishing when and in what circumstances fetal monitoring should be used, especially when chorioamnionitis is suspected
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of local antenatal monitoring guidance to address chorioamnionitis, transfer times and consideration of continuous fetal monitoring
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” Open source report
27 Feb 2026 SUMMER RAE MANT · Prevention of Future Deaths report South Wales Central
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Concerns raised 1 Lack of standardised crash trolleys across hospital settings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
SUMMER RAE MANT · 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
Summer Rae Mant, a four-year-old child with MIRAGE syndrome, developed severe infection and virus while an inpatient and suffered hypoxia and cardiac arrest during events on 17 and 18 March 2024. She later developed sudden multi-organ failure of uncertain cause and died at Ty Hafan on 21 September 2024. A substantive concern was a delay in obtaining adrenaline during resuscitation, associated with non-standardised crash trolleys and staff unfamiliarity with different hospital configurations.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised crash trolleys across hospital settings
Wider context from the report “During the resuscitation of Summer at Prince Charles Hospital in the theatre following intubation, there was a delay in obtaining adrenaline. The incident occurred at night and it involved a skeleton staff including some junior doctors, fairly new to the hospital.
The delay in finding adrenaline, was likely due to the fact that there is no standardised crash trolley , and junior doctors frequently rotate between hospitals and health boards and encounter different set-ups .
Paediatric crash trolleys are necessarily different to adult crash trolleys, but there was consensus in evidence that it would be safer if there was a single standardised version of each type across every hospital setting in which junior doctors rotate , to minimise confusion at a time critical moment.
” Open source report
5 Feb 2026 Della Bridget CALVEY · Prevention of Future Deaths report Gwent
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Concerns raised 1 Unsafe downgrading of NEWS scores for all patients with COPD when baseline oxygen saturations are unknown View source
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Each statement is shown once, even when linked to more than one concern.
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Della Bridget CALVEY · 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
Della Bridget Calvey developed a urinary tract infection, deteriorated with confusion, dehydration and a raised NEWS score, and died at home from overwhelming sepsis caused by the infection. The inquest found that she should have been admitted to hospital but could not determine that admission would have prevented her death. The principal concern was the downgrading of NEWS scores for patients with COPD when baseline oxygen saturations were unknown, and the need for more robust clinical assessments.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Unsafe downgrading of NEWS scores for all patients with COPD when baseline oxygen saturations are unknown
Wider context from the report “The totality of the evidence indicated that it was not unusual for NEWS scores to be downgraded if a patient had COPD, even when their baseline saturations were not known . The rationale being “COPD sufferers often have lower oxygen saturation levels”. Whilst this may be true, applying this to all COPD sufferers, I consider to be an unsafe practice .
1. Confirmation whether downgrading NEWS scores in the circumstances described is acceptable practice (please note that support for this position was provided by the Clinical Lead who has a training remit)
2. What action will be taken to ensure that more robust approach to clinical assessments will take place in the future.
” Open source report
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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 Train all flow centre staff to calculate NEWS2 and monitor compliance through annual staff reviews.
Verbatim wording from the response “NEWS2 was formally launched by the Health Board in September 2025 and all flow centre staff have completed the required training, with ongoing compliance monitored as part of annual staff reviews. As standard practice the call handling staff at the flow centre are trained to calculate the NEWS score based on the observations given and would not adjust this for COPD or other conditions. They now escalate all COPD patient referrals to the qualified nurse, who would consider the NEWS score in the context of the full details of the case including the available past medical history. The qualified nurse would then make any clinically appropriate adjustments to the NEWS2 parameters, with a clear clinical rationale documented.” Source location 2026-0063 -Response from Anueron Bevan University Health Board
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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 Launch and standardise NEWS2, including the COPD-specific oxygen saturation scale, across the Health Board.
Verbatim wording from the response “The adaptation of the NEWS score in the context of patients with known hypercapnic respiratory failure (most commonly due to COPD) is recognised normal clinical practice. This was reinforced and standardised by the introduction of ‘NEWS2’ (first published 2017 but widely adopted across NHS Wales in 2025 – See Welsh Health Circular WHC/2025/002) which specifically has a different oxygen saturation scale for this purpose. Whilst it is recognised that not all patients with COPD will have confirmed hypercapnic respiratory failure and meet this criteria, there is recognition that patients with COPD exacerbations will often tolerate lower oxygen levels safely.” Source location 2026-0063 -Response from Anueron Bevan University Health Board
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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 Escalate all COPD referrals to qualified nurses for contextual NEWS2 assessment, clinically justified parameter adjustments and documented rationale.
Verbatim wording from the response “NEWS2 was formally launched by the Health Board in September 2025 and all flow centre staff have completed the required training, with ongoing compliance monitored as part of annual staff reviews. As standard practice the call handling staff at the flow centre are trained to calculate the NEWS score based on the observations given and would not adjust this for COPD or other conditions. They now escalate all COPD patient referrals to the qualified nurse, who would consider the NEWS score in the context of the full details of the case including the available past medical history. The qualified nurse would then make any clinically appropriate adjustments to the NEWS2 parameters, with a clear clinical rationale documented.” Source location 2026-0063 -Response from Anueron Bevan University Health Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adjusting NEWS oxygen-saturation scores can be acceptable for COPD patients with hypercapnic respiratory failure or lower baseline saturations, when clinically justified.
Verbatim wording from the response “The adaptation of the NEWS score in the context of patients with known hypercapnic respiratory failure (most commonly due to COPD) is recognised normal clinical practice. This was reinforced and standardised by the introduction of ‘NEWS2’ (first published 2017 but widely adopted across NHS Wales in 2025 – See Welsh Health Circular WHC/2025/002) which specifically has a different oxygen saturation scale for this purpose. Whilst it is recognised that not all patients with COPD will have confirmed hypercapnic respiratory failure and meet this criteria, there is recognition that patients with COPD exacerbations will often tolerate lower oxygen levels safely.” Source location 2026-0063 -Response from Anueron Bevan University Health Board
Open published response
16 Dec 2025 Phillip Lawrence HOGGARTH · Prevention of Future Deaths report Gwent
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Concerns raised 1 Lack of a consistent approach to pre-operative management and administration of iron View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Phillip Lawrence HOGGARTH · 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
Phillip Lawrence HOGGARTH was admitted for a total hip replacement, which was performed on 18 March 2025. He deteriorated post-operatively, suffered a myocardial infarction and died on 25 March 2025. The report raised concerns about inconsistent pre-operative management and administration of iron to chronically anaemic patients, communication between clinicians, and delays related to funding responsibility between health boards.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent approach to pre-operative management and administration of iron
Wider context from the report “The deceased died from a heart attack and I did not determine that any omission in the administration of the iron had more than minimally contributed to his death. However the lack of a consistent approach to pre-operative management and administration of iron to a chronically anaemic patient could put patients’ lives at risk in the future .
Kindly address the issues raised, namely:
1. Whether there are clinical guidelines which determine the pre-operative administration of iron therapy.
2. Whether there is a process which supports these guidelines
3. Whether there is an agreement between Health Boards in these circumstances regarding funding to prevent potentially damaging delays in surgery.
” Open source report
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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 Implement a standard operating pathway for surgical patients with anaemia or iron deficiency, incorporating the NHS Wales preoperative anaemia pathway and preoperative intravenous iron guidance.
Verbatim wording from the response “Please find attached to this response the Health Board’s Standard Operating Pathway (SOP) for the management of surgical patients presenting to preassessment clinic with anaemia or iron deficiency.” Source location Response from Aneurin Bevan University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a six-week post-infusion blood test, where surgery timing permits, to confirm improvement and inform whether further intravenous iron is required.
Verbatim wording from the response “Our standard IV iron pathway in preassessment includes a blood test at 6 weeks post iron transfusion (where sufficient time is available before surgery) to confirm improvement or inform decision making if a further iron transfusion is required.” Source location Response from Aneurin Bevan University Health Board
Open published response
6 Oct 2025 Steven Paul TURZYNSKI · Prevention of Future Deaths report Gwent
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Concerns raised 3 Failure to govern and monitor decisions on face to face dietetic appointments View source Lack of adequate dietetic assessment View source Failure of communication between hospital and community dietetic teams View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 11
Action
Embed peer review and clinical supervision within ABUHB dietetic governance, initially focusing on oncology cases.
Stated plannedThe respondent said that this action was planned when they made their response on 9 October 2025. View source
Action
Grant appropriate ABUHB dietitians access to WCP clinical records.
Stated plannedThe respondent said that this action was planned when they made their response on 9 October 2025. View source
Action
Adapt the ABUHB booking process to facilitate face-to-face review as an initial assessment.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025. View source
Action
Conduct annual joint audits of adherence to the transfer-of-care standard and assessment protocol, reporting findings through governance groups.
Stated plannedThe respondent said that this action was planned when they made their response on 9 October 2025. View source
Action
Hold quarterly joint dietetic-lead meetings to review shared cases, incidents, communication issues and process improvement.
Stated plannedThe respondent said that this action was planned when they made their response on 9 October 2025. View source
Action
Provide interim cross-organisational read-only clinical-record access for relevant dietitians.
Status at responseThe respondent said that this action was partly complete when they made their response on 9 October 2025. View source
Action
Introduce a decision-making tool requiring clinicians to document the rationale for remote or in-person assessment.
Stated plannedThe respondent said that this action was planned when they made their response on 9 October 2025. View source
Action
Log communication deficiencies through Datix, review them jointly and feed identified learning into professional development.
Stated plannedThe respondent said that this action was planned when they made their response on 9 October 2025. View source
Action
Develop and update a dietetic assessment guideline defining criteria for face-to-face and remote consultations.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025. View source
Action
Develop a joint transfer-of-care standard operating procedure defining referral, handover, documentation, response-time and professional-contact requirements.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025. View source
Action
Maintain joint monitoring meetings to review action-plan progress, share learning and resolve cross-boundary issues.
Stated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025. View source See 8 more actions
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Steven Paul TURZYNSKI · 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
Steven Paul Turzynski, who had lung cancer and a history of treated oropharyngeal cancer, died from the effects of lung cancer on 29 July 2024. The report identified very limited communication between the two dietetic teams, lack of shared records, and inadequate nutritional assessment, with significant undernutrition by the time of his death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to govern and monitor decisions on face to face dietetic appointments
Wider context from the report “Steven Paul Turzynski died from the effects of cancer, which was also responsible for his nutritional status. However the almost absent communication between the two dietetic teams and the lack of adequate assessment during the last 12 months of Steven’s life contributed to his poor nutritional state.
I was informed at the inquest that the need for a face to face appointment is entirely a matter for the individual dietician. However, this decision making is not governed by guidelines nor is it monitored and can lead to an over-reliance of telephone assessments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate dietetic assessment
Wider context from the report “Steven Paul Turzynski died from the effects of cancer, which was also responsible for his nutritional status. However the almost absent communication between the two dietetic teams and the lack of adequate assessment during the last 12 months of Steven’s life contributed to his poor nutritional state.
I was informed at the inquest that the need for a face to face appointment is entirely a matter for the individual dietician. However, this decision making is not governed by guidelines nor is it monitored and can lead to an over-reliance of telephone assessments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between hospital and community dietetic teams
Wider context from the report “Steven Paul Turzynski died from the effects of cancer, which was also responsible for his nutritional status. However the almost absent communication between the two dietetic teams and the lack of adequate assessment during the last 12 months of Steven’s life contributed to his poor nutritional state.
I was informed at the inquest that the need for a face to face appointment is entirely a matter for the individual dietician. However, this decision making is not governed by guidelines nor is it monitored and can lead to an over-reliance of telephone assessments.
” Open source report
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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 Embed peer review and clinical supervision within ABUHB dietetic governance, initially focusing on oncology cases.
Verbatim wording from the response “• Quality Assurance: Peer review and clinical supervision sessions will be embedded into dietetic governance structures within ABUHB, focusing initially on oncology cases” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Grant appropriate ABUHB dietitians access to WCP clinical records.
Verbatim wording from the response “• Shared Access to Clinical Records:
Both organisations are reviewing long term digital interoperability options with potential single patient care records, dependant on Digital Health & Care Wales support. In the interim, read only access to ABUHB clinical system (CWS) has been granted to VUHNHST dieticians and WCP access will be granted to appropriate cohort of ABUHB Dietitians” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Adapt the ABUHB booking process to facilitate face-to-face review as an initial assessment.
Verbatim wording from the response “• Dietetic Assessment and Consultation Guideline: Development of an operating protocol to define clinical criteria for the mode of assessment. This will include consideration of disease complexity, nutritional risk, treatment phase, and patient preference. ABUHB booking process being adapted to facilitate face to face review as an initial assessment.” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Conduct annual joint audits of adherence to the transfer-of-care standard and assessment protocol, reporting findings through governance groups.
Verbatim wording from the response “• Annual Joint Audit: ABUHB and VUNHST will jointly audit adherence to the Dietetic Transfer of Care Standard Operating Procedure and Assessment Protocol, with findings reported to each organisation’s Nutrition & Hydration Group and/or Quality & Patient Safety assurance group” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Hold quarterly joint dietetic-lead meetings to review shared cases, incidents, communication issues and process improvement.
Verbatim wording from the response “• Multidisciplinary Interface Meetings:
Quarterly meetings will be held between ABUHB and VUHNHST dietetic leads to discuss and review any shared oncology cases, clinical incidents, resolve communication issues, and identify opportunities for process improvement” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Provide interim cross-organisational read-only clinical-record access for relevant dietitians.
Verbatim wording from the response “• Shared Access to Clinical Records:
Both organisations are reviewing long term digital interoperability options with potential single patient care records, dependant on Digital Health & Care Wales support. In the interim, read only access to ABUHB clinical system (CWS) has been granted to VUHNHST dieticians and WCP access will be granted to appropriate cohort of ABUHB Dietitians” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Introduce a decision-making tool requiring clinicians to document the rationale for remote or in-person assessment.
Verbatim wording from the response “• Decision-Making Tool: Decision-making tool to be introduced, requiring clinicians to record their rationale for remote versus in-person assessment in the patient’s notes, promoting transparency and auditability” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Log communication deficiencies through Datix, review them jointly and feed identified learning into professional development.
Verbatim wording from the response “• Exception and Learning Reporting: Any deficiencies or recurrent communication failures will be logged through Datix and reviewed at joint governance meetings. Themes and learning will be fed into professional development sessions.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Develop and update a dietetic assessment guideline defining criteria for face-to-face and remote consultations.
Verbatim wording from the response “Assurance Statement
The Health Board acknowledges the coroner’s concern regarding the absence of guidance for determining when dietetic assessments should be conducted face-to-face versus by telephone. The organisation, in collaboration with Velindre, is updating and enhancing existing clinical standards to guide assessment practice and ensure equity and quality of nutritional care” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Develop a joint transfer-of-care standard operating procedure defining referral, handover, documentation, response-time and professional-contact requirements.
Verbatim wording from the response “Assurance Statement
Aneurin Bevan University Health Board (ABUHB) and Velindre University NHS Trust (VUNHST) recognise the coroner’s concern that inadequate communication between each organisations’ dietetic teams contributed to suboptimal nutritional management. Both organisations are committed to strengthening the safety and consistency of information exchange for all patients whose care is transferred across organisational boundaries.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Maintain joint monitoring meetings to review action-plan progress, share learning and resolve cross-boundary issues.
Verbatim wording from the response “At a system level, the Health Board and VUHNHST have committed to working in close partnership to maintain and monitor these improvements. Regular joint meetings between both organisations will review progress against the action plan, share emerging learning, and resolve any cross-boundary issues in real time.” Source location Response from Aneurin Bevan University Health Board
Open published response
22 Jul 2025 Isaac Arlan Ingle-Gillis · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 1 Lack of CRHTT access to GP records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Isaac Arlan Ingle-Gillis · 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
Isaac Arlan Ingle-Gillis, who was suffering from depression, died at the Ty Hotel in Magor on 9 February 2025 from the effects of an intentional overdose. The concern was that the Crisis Resolution and Home Treatment Team did not have access to GP records, and that information recorded by the GP might be vital in future assessments.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of CRHTT access to GP records
Wider context from the report “During the inquest I heard evidence that the CRHTT do not have access to the GP records . I could not determine on balance of probabilities that access to additional information recorded by the GP in their consultation with Isaac on 9/2/2025 would have changed the assessment made by the CRHTT on this occasion. However, I am concerned that in future this information (or lack of it) may be vital .
” 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 Make summary GP records available to all secondary-care clinicians, including Crisis Resolution and Home Treatment Team staff.
Verbatim wording from the response “A summary/precis version of the GP record is available to clinicians working in secondary care via the Welsh Clinical Portal, until now that availability has been restricted to the medical staff in the Mental Health and Learning Disability Division. Work has commenced to broaden that access to other clinicians including those who work in the CRHTT. This information is a summary/precis record and it is a high-level summary of key diagnoses, medications, allergies and other selected coded information. It may not convey all of the information that could be potentially useful to clinicians from outside the practice.” Source location Response from Bwrdd Lechyd Prifysgol Aneurin Bevan University Health Board
Open published response
×
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 Provide staff training on accessing and using summary GP records, initially prioritising crisis and emergency mental-health clinics.
Verbatim wording from the response “Notwithstanding that the Health Board has made the summary GP record available to all clinicians working in secondary care in the Health Board. Training will be provided to staff, with initial priority given to those in the Mental Health and Learning Disability Division who work in crisis and emergency clinics.” Source location Response from Bwrdd Lechyd Prifysgol Aneurin Bevan University Health Board
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine full GP-record access for external clinicians is constrained by legal, data-controller and logistical barriers.
Verbatim wording from the response “The availability of the summary GP record cannot substitute for the full detail available in the GP record. Unfortunately, there are barriers to making this routinely available for clinicians working outside a GP practice. These include legal and practical barriers.” Source location Response from Bwrdd Lechyd Prifysgol Aneurin Bevan University Health Board
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National bodies control integration and scope of cross-agency GP-record access, including Welsh Clinical Portal data sharing.
Verbatim wording from the response “The integration of records across the architecture of clinical IT systems in Wales, including the scope of shared data, is centrally co-ordinated by Digital Health and Care Wales. We are not aware of any immediate plans to allow full access to systems to users across different agencies with the emphasis being on ensuring that key information can be shared without the need for all clinicians to have individual user access across multiple platforms. The scope of which data is shared via the Welsh Clinical Portal is also determined nationally.” Source location Response from Bwrdd Lechyd Prifysgol Aneurin Bevan University Health Board
Open published response
22 Jul 2025 Robyn Anne Chambers · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 1 Delays in releasing ambulances from emergency departments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Robyn Anne Chambers · 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
Robyn Anne Chambers was born prematurely at 23 weeks gestation and developed significant physical and neurological problems, including ongoing respiratory problems. She developed a chest infection on 26/10/2024 and died on 2/11/2024 at Ty Hafan Hospice. The report noted concerns about the estimated eight-hour ambulance response and delays in releasing ambulances from hospital emergency departments, although these were stated not to have affected Robyn’s care or outcome.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in releasing ambulances from emergency departments
Wider context from the report “However, having heard evidence from Welsh Ambulance Service NHS Trust, I note that the main reason for the delay in dispatching emergency ambulances remains the length of time it is taking for ambulances to be released from the emergency department of Aneurin Bevan University Health Board hospitals , predominantly the Grange University Hospital. Evidence provided at inquest indicated that, at the time that Robyn’s parents called for an ambulance, the longest time an ambulance was delayed at the GUH was in excess of 10 hours .
” 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 Appoint a dedicated Associate Director of Clinical Operations to strengthen senior clinical leadership for patient flow and handover-delay escalation.
Verbatim wording from the response “5. Leadership and Culture” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Continue the focused Handover 45 initiative to reduce ambulance handover delays and sustain performance improvements.
Verbatim wording from the response “d. A national Ministerial Action Group is currently working on a national workstream aiming for no delays over 45 minutes across Wales which we are hugely committed to. This ‘Handover 45’ workstream mandates that there will be no over 45-minute delays from November 2025 in Wales. The Health Board has already commenced a focused initiative based on this approach early September with early indications of positive progress.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Embed the national optimal hospital flow framework, including standardized board rounds, across acute and community hospitals in Gwent.
Verbatim wording from the response “4. Discharge” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Review the Emergency Pressures Escalation Policy against NHS Wales urgent and emergency care escalation guidance.
Verbatim wording from the response “b. Reviewed our Emergency Pressures Escalation Policy to ensure it aligns with the NHS Wales Guidance ‘A Framework for Urgent & Emergency Care System” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Maximize capacity of the dedicated Transfer and Discharge Lounge at Grange University Hospital.
Verbatim wording from the response “b. Maximize capacity of the dedicated Transfer & Discharge Lounge at the Grange University Hospital” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Use weekly scrutiny panels and improved system escalation to focus on longest-staying patients.
Verbatim wording from the response “d. Focus on longest-staying patients via weekly scrutiny panels and improved system escalation” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Appoint six additional whole-time-equivalent Emergency Department consultants to increase assessment and treatment capacity.
Verbatim wording from the response “• The business case for additional ED Consultants to reduce clinical assessment times was approved with the Health Board appointing a further 6 whole time equivalent ED Consultants. All will have commenced their new roles by September 2025. This will improve assessment and treatment capacity which will reduce waits and increase throughput of patients.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Develop a criteria-led discharge approach using agreed clinical criteria for timely and safe discharge.
Verbatim wording from the response “e. Develop a criteria led discharge approach that uses agreed clinical criteria to ensure timely and safe discharge” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Review the internal Immediate Release Protocol for compliance with WAST’s revised purple 999 response.
Verbatim wording from the response “WAST, in conjunction with the Health Boards operating an ‘Immediate Release Direction Protocol’ which outlines the principles and processes for the management of immediate release directions that includes a dynamic escalation process to, as far as possible, minimise patient safety risk for patients awaiting a response in our communities when ambulance capacity is reduced or when the time for patient handover at emergency departments is extended (the handover standard is 15 minutes and considered extended beyond 30 minutes). Review of the internal Immediate Release Protocol is being undertaken to ensure compliance with WAST’s revised ‘purple’ 999 response.” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Refresh weekly whole-system flow oversight with senior executive chairing and action plans for emergency care and ambulance handover delays.
Verbatim wording from the response “In terms of oversight and actions, the Health Board has refreshed its weekly oversight arrangements and changed the focus to whole system flow with the chair now being the Chief Operating Officer, with the Chief Executive chairing every fourth week. Input is also received from the Clinical Executives. These meetings include a clear focus on the delivery and performance of the Health Board’s Emergency Department and Minor Injury Units with very clear action plans to mitigate the risk and seek improvements in” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Operate the larger transfer lounge opened at Grange University Hospital to support earlier transfer of patients from the Emergency Department.
Verbatim wording from the response “• A new larger transfer lounge opened in March 2025 which has capacity of 25 spaces (including chairs and beds) which will support flow throughout the day enabling earlier transfer of patients from the ED department to the relevant ward areas.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Develop a digital platform showing patient status at each pathway stage to improve patient flow.
Verbatim wording from the response “c. Development of digital platform to enhance visibility to patient status at each stage of the pathway, enabling improved patient flow” Source location Response from Aneurin Bevan University Health Board
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation WAST was responsible for contacting the Health Board through approved routes to request release of a delayed ambulance vehicle.
Verbatim wording from the response “During 26 October, whilst noting that the Health Board did have significant challenges with adhering to the nationally agreed 15-minute ambulance handover time, WAST did not contact the Health Board via approved routes to ask for a vehicle to be released. The 999 call to attend to Robyn Chambers had been upgraded and coded as an amber 1 response and fell within the provision of the Immediate Release Direction Protocol. Had this occurred, the Health Board would have endeavoured, as per the protocol to release a delayed vehicle to respond as requested.” Source location Response from Aneurin Bevan University Health Board
Open published response
20 May 2025 Marina Lorraine Waldron · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 4 Failure to heed concerns about inadequate eating or drinking View source Delays in considering dietary advice and parenteral feeding View source Failure to respond to low albumin indicating malnutrition View source Failure to formally monitor dietary intake View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marina Lorraine Waldron · 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
Marina Lorraine Waldron was admitted to hospital on 17 December 2023 with gastrointestinal bleeding caused by angiodysplasia and died on 15 February 2024 despite appropriate treatment. During her admission, her nutritional needs were poorly considered or managed, including failures to respond to family concerns, monitor dietary intake, act on a low albumin level, and consider dietary advice and parenteral feeding promptly. The medical staff who gave evidence agreed that malnutrition contributed to her death.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to heed concerns about inadequate eating or drinking
Wider context from the report “During the 8 ½ weeks of MW’s hospital admission, her nutritional needs were poorly considered or managed.
Examples of this include:
1. An ongoing failure to heed the family’s concerns that from admission to hospital, MW was not eating or drinking adequately
2. A failure to formally monitor MW’s dietary intake
3. A failure to respond to a low Albumin level which is a sign of malnutrition
4. Dietary advice and parenteral feeding were not properly considered until 29/1/2024 (6 weeks after admission)
The medical staff who gave evidence agreed that malnutrition contributed to MW’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in considering dietary advice and parenteral feeding
Wider context from the report “During the 8 ½ weeks of MW’s hospital admission, her nutritional needs were poorly considered or managed.
Examples of this include:
1. An ongoing failure to heed the family’s concerns that from admission to hospital, MW was not eating or drinking adequately
2. A failure to formally monitor MW’s dietary intake
3. A failure to respond to a low Albumin level which is a sign of malnutrition
4. Dietary advice and parenteral feeding were not properly considered until 29/1/2024 (6 weeks after admission)
The medical staff who gave evidence agreed that malnutrition contributed to MW’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to low albumin indicating malnutrition
Wider context from the report “During the 8 ½ weeks of MW’s hospital admission, her nutritional needs were poorly considered or managed.
Examples of this include:
1. An ongoing failure to heed the family’s concerns that from admission to hospital, MW was not eating or drinking adequately
2. A failure to formally monitor MW’s dietary intake
3. A failure to respond to a low Albumin level which is a sign of malnutrition
4. Dietary advice and parenteral feeding were not properly considered until 29/1/2024 (6 weeks after admission)
The medical staff who gave evidence agreed that malnutrition contributed to MW’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to formally monitor dietary intake
Wider context from the report “During the 8 ½ weeks of MW’s hospital admission, her nutritional needs were poorly considered or managed.
Examples of this include:
1. An ongoing failure to heed the family’s concerns that from admission to hospital, MW was not eating or drinking adequately
2. A failure to formally monitor MW’s dietary intake
3. A failure to respond to a low Albumin level which is a sign of malnutrition
4. Dietary advice and parenteral feeding were not properly considered until 29/1/2024 (6 weeks after admission)
The medical staff who gave evidence agreed that malnutrition contributed to MW’s death.
” 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 Incorporate escalation-review learning into multidisciplinary patient-safety and quality forums.
Verbatim wording from the response “• Initiating a thematic review of delayed escalations related to nutritional concerns.” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Promote the Call for Concern protocol so families can escalate concerns directly.
Verbatim wording from the response “We acknowledge the family's repeated concerns and regret that these were not adequately responded to. To address this, the Health Board has implemented or will implement actions under Recommendation 1 of the attached plan, including:” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Reinforce red trays and visual identifiers for patients requiring dietary monitoring.
Verbatim wording from the response “To improve compliance and accuracy in monitoring nutritional intake, Recommendation 2 of the action plan focuses on:” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Use AMaT data to assess and improve ward-level compliance with food-chart use.
Verbatim wording from the response “To improve compliance and accuracy in monitoring nutritional intake, Recommendation 2 of the action plan focuses on:” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Develop and deploy a Gold Standard food chart with a supporting staff briefing.
Verbatim wording from the response “To improve compliance and accuracy in monitoring nutritional intake, Recommendation 2 of the action plan focuses on:” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Embed strengthened nutrition documentation and compliance monitoring within the Quality Management System.
Verbatim wording from the response “The introduction of this governance framework has already supported the implementation of key improvement actions at pace, including enhanced monitoring of fluid balance, improved escalation protocols for malnutrition risk, and strengthened documentation and compliance monitoring. These initiatives are being embedded within our Quality Management System and have enabled a more responsive and accountable approach to preventing avoidable harm.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Embed improved escalation protocols for malnutrition risk within the Quality Management System.
Verbatim wording from the response “The introduction of this governance framework has already supported the implementation of key improvement actions at pace, including enhanced monitoring of fluid balance, improved escalation protocols for malnutrition risk, and strengthened documentation and compliance monitoring. These initiatives are being embedded within our Quality Management System and have enabled a more responsive and accountable approach to preventing avoidable harm.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Conduct a thematic review of delayed escalations involving nutritional concerns.
Verbatim wording from the response “Under Recommendation 3, we are strengthening escalation frameworks to support timely clinical decision-making. Key actions include:” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Improve recording of patient capacity and preferences in feeding decisions.
Verbatim wording from the response “Concern 4: Delayed dietary advice and parenteral feeding consideration” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Review SBAR and transfer documentation to add nutrition-specific prompts.
Verbatim wording from the response “The need for earlier specialist involvement and clear documentation around nutritional care is being addressed through Recommendation 4, including:” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Explore environmental barriers to dietary monitoring, including early tray clearance and single-room isolation.
Verbatim wording from the response “To improve compliance and accuracy in monitoring nutritional intake, Recommendation 2 of the action plan focuses on:” Source location Response from Aneurin Bevan University Health Board
Open published response
23 Oct 2024 Jean THOMAS · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 1 Failure to monitor fluid balance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 11
Action
Use the AMAT tool to standardise fluid-balance compliance audits, conduct audits through ward accreditation and report results to the Nutrition and Hydration Committee.
Stated plannedThe respondent said that this action was planned when they made their response on 3 February 2025. View source
Action
Deliver strengthened multidisciplinary education and training on fluid-balance roles, responsibilities and best practice.
Stated plannedThe respondent said that this action was planned when they made their response on 3 February 2025. View source
Action
Complete the review of Health Board documentation, monitoring tools and relevant national guidelines to establish an evidence base for best practice.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2025. View source
Action
Incorporate Medical Examiner and Quality Safety Learning Forum learning into the fluid-balance improvement plan.
Stated plannedThe respondent said that this action was planned when they made their response on 3 February 2025. View source
Action
Explore using a digital observation platform to record fluid balance.
Status unclearThe respondent did not make the status of this action clear when they made their response on 3 February 2025. View source
Action
Establish and operate a multidisciplinary Fluid Balance Task and Finish Group with defined improvement objectives.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2025. View source
Action
Develop a multidisciplinary fluid-balance standard operating procedure.
Status unclearThe respondent did not make the status of this action clear when they made their response on 3 February 2025. View source
Action
Disseminate expected fluid-balance monitoring standards through feedback sessions, posters, emails, ward meetings and learning events.
Status unclearThe respondent did not make the status of this action clear when they made their response on 3 February 2025. View source
Action
Standardise fluid-balance monitoring documentation across the organisation.
Status unclearThe respondent did not make the status of this action clear when they made their response on 3 February 2025. View source
Action
Initiate a surgical-ward fluid-balance monitoring pilot incorporating staff education, information boards, data sharing and auditing.
Stated plannedThe respondent said that this action was planned when they made their response on 3 February 2025. View source
Action
Engage senior medical staff to support education and establish clinical expectations for fluid-balance monitoring.
Stated plannedThe respondent said that this action was planned when they made their response on 3 February 2025. View source See 8 more actions
×
AI-generated summary
Jean THOMAS · 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
Jean Thomas fell at home, fractured her hip, underwent surgical fixation, developed post-operative sepsis, and died in hospital on 26 October 2023. The inquest found that her fluid balance was not monitored by nursing or medical staff despite heart failure, chronic renal failure, signs of acute kidney injury and sepsis; this was determined to be a failure in care and a grave concern.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor fluid balance
Wider context from the report “Jean was known to have significant cardiovascular problems and from her admission there were signs this was worsening.
Her blood pressure was low, which would normally be treated with intravenous fluids, but excess fluids would put more pressure on her heart, and thus she was also treated with a low dose of furosemide.
The management of Jean’s fluid balance was important for the following reasons; she had heart failure, she had chronic renal failure, she had signs of a superimposing acute kidney injury and she was scoring on the NEWS chart from admission, such that the algorithm required the fluid balance to be monitored. Jean had signs of sepsis.
I find at inquest that Jean’s fluid balance was not monitored , which I determined to be a failure in care. It was not monitored by the nursing or the medical staff . Whilst I could not find that knowledge of Jean’s fluid balance would have altered the outcome, it is a matter of grave concern that this basic nursing care was ignored , and these important clinical indicators not monitored by the medical staff .
” Open source report
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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 Use the AMAT tool to standardise fluid-balance compliance audits, conduct audits through ward accreditation and report results to the Nutrition and Hydration Committee.
Verbatim wording from the response “The AMAT tool will be used to standardise the audit process for fluid balance compliance across the health board. Audits will be carried out in accordance with the Ward / Team Accreditation process and will be reported to the Nutrition & Hydration Committee.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Deliver strengthened multidisciplinary education and training on fluid-balance roles, responsibilities and best practice.
Verbatim wording from the response “(1) Standardisation of Fluid Balance monitoring documentation across the organisation.
(2) Exploration of the possibility of utilising a digital observation platform to record fluid balance.
(3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure.
(4) Increase awareness about the expected standards for fluid balance monitoring across the Health Board through various communication methods, such as feedback sessions, posters, emails, ward meetings, weekly cross-divisional ward meetings, and learning events.
(5) Identification and delivery of the multidisciplinary training requirements to ensure sustainable improvement in fluid balance monitoring.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Complete the review of Health Board documentation, monitoring tools and relevant national guidelines to establish an evidence base for best practice.
Verbatim wording from the response “A review of current Health Board documentation and monitoring tools across the Region, alongside a review of recommended National Guidelines has taken place to provide the evidence base that will lead to best practice.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Incorporate Medical Examiner and Quality Safety Learning Forum learning into the fluid-balance improvement plan.
Verbatim wording from the response “Compliance with fluid balance monitoring and subsequent improvements will be incorporated into the work of the Nutritional and Hydration Committee. Senior medical staff will be engaged clinically to support education and establish clinical expectations. Learning from Medical Examiner feedback and the Quality Safety Learning Forum will be incorporated into the improvement plan.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Explore using a digital observation platform to record fluid balance.
Verbatim wording from the response “(1) Standardisation of Fluid Balance monitoring documentation across the organisation.
(2) Exploration of the possibility of utilising a digital observation platform to record fluid balance.
(3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure.
(4) Increase awareness about the expected standards for fluid balance monitoring across the Health Board through various communication methods, such as feedback sessions, posters, emails, ward meetings, weekly cross-divisional ward meetings, and learning events.
(5) Identification and delivery of the multidisciplinary training requirements to ensure sustainable improvement in fluid balance monitoring.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Establish and operate a multidisciplinary Fluid Balance Task and Finish Group with defined improvement objectives.
Verbatim wording from the response “A Health Board Multidisciplinary Fluid Balance Task & Finish Group has formed with key objectives set which include:” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Develop a multidisciplinary fluid-balance standard operating procedure.
Verbatim wording from the response “(1) Standardisation of Fluid Balance monitoring documentation across the organisation.
(2) Exploration of the possibility of utilising a digital observation platform to record fluid balance.
(3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure.
(4) Increase awareness about the expected standards for fluid balance monitoring across the Health Board through various communication methods, such as feedback sessions, posters, emails, ward meetings, weekly cross-divisional ward meetings, and learning events.
(5) Identification and delivery of the multidisciplinary training requirements to ensure sustainable improvement in fluid balance monitoring.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Disseminate expected fluid-balance monitoring standards through feedback sessions, posters, emails, ward meetings and learning events.
Verbatim wording from the response “(1) Standardisation of Fluid Balance monitoring documentation across the organisation.
(2) Exploration of the possibility of utilising a digital observation platform to record fluid balance.
(3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure.
(4) Increase awareness about the expected standards for fluid balance monitoring across the Health Board through various communication methods, such as feedback sessions, posters, emails, ward meetings, weekly cross-divisional ward meetings, and learning events.
(5) Identification and delivery of the multidisciplinary training requirements to ensure sustainable improvement in fluid balance monitoring.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Standardise fluid-balance monitoring documentation across the organisation.
Verbatim wording from the response “(1) Standardisation of Fluid Balance monitoring documentation across the organisation.
(2) Exploration of the possibility of utilising a digital observation platform to record fluid balance.
(3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure.
(4) Increase awareness about the expected standards for fluid balance monitoring across the Health Board through various communication methods, such as feedback sessions, posters, emails, ward meetings, weekly cross-divisional ward meetings, and learning events.
(5) Identification and delivery of the multidisciplinary training requirements to ensure sustainable improvement in fluid balance monitoring.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Initiate a surgical-ward fluid-balance monitoring pilot incorporating staff education, information boards, data sharing and auditing.
Verbatim wording from the response “A pilot project on fluid balance monitoring will be initiated on a surgical ward, incorporating education, information boards, and sharing and auditing of data. The pilot will evolve into a broader implementation project once the PDSA improvement tools demonstrate progress in the pilot area.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Engage senior medical staff to support education and establish clinical expectations for fluid-balance monitoring.
Verbatim wording from the response “Compliance with fluid balance monitoring and subsequent improvements will be incorporated into the work of the Nutritional and Hydration Committee. Senior medical staff will be engaged clinically to support education and establish clinical expectations. Learning from Medical Examiner feedback and the Quality Safety Learning Forum will be incorporated into the improvement plan.” Source location Response from Aneurin Bevan University Health Board
Open published response
15 Aug 2024 Kay SIMMONDS · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 4 Failure to recognise deteriorating patients View source Incorrect calculation of NEWS scores View source Failure to perform observations in line with NEWS requirements View source Failure to refer patients to a senior medical practitioner in line with the NEWS algorithm View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kay SIMMONDS · 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
Kay Simmonds attended hospital with signs of sepsis arising from an infected haemodialysis central line, developed septic shock, and died on 22 July 2022. Concerns included an incorrect NEWS score calculation, failure to refer her to a senior medical practitioner, observations not being performed in line with NEWS requirements, and her transfer to a hospital without an available ITU bed.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deteriorating patients
Wider context from the report “Kay Simmonds was admitted to the Emergency Department of the Grange University Hospital on 21/7/2022. At 14:40 a nurse performed observations and calculated her NEWS score. However this calculation was incorrect. As a result Kay was not referred to a senior medical practitioner in line with the NEWS algorithm. Additionally, the observations were not thereafter performed in line with the NEWS requirements.
The miscalculation of NEWS and failure to recognise a deteriorating patient can put lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Incorrect calculation of NEWS scores
Wider context from the report “Kay Simmonds was admitted to the Emergency Department of the Grange University Hospital on 21/7/2022. At 14:40 a nurse performed observations and calculated her NEWS score. However this calculation was incorrect. As a result Kay was not referred to a senior medical practitioner in line with the NEWS algorithm. Additionally, the observations were not thereafter performed in line with the NEWS requirements.
The miscalculation of NEWS and failure to recognise a deteriorating patient can put lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to perform observations in line with NEWS requirements
Wider context from the report “Kay Simmonds was admitted to the Emergency Department of the Grange University Hospital on 21/7/2022. At 14:40 a nurse performed observations and calculated her NEWS score. However this calculation was incorrect. As a result Kay was not referred to a senior medical practitioner in line with the NEWS algorithm. Additionally, the observations were not thereafter performed in line with the NEWS requirements.
The miscalculation of NEWS and failure to recognise a deteriorating patient can put lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to refer patients to a senior medical practitioner in line with the NEWS algorithm
Wider context from the report “Kay Simmonds was admitted to the Emergency Department of the Grange University Hospital on 21/7/2022. At 14:40 a nurse performed observations and calculated her NEWS score. However this calculation was incorrect. As a result Kay was not referred to a senior medical practitioner in line with the NEWS algorithm. Additionally, the observations were not thereafter performed in line with the NEWS requirements.
The miscalculation of NEWS and failure to recognise a deteriorating patient can put lives at risk.
” 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 Obtain supplier quotations and prepare a capital bid while seeking funding prioritisation for the electronic observation project.
Verbatim wording from the response “Digital team have made contact with the system suppliers and have received quotes for this work and have also prepared a capital bid and are seeking prioritisation of funding.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Map Emergency Department processes and requirements to support electronic observation implementation.
Verbatim wording from the response “Following the meeting, a member of the digital team attended the ED on 17 September 2024, to map the current processes and requirements and following this visit the digital team are developing an options appraisal to determine how the recording of electronic observations can be recorded within the ED.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Introduce an electronic observation and NEWS recording system in the Emergency Department.
Verbatim wording from the response “1. Action that will be taken to introduce an electronic observation and NEWS recording system within the Emergency Department (ED) at the Grange University Hospital (GUH)” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Meet with the digital team to define the requirement and prioritise introducing electronic observations in the Emergency Department.
Verbatim wording from the response “The Urgent Care Division has met with the Health Board’s digital team on 29 August 2024 to discuss the requirement and urgency to introduce CareFlow within the ED, this is now a priority for the Division.” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Develop an options appraisal identifying the safest, quickest and most cost-effective approach to electronic observations, including licensing and integration costs.
Verbatim wording from the response “Following the meeting, a member of the digital team attended the ED on 17 September 2024, to map the current processes and requirements and following this visit the digital team are developing an options appraisal to determine how the recording of electronic observations can be recorded within the ED.” Source location Response from Aneurin Bevan University Health Board
Open published response
20 May 2024 Sylvia Eileen Evans · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 2 Delays in hospital handover View source Delays in ambulance response to life-threatening emergencies View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sylvia Eileen Evans · 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
Sylvia Eileen Evans sustained an accidental leg wound at home on 5 September 2023, causing severe haemorrhage, and died at home the following day. She called for an ambulance at 22:56, but the call ended abruptly before the nature of her injuries was conveyed. An ambulance arrived at 07:45, almost 8 hours and 49 minutes after the call was registered, and the report identifies hospital handover delay as contributing in part to the delay.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital handover
Wider context from the report “The correct procedure was adopted by the Welsh Ambulance Service and Sylvia was categorised as requiring an Amber 1 response. The inquest heard that Amber 1 is the second highest category, reserved for people who are likely to be suffering from a life-threatening emergency.
An ambulance eventually arrived at 07:45 on 06/09/2023. This was almost 8 hours and 49 minutes after the call was registered. Sylvia had died by the time the ambulance arrived.
The reason for the delay was explored at the inquest and in part determined to be due to hospital handover delay.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance response to life-threatening emergencies
Wider context from the report “The correct procedure was adopted by the Welsh Ambulance Service and Sylvia was categorised as requiring an Amber 1 response. The inquest heard that Amber 1 is the second highest category, reserved for people who are likely to be suffering from a life-threatening emergency.
An ambulance eventually arrived at 07:45 on 06/09/2023. This was almost 8 hours and 49 minutes after the call was registered. Sylvia had died by the time the ambulance arrived.
The reason for the delay was explored at the inquest and in part determined to be due to hospital handover delay.
” 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 Create a post supporting the Chief Operating Officer’s team to increase urgent-care operational and escalation capacity.
Verbatim wording from the response “2. A new post supporting the Chief Operating Officer’s team to enhance capacity and focus on the urgent care system daily operating and escalation where appropriate.” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Deliver a proactive discharge project with Monmouthshire Local Authority at Nevill Hall Hospital.
Verbatim wording from the response “e. A focused project at Nevill Hall Hospital working with Monmouthshire Local Authority focused on proactive discharge arrangements to people’s own homes” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Create a discharge hub at Royal Gwent Hospital jointly with social care.
Verbatim wording from the response “b. Creation of a discharge hub at the Royal Gwent Hospital jointly with social care” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Improve Same Day Emergency Care services and increase patient selection to release emergency-department and assessment capacity.
Verbatim wording from the response “2. Workstream 2 - Urgent & Emergency Care Redesign” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Improve discharge-lounge use to create capacity and support ambulance handover times.
Verbatim wording from the response “3. Discharge Logistics” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Revise the escalation framework for ambulance handover delays.
Verbatim wording from the response “a. Revision of the escalation framework to ensure that the points of escalation during any ambulance handover delays are appropriate” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Introduce focused patient-safety events across Health Board sites to improve discharge processes and reduce discharge delays.
Verbatim wording from the response “3. Workstream 3 - Discharge Improvement to support more timely discharge and supporting people back to their own homes thereby reducing urgent and emergency care delays” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Create a Hospital to Home service providing additional community support.
Verbatim wording from the response “d. Creation of a Hospital to Home service to provide additional support within the community” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Increase substantive Physician Response Unit provision to deliver community emergency medicine and reduce emergency-department conveyance.
Verbatim wording from the response “3. A number of priority developments being tested and considered as part of the improvement programme.:” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Create a Ready to Go Ward and discharge floor at Royal Gwent Hospital to coordinate discharge and transition home.
Verbatim wording from the response “c. Creation of a Ready to Go Ward and a discharge floor at the Royal Gwent to bring together a discharge lounge, the Ready to Go Ward and an integrated hub to manage patients transition more effectively to their own home” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Hold weekly Patient Safety Flow meetings with defined action plans addressing patient flow and ambulance handover delays.
Verbatim wording from the response “Recent initiatives to improve patient flow and subsequent ambulance handover delays saw the introduction of weekly Patient Safety Flow meetings during May 2023, chaired by the Deputy Director of Operations with input from the Executive team including the Chief Executive, Chief Operating Officer, Director of Nursing, Director of Therapies and Medical Director. These meetings focus on the delivery and performance of the Health Board’s ED and MIUs with very clear action plans to mitigate the risk and seek improvements in patient flow and ambulance handover delays. The focus has been on the following workstreams:” Source location Response from Aneurin Bevan University Health Board
Open published response
20 Mar 2024 Neil Francis Edwards · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 1 Failure to investigate in-patient falls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Neil Francis Edwards · 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
Neil Francis Edwards was admitted to hospital in respiratory failure, was at high risk of falling, and required 1:1 observation. He suffered four falls, including an unobserved fall on 01/05/2023 that caused a hip fracture; after surgery, he suffered a gastrointestinal haemorrhage and died. The principal concerns were that the falls, including the fall contributing to his death, were not investigated and that this left insufficient reassurance about preventing similar deaths.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate in-patient falls
Wider context from the report “The inquest was advised that a Falls Panel had been convened to determine, in part, whether action could have been taken to prevent a fall which had occurred on 23/04/23.
I received no evidence that there had been any investigation into the other falls including, importantly, the fall on 01/05/23 that contributed to Mr Edwards’ death.
The court regularly hears that investigations into the circumstances of in-patient falls is central to minimising the risk going forward . It is of concern that no such investigation was undertaken at this time .
Additionally, as there was no investigation, the court was not reassured as to how deaths in similar circumstances might be prevented in the future.
” Open source report
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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 Strengthen the Serious Incident process by appointing investigating officers before initial meetings, providing investigation training, and applying enhanced governance and approval of reports and action plans.
Verbatim wording from the response “The Health Board’s Serious Incident Process has been reviewed to improve the scrutiny of incidents. Serious Incident meetings are considered mandatory and investigating officers are now appointed in advance of the first meeting to ensure the investigating officer can be present and engaged from the outset. The Health Board has been delivering Investigating officer training since September 2020 which includes SIs and complaints. The workshops are half day workshops based and provide Investigating Officers with a range of methodologies to use in their investigations.” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Use standardised Serious Incident agendas to define investigation scope, capture robust terms of reference, involve families from the outset and prompt reporting to external agencies.
Verbatim wording from the response “Improved and standardised agendas have been introduced as part of the SI process to ensure that the scope of investigation and robust terms of reference are captured and referred back to at the end of the process and this will include the involvement of patient families and any concerns they may have, from the outset. The standardised agenda includes a prompt to ensure reporting to external Agencies such as NHS Executive and the HSE.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Report inpatient falls through RLDatix and investigate falls causing fractures, with escalation through serious-incident and Duty of Candour processes where moderate or greater harm occurs.
Verbatim wording from the response “Falls are reported via the Health Board’s incident reporting procedures, namely by completing an incident report via our electronic ‘RL Datix Incident’ reporting system. These reports are circulated to relevant staff and senior managers for review and action. Where any concerns are identified, consideration will then be given to the form and type of post fall investigation required. For cases identified where moderate harm or above, these will be managed in line with the Health Board’s” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Operate a monthly Falls Review Panel to investigate injurious inpatient falls, identify learning, agree remedial actions and monitor fracture-related fall trends.
Verbatim wording from the response “The Health Board has a Falls Policy in place for Hospital Adult inpatients. The Falls Policy must be implemented at all levels within the organisation to ensure a safe and consistent approach is adopted. The aim is to reduce avoidable, injurious falls whilst ensuring appropriate management of patients who experience a fall, to include collaboration with intermediate care and the frailty programme.” Source location Response from Aneurin Bevan University Health Board
Open published response
4 Dec 2023 Catriona Ellen Martin · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 2 Unclear nursing-team requirements for supervising, supporting and intervening in care View source Lack of guidelines establishing the level of delegation of nursing duties View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Catriona Ellen Martin · 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
Catriona Ellen Martin was admitted to hospital with autoimmune encephalitis and died on 25 December 2020 after developing dehydration, acute kidney injury and uncontrolled seizures. The report identified inadequate nursing care, including failures to observe her and administer medication, and noted concerns about reliance on her mother to provide care without clear guidance on delegation and nursing staff support.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Unclear nursing-team requirements for supervising, supporting and intervening in care
Wider context from the report “At the inquest I determined that the level of care that Catriona’s mother was expected to provide was unacceptable but was informed that there are no guidelines to establish the level of delegation of nursing duties in such circumstances, and the requirement of the nursing team to not only continue to supervise care but to support and intervene as required .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines establishing the level of delegation of nursing duties
Wider context from the report “At the inquest I determined that the level of care that Catriona’s mother was expected to provide was unacceptable but was informed that there are no guidelines to establish the level of delegation of nursing duties in such circumstances , and the requirement of the nursing team to not only continue to supervise care but to support and intervene as required.
” Open source report
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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 Deliver staff education and training on safe delegation of care, family involvement and use of the enhanced observation framework.
Verbatim wording from the response “Following the raising of the matters of concern, it is recognised that additional training and education is required to ensure staff are clear in their responsibilities in regards appropriate delegation of care to family members. This can include patient care that is not only prescribed through cognitive impairment but is associated with acuity and complexity associated with intervention such as, post operative procedures. Education and training will be delivered via Patient Safety and Quality focused study sessions, supported by a bespoke programme of work with the Person-Centred Care Team. Throughout this work increased emphasis will be placed on appropriate and safe delegation, family involvement and utilising the framework not only for those patients with cognitive impairment but for those patients with complex medical acuity.” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Implement and roll out the Person-Centred Enhanced Observational Framework across acute and community wards.
Verbatim wording from the response “In August 2021, the Health Board developed and then launched a Person-Centred Enhanced Observational Framework. The purpose of the framework is to provide personalised, appropriate, consistent and high-quality enhanced observation/care for those patients deemed appropriate to receive such care requirements. The person-centred enhanced observation framework incorporates an individual management plan and tool kit which assesses a patient’s needs and supports the delivery of care to provide safe and dignified patient centred care.” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Revise the enhanced observation framework to document family discussions, delegation responsibilities and collaborative care planning.
Verbatim wording from the response “The Health Board is currently in the process of revising the Person-Centred Enhanced Observational Framework. The revised version will include the following requirements to be documented:” Source location Response from Aneurin Bevan University Health Board
Open published response
15 Nov 2023 Lynda BLACKMORE · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Handover delays impacting ambulance response times for patients requiring emergency treatment or conveyance to hospital View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lynda BLACKMORE · 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
Lynda Blackmore had established heart failure and diabetes and developed a painful, bruised and swollen left leg. After becoming acutely unwell, she experienced a delay of about 13 hours before an ambulance took her to hospital, where she was diagnosed with sepsis and died later that day. The principal concern was that ambulance response times were affected by mis-categorisation, resource availability and hospital handover delays, posing a risk to people requiring emergency treatment or hospital conveyance.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Handover delays impacting ambulance response times for patients requiring emergency treatment or conveyance to hospital
Wider context from the report “My concern here is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital . As Mr Garner stated in his evidence at para 45, the handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016 .
Such delays pose a risk to the lives of those requiring emergency treatment/conveyance to hospital.
” Open source report
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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 Operate a Flow Centre that screens ambulance and general-practitioner admissions and streams patients to appropriate hospitals and departments.
Verbatim wording from the response “1. Pre-Hospital / Flow Centre. Due to the unique nature of the Clinical Futures model that the Health Board manages, a Flow Centre is operated to ensure that all ambulance admissions (excepting life threatening emergencies) and admissions received from General Practitioners are screened to ensure that the patient is referred and streamed to the correct hospital and department. Further actions within this workstream include:” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Introduce focused patient-safety events across Health Board sites to improve discharge processes and reduce patients awaiting discharge.
Verbatim wording from the response “3. Discharge Improvement to support more timely discharge and supporting people back to their own homes thereby reducing urgent and emergency care delays” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Redirect clinically appropriate patients with specified conditions to eLGH sites for more rapid assessment and treatment.
Verbatim wording from the response “1. Pre-Hospital / Flow Centre. Due to the unique nature of the Clinical Futures model that the Health Board manages, a Flow Centre is operated to ensure that all ambulance admissions (excepting life threatening emergencies) and admissions received from General Practitioners are screened to ensure that the patient is referred and streamed to the correct hospital and department. Further actions within this workstream include:” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Improve Same Day Emergency Care services at GUH and YYF Hospitals and increase patient selection to release emergency capacity.
Verbatim wording from the response “2. Workstream 2 Urgent & Emergency Care Redesign” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Improve discharge-lounge use to create ward capacity and support ambulance handover times.
Verbatim wording from the response “3. Discharge Logistics” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Hold weekly Patient Safety Flow meetings with executive participation and action plans addressing patient flow and ambulance handover delays.
Verbatim wording from the response “Other initiatives have seen the introduction of weekly Patient Safety Flow meetings during May 2023, chaired by the Deputy Director of Operations with input from the Executive team including the Chief Executive, Chief Operating Officer, Director of Nursing, Director of Therapies and Medical Director. These meetings focus on the delivery and performance of the Health Board’s ED and MIUs with very clear action plans to mitigate the risk and seek improvements in patient flow and ambulance handover delays. The focus has been on the following areas:” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Revise the escalation framework so ambulance handover delay escalation points are appropriate.
Verbatim wording from the response “2. Emergency Department/Assessment Area Focus” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Strengthen divisional structures by giving Urgent Care full responsibility for corporate site management and coordinated patient flow.
Verbatim wording from the response “Since this incident, a review of the Health Board’s Divisional structures have been strengthened, with the Division of Urgent Care now assuming full responsibility for the Corporate Site management team to ensure a full and co-ordinated focus is maintained on safe patient flow and ambulance handover delays.” Source location Response from Aneurin Bevan University Health Board
Open published response
30 Jun 2023 Kaye McCoy · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 3 Failure to fully incorporate suicide-prevention guidelines into policy and practice View source Unavailability of 24-hour crisis support View source Lack of a strategy for engagement with the family View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kaye McCoy · 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
Kaye McCoy, who had depression, anxiety and Unstable Affective Disorder, died by hanging on 11 September 2022 after a severe downturn in her mental health. The report identified concerns about inadequate family involvement in her care and the lack of weekend or out-of-hours crisis support for Older Adults.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to fully incorporate suicide-prevention guidelines into policy and practice
Wider context from the report “At the inquest I was referred to the National Confidential Enquiry into Suicides. I was informed that the Enquiry identified key factors that should be adopted by Health Organisations to reduce the incidence of suicides, including:
• That there should be a strategy for engagement with the family.
• That every patient should have access to 24-hour Crisis Support
Neither of these key components of care were available to Kaye.
Whilst I was informed that there were steps being taken to address these I was not persuaded that these guidelines had been fully inculcated into policy and practice at Aneurin Bevan University Health Board .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Unavailability of 24-hour crisis support
Wider context from the report “At the inquest I was referred to the National Confidential Enquiry into Suicides. I was informed that the Enquiry identified key factors that should be adopted by Health Organisations to reduce the incidence of suicides, including:
• That there should be a strategy for engagement with the family.
• That every patient should have access to 24-hour Crisis Support
Neither of these key components of care were available to Kaye.
Whilst I was informed that there were steps being taken to address these I was not persuaded that these guidelines had been fully inculcated into policy and practice at Aneurin Bevan University Health Board.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of a strategy for engagement with the family
Wider context from the report “At the inquest I was referred to the National Confidential Enquiry into Suicides. I was informed that the Enquiry identified key factors that should be adopted by Health Organisations to reduce the incidence of suicides, including:
• That there should be a strategy for engagement with the family.
• That every patient should have access to 24-hour Crisis Support
Neither of these key components of care were available to Kaye.
Whilst I was informed that there were steps being taken to address these I was not persuaded that these guidelines had been fully inculcated into policy and practice at Aneurin Bevan University Health Board.
” 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 Explore alternative crisis-service models, review other Welsh Health Boards’ provision, and develop associated standards for ongoing audit.
Verbatim wording from the response “In addition to the pathways described above, the Health Board is exploring other alternatives including understanding the offers of other Health Boards in Wales from a future review of crisis provision for this group, with associated standards for ongoing audit. In the interim, the Health Board will continue to audit use of the current pathway by the older adult population to continue to inform service development.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Produce staff guidance on principles for family and supporter involvement in care and care planning, including confidentiality and inclusion.
Verbatim wording from the response “This year’s National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) Annual Report also provides data and evidence relating to family and supporter involvement in patient care. This is discussed during the Division’s awareness-raising training to registrants about NCISH findings which highlights and promotes helpful and inclusive dialogue with patients and their families/supporters. The Division will be producing a guidance document – ‘Principles for family/supporter involvement in care and care planning’ for staff which will also include advice and principles in relation to confidentiality and inclusion. This will be drafted by the end of October 2023.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Make Tŷ Cynnаl crisis-sanctuary support available to older people known to the mental health service.
Verbatim wording from the response “e. Tŷ Cynnаl is a house provided in partnership with ‘Platform’, a third sector organisation that supports people with mental health issues when housing. The house is available to support people experiencing mental health crisis who do not require medical/hospital support but require a safe sanctuary for support to manage their distress. People are referred to Tŷ Cynnаl by the mental health service. This option has only recently become available to older people experiencing crisis who are already known to the mental health service.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Strengthen family-engagement content in Care and Treatment Planning and WARRN risk-formulation training.
Verbatim wording from the response “With regard to the first point, the Division of Mental Health and Learning Disabilities has a number of processes currently in place to support family engagement, for example, training in both Care and Treatment Planning and in Wales Applied Risk Research Network (WARRN) risk formulation, which emphasises the importance of family involvement and engagement, particularly in the recognition and management of relapse indicators and contingency” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Consider the completed pilot’s findings and recommendations for future crisis-service provision.
Verbatim wording from the response “Additionally, the Older Adult Mental Health service has completed a 6-month pilot extending the hours of the Community Mental Health Team in Caerphilly, to include evenings and weekends. The pilot funded extra clinical staff to support this function and Caerphilly was chosen as the pilot area as the highest populated borough within Gwent to establish need and demand. One of the terms of reference of the Health Board’s incident review into Mrs McCoy’s death was whether her needs would have met the criteria for inclusion in this pilot. The Investigating Officer found that she would have been offered this service if she lived in Caerphilly at that time.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Continue auditing older adults’ use of current crisis pathways to inform service development.
Verbatim wording from the response “In addition to the pathways described above, the Health Board is exploring other alternatives including understanding the offers of other Health Boards in Wales from a future review of crisis provision for this group, with associated standards for ongoing audit. In the interim, the Health Board will continue to audit use of the current pathway by the older adult population to continue to inform service development.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Extend the Shared Lives crisis-support project to include older people.
Verbatim wording from the response “d. The ‘Shared Lives’ project, previously available to younger adults, has recently been extended to include older people in crisis. The schemes match someone who needs care with an approved carer. The carer shares their family and community life, and gives care and support to the person with care needs. (This service was not available at the time that Mrs McCoy was experiencing crisis.)” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Extend Community Mental Health Team operating hours into evenings and weekends through a six-month pilot funded with additional clinical staff.
Verbatim wording from the response “Additionally, the Older Adult Mental Health service has completed a 6-month pilot extending the hours of the Community Mental Health Team in Caerphilly, to include evenings and weekends. The pilot funded extra clinical staff to support this function and Caerphilly was chosen as the pilot area as the highest populated borough within Gwent to establish need and demand. One of the terms of reference of the Health Board’s incident review into Mrs McCoy’s death was whether her needs would have met the criteria for inclusion in this pilot. The Investigating Officer found that she would have been offered this service if she lived in Caerphilly at that time.” Source location Response from Aneurin Bevan University Health Board
Open published response
21 Apr 2023 Maria Christine Shafighian · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 2 Failure to bring urgent matters immediately to the attention of referring teams View source Failure to ensure timely handling of internal post View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maria Christine Shafighian · 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
Maria Christine Shafighian died from the effects of metastatic oesophageal cancer on 24 November 2020. During the inquest, missed opportunities to identify and treat the tumour earlier were identified, although it could not be determined that earlier treatment would have altered the outcome. A concern was raised that urgent information from the Speech and Language Therapists was sent through an internal postal system without a process for immediate notification or timely handling, and was apparently delayed by a month before being noticed by the ENT team.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to bring urgent matters immediately to the attention of referring teams
Wider context from the report “During the inquest I heard that the process by which the SALT team notified the ENT department of the change in Maria’s presentation and the development of dysphagia was through an internal postal system. Following assessment by SALT on 4/5/2020, a letter was written to the ENT team which was printed and left in a pigeon hole.
No evidence was forthcoming to describe a system whereby urgent matters would be brought immediately to the attention of the referring team and there was no process for ensuring that the post was dealt with in a timely manner.
In Maria’s case there appears to have been a delay of a month between the letter being sent and being noticed by the ENT team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely handling of internal post
Wider context from the report “During the inquest I heard that the process by which the SALT team notified the ENT department of the change in Maria’s presentation and the development of dysphagia was through an internal postal system. Following assessment by SALT on 4/5/2020, a letter was written to the ENT team which was printed and left in a pigeon hole.
No evidence was forthcoming to describe a system whereby urgent matters would be brought immediately to the attention of the referring team and there was no process for ensuring that the post was dealt with in a timely manner .
In Maria’s case there appears to have been a delay of a month between the letter being sent and being noticed by the ENT team.
” 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 Require urgent clinical developments needing ENT opinion to be emailed to the Head and Neck MDTs and supporting services.
Verbatim wording from the response “In addition, ████████ Head and Neck Cancer Lead, has communicated to the Head and Neck MDTs and supporting services that for any urgent clinical developments requiring an ENT opinion, these should also be e-mailed.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Route internal ENT referrals directly to Central Registration for electronic upload and consultant triage.
Verbatim wording from the response “In order to improve the system, speed up the process, and provide a more robust audit trail of referral demands, it has been discussed and agreed that internal referrals to the ENT department need to be sent straight to the Central Registration department for them to take action and upload the information on the referral, and send this electronically to the ENT consultants for triage. This would mirror the GP process.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Develop a generic internal electronic referral form for patients requiring ENT input or an opinion.
Verbatim wording from the response “The Directorate is also in the process of developing a generic internal electronic referral form that would need to be completed for any patients needing ENT input or an opinion. This would remove the need for paper letters or referrals to be sent, speed up the process, and provide an audit trail of receipt and action on the system.” Source location Response from Aneurin Bevan University Health Board
Open published response
11 Jan 2023 Lucy Amanda Jones · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 3 Delays in access to Cognitive Behavioural Therapy View source Failure to make adequate efforts to establish contact when a patient cannot be reached View source Failure to provide planned community follow-up within the required timeframe View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lucy Amanda Jones · 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
Lucy Amanda Jones developed a serious mental illness in 2019 and died by hanging on 12 March 2022. She remained on a waiting list for Cognitive Behavioural Therapy and was not seen in the community after a planned follow-up in January 2022; attempts to contact her were limited to two phone calls, with no cold call made when she could not be contacted.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in access to Cognitive Behavioural Therapy
Wider context from the report “1. Lucy Amanda Jones was admitted to Talygarn Ward at The County Hospital Pontypool in December 2019 under Section 2 of the Mental Health Act. On discharge from hospital, she was placed on the waiting list for Cognitive Behavioural Therapy (CBT). In evidence provided by her General Practitioner, I was informed that Lucy was still waiting for CBT at the time of her death in March 2022.
2. Following Lucy’s death a concise review of the care she had received from the mental health team was undertaken. The review noted that following a consultant review in January 2022, Lucy was due to be followed up in the community within 2 weeks, but that in fact she was not seen again prior to her death. The Community Psychiatric Nurse (CPN) attempted to make contact by phone only 2 occasions and did not speak to Lucy. The CPN was apparently reassured by Lucy’s housemate, who had no concerns for Lucy.
No efforts were made to “cold call” when Lucy could not be contacted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to make adequate efforts to establish contact when a patient cannot be reached
Wider context from the report “1. Lucy Amanda Jones was admitted to Talygarn Ward at The County Hospital Pontypool in December 2019 under Section 2 of the Mental Health Act. On discharge from hospital, she was placed on the waiting list for Cognitive Behavioural Therapy (CBT). In evidence provided by her General Practitioner, I was informed that Lucy was still waiting for CBT at the time of her death in March 2022.
2. Following Lucy’s death a concise review of the care she had received from the mental health team was undertaken. The review noted that following a consultant review in January 2022, Lucy was due to be followed up in the community within 2 weeks, but that in fact she was not seen again prior to her death. The Community Psychiatric Nurse (CPN) attempted to make contact by phone only 2 occasions and did not speak to Lucy. The CPN was apparently reassured by Lucy’s housemate, who had no concerns for Lucy.
No efforts were made to “cold call” when Lucy could not be contacted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to provide planned community follow-up within the required timeframe
Wider context from the report “1. Lucy Amanda Jones was admitted to Talygarn Ward at The County Hospital Pontypool in December 2019 under Section 2 of the Mental Health Act. On discharge from hospital, she was placed on the waiting list for Cognitive Behavioural Therapy (CBT). In evidence provided by her General Practitioner, I was informed that Lucy was still waiting for CBT at the time of her death in March 2022.
2. Following Lucy’s death a concise review of the care she had received from the mental health team was undertaken. The review noted that following a consultant review in January 2022, Lucy was due to be followed up in the community within 2 weeks, but that in fact she was not seen again prior to her death . The Community Psychiatric Nurse (CPN) attempted to make contact by phone only 2 occasions and did not speak to Lucy. The CPN was apparently reassured by Lucy’s housemate, who had no concerns for Lucy.
No efforts were made to “cold call” when Lucy could not be contacted.
” 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 Finalize, consult on and submit the Disengagement and Did Not Attend policy for ratification.
Verbatim wording from the response “With regard to the policy that determines what steps should be taken to ensure that mental health practitioners can be properly reassured about the health of their patients who are refusing or reluctant to engage, the Adult Mental Health and Specialist Services Directorate has developed a policy to guide clinicians in their next steps when a person does not attend” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Pilot embedded psychological care with outpatient follow-up and smoother transition pathways.
Verbatim wording from the response “In regard to this particular case, since this time the Health Board has invested further in psychological input to acute treatment areas and is piloting a model of embedded psychological care which gives some provision for outpatient follow-up. This allows for smoother transitions, increased relational consistency (rather than needing to develop a new therapeutic relationship with a different clinician), and more effective care pathways. There is, of course, also the growth in the ‘Open Dialogue’ model of care (a model of mental health care which involves a consistent family and social network approach where all treatment is carried out via a whole system/network meeting, which always include the patient) and this is being provided by multi-disciplinary staff embedded in both acute care environments and community provision.” Source location Response from Aneurin Bevan University Health Board
Open published response
31 Aug 2022 Gareth WILLIAMS · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 2 Failure to establish clear ownership of care between mental health and ENT teams View source Failure of direct communication between mental health and ENT teams View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gareth WILLIAMS · 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
Gareth Williams, who had worsening tinnitus and declining mental health with suicidal thoughts, was discovered hanging on 23 August 2021 and could not be revived. The concern was that he was left without sufficient support because mental health and ENT services transferred him between teams without directly communicating.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to establish clear ownership of care between mental health and ENT teams
Wider context from the report “Gareth Williams found himself in a no-win situation. His mental health could not be improved without a resolution to his hearing problems and his tinnitus was untreatable. During the course of his treatment, Gareth was regularly transferred back to the “other” team , being told that either mental health or ENT was the most appropriate speciality .
I found that Gareth was left without sufficient support, falling between 2 teams, who did not directly communicate with each other.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of direct communication between mental health and ENT teams
Wider context from the report “Gareth Williams found himself in a no-win situation. His mental health could not be improved without a resolution to his hearing problems and his tinnitus was untreatable. During the course of his treatment, Gareth was regularly transferred back to the “other” team, being told that either mental health or ENT was the most appropriate speciality.
I found that Gareth was left without sufficient support , falling between 2 teams , who did not directly communicate with each other .
” 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 Map existing services to support appropriate pathway allocation for people referred to the expanded Adferiad service.
Verbatim wording from the response “I am pleased to share that Welsh Government has confirmed that a Health Board service - ‘Adferiad’ - originally developed for people experiencing the effects of ‘Long Covid’ will be receiving substantive, recurrent funding from April 2023 which will also allow it to broaden its inclusion criteria to people with other medical and long-term conditions for whom there are no existing care pathways. This service will be delivered by a team of medical, nursing and Allied Health Professionals – including Health and Clinical Psychologists, thus offering a multi-disciplinary perspective from the point of referral and for consultation to other disciplines & specialties. Part of the expansion of the service will be to map existing services to ensure the person is on the ‘right’ pathway, with a ‘bespoke’ approach to each person’s needs.” Source location Response from Aneurin Bevan University Health Board
Open published response
×
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 Expand Adferiad through recurrent funding, broader eligibility and a multidisciplinary team providing assessment, care planning and rehabilitation expertise.
Verbatim wording from the response “I am pleased to share that Welsh Government has confirmed that a Health Board service - ‘Adferiad’ - originally developed for people experiencing the effects of ‘Long Covid’ will be receiving substantive, recurrent funding from April 2023 which will also allow it to broaden its inclusion criteria to people with other medical and long-term conditions for whom there are no existing care pathways. This service will be delivered by a team of medical, nursing and Allied Health Professionals – including Health and Clinical Psychologists, thus offering a multi-disciplinary perspective from the point of referral and for consultation to other disciplines & specialties. Part of the expansion of the service will be to map existing services to ensure the person is on the ‘right’ pathway, with a ‘bespoke’ approach to each person’s needs.” Source location Response from Aneurin Bevan University Health Board
Open published response
3 Mar 2022 Marvin John RUE · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 3 Failure to investigate why staff did not follow falls risk assessment procedures View source Failure to complete Multifactorial Risk Assessments at admission and after hospital transfers or falls View source Failure to complete regular ward audits of falls risk assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Marvin John RUE · 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
Marvin Rue was admitted to hospital on 8 January 2021 after a fall and fell five times during his admission. On 2 February 2021, he suffered a fatal head injury after another fall and died on 3 February 2021. The principal concerns were failures to complete falls-risk assessments after admission, hospital transfers and previous falls, resulting in inadequate supervision; the report also identified failures to investigate staff non-compliance and to carry out audits.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate why staff did not follow falls risk assessment procedures
Wider context from the report “Marvin Rue had fallen prior to his admission to hospital on 8th January 2021 and was therefore, due to his age and circumstances, a “known falls risk”. In evidence I heard that in these circumstances a Multifactorial Risk Assessment (MFRA) should take place within 6 hours of admission to hospital. It was not.
Mr Rue was transferred between hospitals during his admission, initially to Nevill Hall Hospital and then to Ysbyty Aneurin Bevan. I heard in evidence that a review of the MFRA should take place after every hospital transfer. Mr Rue had no MFRA undertaken after his transfers.
Mr Rue fell 5 times prior to his fatal fall in hospital on 2nd February 2021. Contrary to Health Board Policy, Mr Rue did not have an MFRA undertaken after any of these falls. In fact there was never an MFRA correctly completed for Mr Rue throughout his hospital admission.
I heard evidence that during this time the staff were under significant pressure due to the effects of the pandemic, and I accept that. However the care that Mr Rue was denied was basic nursing care. ████████ the Lead Nurse and author of the Serious Concerns Report, indicated that had Mr Rue been assessed, he would have warranted 1:1 supervision . As a result I concluded that the failures in care directly contributed to Mr Rue’s death.
During the inquest I have been presented with an action plan, however this is not the first action plan I have been presented with (in very similar circumstances) and sadly I am not convinced that this plan will prevent future deaths for the following reasons. The policies referred to above have been in place for several years. I am informed that although there is bespoke documentation training, all staff are trained in falls risk assessment from the time they are in nurse training. Therefore it is not a lack of understanding or policies which have caused these failures.
None of the staff were interviewed during the internal investigation and no evidence was forthcoming as to why staff did not follow the procedures. Without this information I do not consider that the actions plan will prevent future deaths. I refer you to your previous responses to PFDs which have clearly not had the desired outcome.
Despite being previously reassured that regular ward audits would take place to ensure that the risk assessment were being undertaken I heard no evidence that audits were completed at this time and so the failures went unnoticed until after Mr Rue’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to complete Multifactorial Risk Assessments at admission and after hospital transfers or falls
Wider context from the report “Marvin Rue had fallen prior to his admission to hospital on 8th January 2021 and was therefore, due to his age and circumstances, a “known falls risk”. In evidence I heard that in these circumstances a Multifactorial Risk Assessment (MFRA) should take place within 6 hours of admission to hospital. It was not.
Mr Rue was transferred between hospitals during his admission, initially to Nevill Hall Hospital and then to Ysbyty Aneurin Bevan. I heard in evidence that a review of the MFRA should take place after every hospital transfer. Mr Rue had no MFRA undertaken after his transfers.
Mr Rue fell 5 times prior to his fatal fall in hospital on 2nd February 2021. Contrary to Health Board Policy, Mr Rue did not have an MFRA undertaken after any of these falls. In fact there was never an MFRA correctly completed for Mr Rue throughout his hospital admission.
I heard evidence that during this time the staff were under significant pressure due to the effects of the pandemic, and I accept that. However the care that Mr Rue was denied was basic nursing care. ████████ the Lead Nurse and author of the Serious Concerns Report, indicated that had Mr Rue been assessed, he would have warranted 1:1 supervision . As a result I concluded that the failures in care directly contributed to Mr Rue’s death.
During the inquest I have been presented with an action plan, however this is not the first action plan I have been presented with (in very similar circumstances) and sadly I am not convinced that this plan will prevent future deaths for the following reasons. The policies referred to above have been in place for several years. I am informed that although there is bespoke documentation training, all staff are trained in falls risk assessment from the time they are in nurse training. Therefore it is not a lack of understanding or policies which have caused these failures.
None of the staff were interviewed during the internal investigation and no evidence was forthcoming as to why staff did not follow the procedures. Without this information I do not consider that the actions plan will prevent future deaths. I refer you to your previous responses to PFDs which have clearly not had the desired outcome.
Despite being previously reassured that regular ward audits would take place to ensure that the risk assessment were being undertaken I heard no evidence that audits were completed at this time and so the failures went unnoticed until after Mr Rue’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to complete regular ward audits of falls risk assessments
Wider context from the report “Marvin Rue had fallen prior to his admission to hospital on 8th January 2021 and was therefore, due to his age and circumstances, a “known falls risk”. In evidence I heard that in these circumstances a Multifactorial Risk Assessment (MFRA) should take place within 6 hours of admission to hospital. It was not.
Mr Rue was transferred between hospitals during his admission, initially to Nevill Hall Hospital and then to Ysbyty Aneurin Bevan. I heard in evidence that a review of the MFRA should take place after every hospital transfer. Mr Rue had no MFRA undertaken after his transfers.
Mr Rue fell 5 times prior to his fatal fall in hospital on 2nd February 2021. Contrary to Health Board Policy, Mr Rue did not have an MFRA undertaken after any of these falls. In fact there was never an MFRA correctly completed for Mr Rue throughout his hospital admission.
I heard evidence that during this time the staff were under significant pressure due to the effects of the pandemic, and I accept that. However the care that Mr Rue was denied was basic nursing care. ████████ the Lead Nurse and author of the Serious Concerns Report, indicated that had Mr Rue been assessed, he would have warranted 1:1 supervision . As a result I concluded that the failures in care directly contributed to Mr Rue’s death.
During the inquest I have been presented with an action plan, however this is not the first action plan I have been presented with (in very similar circumstances) and sadly I am not convinced that this plan will prevent future deaths for the following reasons. The policies referred to above have been in place for several years. I am informed that although there is bespoke documentation training, all staff are trained in falls risk assessment from the time they are in nurse training. Therefore it is not a lack of understanding or policies which have caused these failures.
None of the staff were interviewed during the internal investigation and no evidence was forthcoming as to why staff did not follow the procedures. Without this information I do not consider that the actions plan will prevent future deaths. I refer you to your previous responses to PFDs which have clearly not had the desired outcome.
Despite being previously reassured that regular ward audits would take place to ensure that the risk assessment were being undertaken I heard no evidence that audits were completed at this time and so the failures went unnoticed until after Mr Rue’s death.
” Open source report
14 Jan 2022 Brian Wareham · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 2 Failure of communication and collaboration between primary and secondary care View source Failure to directly contact the responsible medical team to address significant concerns View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brian Wareham · 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
Brian Wareham was diagnosed with oesophageal dysmotility, which worsened and prevented him from eating sufficiently to maintain his nutritional status; he died at St David’s Hospice on 2 November 2020. The report raised concerns about communication and collaboration between primary and secondary care, including uncertainty about his treatment approach and a breakdown in communication, trust and respect between clinicians.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of communication and collaboration between primary and secondary care
Wider context from the report “1. Communication and collaboration between primary and secondary care.
Brian Wareham had been admitted to hospital in May 2020 with ongoing symptoms of weight loss, dysphagia and general weakness. He was discharged in June 2020 with a package of care and the treating clinicians felt that his condition had stabilised. There was no immediate cure for Brian’s problems and he was provided with advice about a softer, more manageable diet.
In evidence his GP (Dr ████████of the Richmond clinic in Newport) stated that he thought Brian should have remained in hospital, that he was not fit to be at home. Dr ████████ stated that he did not understand the relationship between Brian’s gastroenterology problems and his newly diagnosed lung cancer, specifically whether he was for active treatment or whether the approach was to be palliative.
Given the GPs considerable concerns which he voiced with frustration and disdain, I questioned why he made no effort to try to address these problems by directly contacting the medical team in Nevill Hall Hospital responsible for Mr Wareham and who had in fact written to the GP practice at the time of his discharge.
When these questions were put to Dr ████████he stated that he thought this would be futile and it appeared that there was a significant breakdown in communication, trust and respect between primary and secondary care.
The current situation appears to leave vulnerable patients without appropriate information and support due to a breakdown in the relationship between clinicians.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to directly contact the responsible medical team to address significant concerns
Wider context from the report “1. Communication and collaboration between primary and secondary care.
Brian Wareham had been admitted to hospital in May 2020 with ongoing symptoms of weight loss, dysphagia and general weakness. He was discharged in June 2020 with a package of care and the treating clinicians felt that his condition had stabilised. There was no immediate cure for Brian’s problems and he was provided with advice about a softer, more manageable diet.
In evidence his GP (Dr ████████of the Richmond clinic in Newport) stated that he thought Brian should have remained in hospital, that he was not fit to be at home. Dr ████████ stated that he did not understand the relationship between Brian’s gastroenterology problems and his newly diagnosed lung cancer, specifically whether he was for active treatment or whether the approach was to be palliative.
Given the GPs considerable concerns which he voiced with frustration and disdain, I questioned why he made no effort to try to address these problems by directly contacting the medical team in Nevill Hall Hospital responsible for Mr Wareham and who had in fact written to the GP practice at the time of his discharge.
When these questions were put to Dr ████████he stated that he thought this would be futile and it appeared that there was a significant breakdown in communication, trust and respect between primary and secondary care.
The current situation appears to leave vulnerable patients without appropriate information and support due to a breakdown in the relationship between clinicians.
” 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 Provide GPs with intranet access to information on pathways, Secondary Care Services and advice lines.
Verbatim wording from the response “We also send all GPs a weekly message from the Deputy Medical Director, highlighting key information and any changes to Secondary Care Services to ensure Primary Care remain up to date on how to access and communicate with Specialist Services. Information on pathways, Secondary Care Services and advice lines is also obtainable on the ABUHB intranet, which is accessible to GPs through the NHS computer network. As part of our urgent care and outpatient transformation work streams, we aim to keep these resources up to date as Services evolve.” Source location 2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Open published response
×
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 Create a bypass-number directory enabling hospital teams to contact GP surgeries directly when immediately necessary.
Verbatim wording from the response “Since 2020, major changes have taken place within ABUHB boundary due to Covid 19, but also due to the reorganisation of our Services and the opening of the Grange University Hospital. These changes have required us to develop methods and strategies to enhance communication at the interface between Primary and Secondary care. Some of the main changes we have made include:” Source location 2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Open published response
×
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 Send GPs weekly updates from the Deputy Medical Director about key information and changes to Secondary Care Services.
Verbatim wording from the response “We also send all GPs a weekly message from the Deputy Medical Director, highlighting key information and any changes to Secondary Care Services to ensure Primary Care remain up to date on how to access and communicate with Specialist Services. Information on pathways, Secondary Care Services and advice lines is also obtainable on the ABUHB intranet, which is accessible to GPs through the NHS computer network. As part of our urgent care and outpatient transformation work streams, we aim to keep these resources up to date as Services evolve.” Source location 2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Open published response
×
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 Launch direct-access telephone advice lines for urgent and outpatient queries through Consultant Connect.
Verbatim wording from the response “Since 2020, major changes have taken place within ABUHB boundary due to Covid 19, but also due to the reorganisation of our Services and the opening of the Grange University Hospital. These changes have required us to develop methods and strategies to enhance communication at the interface between Primary and Secondary care. Some of the main changes we have made include:” Source location 2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Open published response
×
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 Operate a Medical Examiner service with multidisciplinary panel review, including Primary Care input, to identify and review interface issues.
Verbatim wording from the response “As you will be aware, the Medical Examiner (ME) Service is now operating in Gwent with cases referred by the ME being reviewed by a Multidisciplinary Panel, which includes Primary Care input. This provides us with a further mechanism to identify and review any issues regarding the interface between Primary and Secondary care.” Source location 2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Open published response
×
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 Provide access to a medical consultant for clinical advice through the Flow Centre telephone line.
Verbatim wording from the response “Since 2020, major changes have taken place within ABUHB boundary due to Covid 19, but also due to the reorganisation of our Services and the opening of the Grange University Hospital. These changes have required us to develop methods and strategies to enhance communication at the interface between Primary and Secondary care. Some of the main changes we have made include:” Source location 2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing clinical systems, letters, directories and switchboards provide GPs with sufficient access to hospital records, clinicians and support.
Verbatim wording from the response “In the Gwent area, GPs have access to the Clinical Workstation (CWS) system where all clinic letters and hospital records are stored. This enables a GP to review records and past/future appointments to ascertain which hospital clinicians are involved in an individual’s care. Clinic and Discharge letters would usually also be sent directly to a GP Practice, which will include the name of the responsible consultant and contact details for the secretary. Contact details for hospital based clinicians can be obtained through hospital telephony switchboards or via the NHS email address book, which is available to GPs. These sources of information and support would have been available to Dr ████████ when delivering care to Mr Wareham.” Source location 2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation For community patients, the registered GP and Primary Care team have overall responsibility for medical care coordination.
Verbatim wording from the response “For individuals in the community, the registered GP has overall responsibility for their medical care. The Primary Care team will therefore be the first point of contact for most health issues, and will take the role of coordinators in a patient’s health care management. However, we acknowledge that in these situations it can be difficult for Primary Care teams to ascertain who is the most appropriate single point of contact when needing support to care for individuals who have multiple complex health issues. Due to specialisation in hospital medicine, there may not be a single point of contact which requires Primary Care teams to be a point of continuity and coordination. There are multiple ways in which Primary Care teams can obtain information regarding an individual’s hospital care.” Source location 2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Open published response
13 Jul 2021 Valmai Ann WEST · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 2 Failure to perform patient observations at the required frequency View source Inadequate staffing levels for the full range of Emergency Department duties View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Valmai Ann WEST · 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
Valmai West suffered falls on 11 and 16 January 2020, was admitted to hospital after fracturing her pubic ramus, and was later found unresponsive with an extensive subdural haemorrhage. She died at the Royal Gwent Hospital on 22 January 2020. The concern identified was that Emergency Department staffing levels may have contributed to observations not being performed in accordance with hospital protocol and NICE guidance, potentially putting future patients at risk.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to perform patient observations at the required frequency
Wider context from the report “During the course of the inquest, consideration was given to the clinical decisions made in the Emergency Department of the Royal Gwent Hospital. I concluded that there was no evidence that Mrs West was displaying signs that would alert the staff to a possible intracranial bleed. However in evidence Dr ████████ Consultant in Emergency Medicine, acknowledged that the staff had not followed hospital protocol or the NICE guidance in relation to the frequency with which observations should be performed . Dr ████████ assessment of the situation was that this was probably caused by inadequate staff numbers to undertake the full range of duties required. She further stated that this is a frequent and ongoing problem in the Emergency Department.
Whilst this did not influence the outcome for Mrs West I am concerned that this may put the lives of future patients at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing levels for the full range of Emergency Department duties
Wider context from the report “During the course of the inquest, consideration was given to the clinical decisions made in the Emergency Department of the Royal Gwent Hospital. I concluded that there was no evidence that Mrs West was displaying signs that would alert the staff to a possible intracranial bleed. However in evidence Dr ████████ Consultant in Emergency Medicine, acknowledged that the staff had not followed hospital protocol or the NICE guidance in relation to the frequency with which observations should be performed. Dr ████████ assessment of the situation was that this was probably caused by inadequate staff numbers to undertake the full range of duties required . She further stated that this is a frequent and ongoing problem in the Emergency Department .
Whilst this did not influence the outcome for Mrs West I am concerned that this may put the lives of future patients at risk.
” 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 Undertake a review of Emergency Department medical staffing alongside the nurse staffing review.
Verbatim wording from the response “Senior Nurse Manager for ED and the Assistant Head of Nursing, supported by the Deputy Director of Nursing. The assessment is based on RCN Guidance, RCEM Guidance, Nurse Staffing Levels (Wales) Act 2016 and, importantly, professional judgement. A similar review of medical staffing is also being undertaken.” Source location 2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
Open published response
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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 Complete a review of Emergency Department nurse staffing levels following the Regulation 28 Report.
Verbatim wording from the response “Following receipt of the Regulation 28 Report a review of the nurse staffing levels was undertaken by the Senior Nurse Manager of the Emergency Department. I can confirm nurse staffing levels at the index time were appropriate and adequate and as per the roster for the area the patient was cared for. The staffing levels would not have impacted on the ability to undertake neurological observations.” Source location 2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
Open published response
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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 Complete an in-depth review of Emergency Department nurse staffing levels at Grange University Hospital, considering increased demand and relevant staffing guidance.
Verbatim wording from the response “I thought it would be helpful to share that an in-depth review of nurse staffing levels for the Emergency Department (ED) at the Grange University Hospital was commissioned as a result of the early opening of the hospital and in light of increased patient demand. This has been undertaken by the” Source location 2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Nurse staffing levels were adequate and did not prevent neurological observations.
Verbatim wording from the response “Following receipt of the Regulation 28 Report a review of the nurse staffing levels was undertaken by the Senior Nurse Manager of the Emergency Department. I can confirm nurse staffing levels at the index time were appropriate and adequate and as per the roster for the area the patient was cared for. The staffing levels would not have impacted on the ability to undertake neurological observations.” Source location 2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
Open published response
12 Mar 2021 Elizabeth Robinson · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 5 Failure to disseminate internal investigation findings to relevant nursing staff View source Failure to complete falls risk assessments and documentation View source Insufficient nursing staffing levels for delivery of safe patient care View source Failure to consider staffing levels in internal investigations View source Omissions in the falls risk assessment process View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elizabeth Robinson · 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
Elizabeth Robinson, an 87-year-old woman at Ysbyty Ystrad Fawr for rehabilitation after hip surgery, fell and sustained a fatal head injury on 21 October 2019. Concerns included inadequate falls-risk assessment and documentation, staffing levels that nurses considered insufficient to deliver safe care, and nursing staff not having seen the internal investigation findings more than a year after her death.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate internal investigation findings to relevant nursing staff
Wider context from the report “2. Serious Concerns report findings
At the inquest, Mrs Rowlands described the omissions in the falls risk assessment process and the steps that are now being taken to ensure that staff complete the documentation properly. It is my understanding that the internal investigation is an essential component of organisational learning to improve the quality of care to patients and also prevent future deaths. Mrs Rowlands informed me that falls were the greatest risk posed to patients by the Health Board. I was therefore concerned to hear that neither of the nursing staff who gave evidence had seen the findings of the internal investigation some 1 years and 4 months since Mrs Robinson’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to complete falls risk assessments and documentation
Wider context from the report “1. Staffing Levels
Aneurin Bevan University Health Board undertook an internal investigation which was presented at the inquest by ████████ and ████████ confirmed that Mrs Robinson had not been correctly assessed and warranted a higher level of supervision to minimise the risk of her falling . Whilst the documentation was not completed , two nurses gave evidence and I was reassured that they both understood that Mrs Robinson was at high risk of falls and were monitoring her as closely as possible with the staffing complement available. I was informed that on the ward at YYF there were usually 3 members of nursing staff to care for 15 patients. Mrs Robinson was in a cohorted group which meant that 1 member of staff was assigned to observe a group of 4 patients at all times. This left 2 nurses for the remaining 11 patients. The nurses who gave evidence both told me that they rarely managed to get their full breaks (40 minutes in a 12 hour shift) and were constantly in a position where they did not feel they could deliver a safe standard of care to the patients.
Mrs Rowlands confirmed that staffing levels were not considered during the investigation and it was further confirmed that these apparently low staffing levels still exist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing staffing levels for delivery of safe patient care
Wider context from the report “1. Staffing Levels
Aneurin Bevan University Health Board undertook an internal investigation which was presented at the inquest by ████████ and ████████ confirmed that Mrs Robinson had not been correctly assessed and warranted a higher level of supervision to minimise the risk of her falling. Whilst the documentation was not completed, two nurses gave evidence and I was reassured that they both understood that Mrs Robinson was at high risk of falls and were monitoring her as closely as possible with the staffing complement available. I was informed that on the ward at YYF there were usually 3 members of nursing staff to care for 15 patients . Mrs Robinson was in a cohorted group which meant that 1 member of staff was assigned to observe a group of 4 patients at all times. This left 2 nurses for the remaining 11 patients. The nurses who gave evidence both told me that they rarely managed to get their full breaks (40 minutes in a 12 hour shift) and were constantly in a position where they did not feel they could deliver a safe standard of care to the patients .
Mrs Rowlands confirmed that staffing levels were not considered during the investigation and it was further confirmed that these apparently low staffing levels still exist .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to consider staffing levels in internal investigations
Wider context from the report “1. Staffing Levels
Aneurin Bevan University Health Board undertook an internal investigation which was presented at the inquest by ████████ and ████████ confirmed that Mrs Robinson had not been correctly assessed and warranted a higher level of supervision to minimise the risk of her falling. Whilst the documentation was not completed, two nurses gave evidence and I was reassured that they both understood that Mrs Robinson was at high risk of falls and were monitoring her as closely as possible with the staffing complement available. I was informed that on the ward at YYF there were usually 3 members of nursing staff to care for 15 patients. Mrs Robinson was in a cohorted group which meant that 1 member of staff was assigned to observe a group of 4 patients at all times. This left 2 nurses for the remaining 11 patients. The nurses who gave evidence both told me that they rarely managed to get their full breaks (40 minutes in a 12 hour shift) and were constantly in a position where they did not feel they could deliver a safe standard of care to the patients.
Mrs Rowlands confirmed that staffing levels were not considered during the investigation and it was further confirmed that these apparently low staffing levels still exist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Omissions in the falls risk assessment process
Wider context from the report “2. Serious Concerns report findings
At the inquest, Mrs Rowlands described the omissions in the falls risk assessment process and the steps that are now being taken to ensure that staff complete the documentation properly. It is my understanding that the internal investigation is an essential component of organisational learning to improve the quality of care to patients and also prevent future deaths. Mrs Rowlands informed me that falls were the greatest risk posed to patients by the Health Board. I was therefore concerned to hear that neither of the nursing staff who gave evidence had seen the findings of the internal investigation some 1 years and 4 months since Mrs Robinson’s death.
” Open source report
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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 Capture patient acuity data to determine workforce requirements.
Verbatim wording from the response “A very recent triangulated approach to review Community Ward establishments in YYF has been undertaken by the Head of Nursing for Nevill Hall Hospital (NHH) and YYF. The purpose of this is to review the current ward establishments and determine if they are fit for purpose to meet the acuity and dependency of patients, considering all available quality metrics to inform and support additional requirements. In line with the Nursing Staff Levels (Wales) Act 2016 (NSLWA), a full acuity audit will take place during the month of June. This will provide essential intelligence to support a triangulated re-calculation in August 2021, to determine appropriate nurse staffing levels on all Community Wards in YYF. YYF has been proactive in its approach to determine patients’ acuity and commenced acuity capture as of April 2021 to determine workforce requirements.” Source location 2021-0072-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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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 Share interim post-fall guidance and broader thematic findings with medical and nursing staff across the Health Board.
Verbatim wording from the response “and YYF was established following this incident and interim post-fall guidance has been widely shared with medical and nursing staff across the Health Board to ensure awareness of, and compliance with Health Board policy. Whilst the report itself was not shared with the staff involved, the broader findings have been shared widely.” Source location 2021-0072-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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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 Complete an acuity audit and triangulated recalculation to determine appropriate nurse staffing levels on Ysbyty Ystrad Fawr Community Wards.
Verbatim wording from the response “A very recent triangulated approach to review Community Ward establishments in YYF has been undertaken by the Head of Nursing for Nevill Hall Hospital (NHH) and YYF. The purpose of this is to review the current ward establishments and determine if they are fit for purpose to meet the acuity and dependency of patients, considering all available quality metrics to inform and support additional requirements. In line with the Nursing Staff Levels (Wales) Act 2016 (NSLWA), a full acuity audit will take place during the month of June. This will provide essential intelligence to support a triangulated re-calculation in August 2021, to determine appropriate nurse staffing levels on all Community Wards in YYF. YYF has been proactive in its approach to determine patients’ acuity and commenced acuity capture as of April 2021 to determine workforce requirements.” Source location 2021-0072-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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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 Review Community Ward establishments against patient acuity, dependency and quality metrics to determine whether staffing levels are fit for purpose.
Verbatim wording from the response “A very recent triangulated approach to review Community Ward establishments in YYF has been undertaken by the Head of Nursing for Nevill Hall Hospital (NHH) and YYF. The purpose of this is to review the current ward establishments and determine if they are fit for purpose to meet the acuity and dependency of patients, considering all available quality metrics to inform and support additional requirements. In line with the Nursing Staff Levels (Wales) Act 2016 (NSLWA), a full acuity audit will take place during the month of June. This will provide essential intelligence to support a triangulated re-calculation in August 2021, to determine appropriate nurse staffing levels on all Community Wards in YYF. YYF has been proactive in its approach to determine patients’ acuity and commenced acuity capture as of April 2021 to determine workforce requirements.” Source location 2021-0072-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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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 Trial standardised serious incident investigation meeting agendas, review them using trial feedback, and share the revised templates across the Health Board.
Verbatim wording from the response “In addition, the Team is trialling standardised template agendas for use at Serious Incident investigation meetings to act as prompts to ensure that key points such as sharing report findings with stakeholders and with individual staff involved are implemented. A copy of these is enclosed. These templates will be reviewed, modified to reflect any feedback from the trial phase, and shared for use across the Health Board.” Source location 2021-0072-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
×
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 Establish a falls thematic review for Ysbyty Aneurin Bevan and Ysbyty Ystrad Fawr.
Verbatim wording from the response “Unfortunately, in this instance, the investigation report into the events leading to Mrs Robinson’s death was not shared with the staff involved in a timely manner. However, a falls thematic review for Ysbyty Aneurin Bevan (YAB)” Source location 2021-0072-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The planned nursing roster was met, and the requested additional staffing for enhanced care was escalated and filled when the fall occurred.
Verbatim wording from the response “Aneurin Bevan University Health Board (ABUHB) has processes in place across its sites to escalate any staffing deficits within a planned roster and/or any requests for additional staffing requirements. At the time of Mrs Robinson’s fall, a Nurse Staffing Escalation Policy (NSEP) was in place. This articulates everyone’s responsibility to maintain appropriate nurse staffing levels and sets clear actions if there is a deviation from what is required. Having reviewed the roster on the night of 20-21 October 2019, when Mrs Robinson fell on Oakdale Ward, it is noted that the planned nursing roster was met.” Source location 2021-0072-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
16 Feb 2021 Alan Jones · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 3 Failure to provide required enhanced supervision for high-falls-risk patients View source Failure to provide multidisciplinary falls prevention and management View source Unsafe ward staffing levels failing to account for fluctuations in patient acuity View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alan Jones · 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
Alan Jones was admitted to Neville Hall Hospital after a fall at home and, during his admission, fell seven times. On 13 November 2019 he fell while he should have been under constant supervision, suffered a fatal head injury, and died the following day. Concerns included inadequate multidisciplinary management of his falls risk, failure to provide the required supervision, and unsafe staffing levels.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to provide required enhanced supervision for high-falls-risk patients
Wider context from the report “1:1 Supervision
Throughout Mr Jones’ admission I heard evidence that he required either 1:1 supervision (Enhanced Care Level 5) or to be supervised in a cohorted bay (Enhanced Care Level 4). This level of care was not achieved and as a result within less than 3 weeks of his admission, Mr Jones had fallen on 7 occasions, at times as a direct result of a failure to provide adequate supervision . I am satisfied that the nursing staff were aware of the level of supervision required and regularly requested additional nursing support. These requests were not resourced.
It appears that the nursing staff had become used to this situation and tried to do the best they could in the circumstances. It also appeared that a ward which cares for patients who are the most likely to require extra support because they are confused, elderly and at risk of falls, is staffed to a minimum level which does not take account of any fluctuations in acuity.
Of concern was that despite hearing evidence that improvements in falls management had been introduced, I also heard evidence that nursing staff on the ward continue to find themselves nursing with unsafe levels of staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to provide multidisciplinary falls prevention and management
Wider context from the report “Multidisciplinary Care
Mr Jones’ level of confusion and his agitation appears to have increased during his admission and yet I have seen no evidence of a truly multidisciplinary approach to how this should be managed .
The risk assessment is multifactorial but the evidence presented suggested that care lies wholly within the nursing domain.
Throughout this time, Mr Jones was clearly in the highest category of falls risk, he was confused, agitated, unsafe on his feet and yet there is no evidence that nurses and doctors and physios and pharmacists met together to discuss how these problems would be managed . The fact that during Mr Jones’ hospital stay from 25th October 2019 to his death on 14th November 2019 he fell 7 times and the last time resulted in his death, demonstrates a complete failure in the falls prevention strategy at ABUHB .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Unsafe ward staffing levels failing to account for fluctuations in patient acuity
Wider context from the report “1:1 Supervision
Throughout Mr Jones’ admission I heard evidence that he required either 1:1 supervision (Enhanced Care Level 5) or to be supervised in a cohorted bay (Enhanced Care Level 4). This level of care was not achieved and as a result within less than 3 weeks of his admission, Mr Jones had fallen on 7 occasions, at times as a direct result of a failure to provide adequate supervision. I am satisfied that the nursing staff were aware of the level of supervision required and regularly requested additional nursing support. These requests were not resourced .
It appears that the nursing staff had become used to this situation and tried to do the best they could in the circumstances. It also appeared that a ward which cares for patients who are the most likely to require extra support because they are confused, elderly and at risk of falls, is staffed to a minimum level which does not take account of any fluctuations in acuity .
Of concern was that despite hearing evidence that improvements in falls management had been introduced, I also heard evidence that nursing staff on the ward continue to find themselves nursing with unsafe levels of staff .
” Open source report
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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 Develop and implement a multidisciplinary falls-policy implementation plan, including ward-based and online staff training.
Verbatim wording from the response “The Health Board recognises that publishing a revised policy will not in itself enable the required change in emphasis towards multidisciplinary care planning and so a policy implementation plan is being developed. The policy implementation plan will be overseen and monitored by the Falls & Bone Health Steering Group, which is both multidisciplinary in its membership and also diverse in representing all divisions across the Health Board. The Falls & Bone Health Steering Group reports to the Health Board’s Quality and Patient Safety Committee (a formal committee of the Board). The implementation plan will largely focus on training, targeting the multidisciplinary team and will be delivered both through online learning but also, importantly, through face to face training on the wards.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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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 Increase the substantive Health Care Support Worker workforce to support enhanced care and continuity.
Verbatim wording from the response “previously identified a need for an increase in Health Care Support Worker’s to support enhanced care by night and as a consequence the substantive HCSW workforce was increased to support this requirement.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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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 Revise the Falls Policy for Hospital Adult Inpatients to define multidisciplinary assessment, care planning and professional responsibilities.
Verbatim wording from the response “Your concerns as set out in the Regulation 28 notice, rightly point to the care planning that follows from the initial multifactorial assessment when a patient arrives on a ward or their circumstances change. To be effective in reducing falls and protecting patients from related harm, the care plan must be multidisciplinary, which the Health Board has recognised in revising its Falls Policy for Hospital Adult Inpatients. The entire policy has been reviewed through this lens, to make clear the responsibilities of all professions and disciplines that can contribute to the care of a hospital patient. The policy makes clear the expectation of joint multidisciplinary assessment and care planning. The policy revisions have been completed and are awaiting ratification by the Health Board’s Clinical Standards and Policy Group before publication.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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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 Maintain registered-nurse and Health Care Support Worker pools on acute sites to support staff deployment.
Verbatim wording from the response “The establishment of Registered Nurse and HCSW pools on each acute site to support deployment of staff – taking all reasonable steps to ensure planned rosters were maintained on a backdrop of significant absenteeism and fluctuation in capacity required to manage the pandemic.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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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 Evaluate falls training and monitor compliance, including multidisciplinary participation.
Verbatim wording from the response “Informing the training will be learning taken directly from serious incident investigations involving hospital falls, using actual case studies. The training will be evaluated and compliance will be monitored, including multidisciplinary participation.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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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 Obtain ratification and publish the revised Falls Policy for Hospital Adult Inpatients.
Verbatim wording from the response “Your concerns as set out in the Regulation 28 notice, rightly point to the care planning that follows from the initial multifactorial assessment when a patient arrives on a ward or their circumstances change. To be effective in reducing falls and protecting patients from related harm, the care plan must be multidisciplinary, which the Health Board has recognised in revising its Falls Policy for Hospital Adult Inpatients. The entire policy has been reviewed through this lens, to make clear the responsibilities of all professions and disciplines that can contribute to the care of a hospital patient. The policy makes clear the expectation of joint multidisciplinary assessment and care planning. The policy revisions have been completed and are awaiting ratification by the Health Board’s Clinical Standards and Policy Group before publication.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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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 Introduce ward-level Falls Prevention Collaboratives using quality-improvement methods, thematic reviews and multidisciplinary participation.
Verbatim wording from the response “To further support awareness of the multidisciplinary requirements set out in the revised policy, a Health Board wide communications campaign will be developed and launched to coincide with the publication of the policy. The Falls & Bone Health Steering Group has also developed an action plan for reducing inpatient falls (enclosed). This action plan includes a wide range of action beyond the revision of the policy. A key action in the plan is introducing ‘Falls Prevention Collaboratives’, which utilise quality improvement methodologies which support identification of specific areas for focus alongside thematic reviews. The ‘Collaboratives’ follow a similar approach adopted by the Health Board to successfully reduce pressure damage in hospital; they are delivered at ward level with full multidisciplinary participation.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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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 Review and monitor completion of falls-prevention actions and evidence of multidisciplinary care-plan participation and ownership.
Verbatim wording from the response “In direct response to the Coroner’s concerns about multidisciplinary care, the Falls & Bone Health Steering Group will be actively reviewing and monitoring completion of the actions described, with a clear expectation that multidisciplinary participation and ownership of falls prevention care plans can be evidenced.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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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 Introduce and embed the multidisciplinary core care team model, including assistant practitioners, roster creators and ward assistants.
Verbatim wording from the response “In 2019, on the backdrop of significant vacancies, circa 350 Whole Time Equivalent (WTE), it was imperative that the Health Board considered new roles and responsibilities for acute wards, promoting the principle of the ‘Prudent Registered Nurse’ with emphasis on appropriate and safe delegation practices. The core care team model was introduced as a result of a collaborative approach between Divisional and Corporate Nursing together with Workforce and Organisational Development. Ward 4/1 was identified as an ideal ward to embed this new model due to the dependency of the patients cared for, hence the recalculation undertaken in September 2019 incorporated the core care team model. The core care team comprised of several different roles, to include:” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Some temporary staffing requests could not be filled despite escalation and other reasonable steps to address identified nurse staffing deficits.
Verbatim wording from the response “Clear processes are in place within the Health Board to escalate any staffing deficits with the planned roster and/or any requests for additional staffing requirements. At the time of Mr Jones’ fall the Health Board had in place a Nurse Staffing Escalation Policy which articulates everyone responsibility, from Ward to Board, in maintaining appropriate nurse staffing levels and sets out clear actions if there is a deviation from what is required. In addition, daily site meetings occur to manage nurse staffing levels, consider any deficits, manage and identify any potential risks and escalate any supplementary requirements to the Resource Bank. There is clear evidence, by way of ‘Healthroster’, to indicate there was a recognition and identified need to increase nurse staffing levels to manage enhanced care on many occasions throughout Mr Jones’s admission.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
10 Dec 2020 Rory Attwood · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 1 Failure to involve primary care contacts in internal or serious incident reviews View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rory Attwood · 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
Rory Attwood died at home on 9 October 2018 after an acute cardiac event attributed by the pathologist to excessive MDMA consumption. The report raised concerns that he had fallen between gaps in health and social care services and that his GP was not involved in the internal investigation after his death.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to involve primary care contacts in internal or serious incident reviews
Wider context from the report “After his death the charity MIND wrote to me and expressed concerns that Rory had fallen between gaps in services. This was addressed in the internal investigation undertaken by ABUHB, however it is surprising that his GP was not involved in this review and Dr ████████ told me that GPs are rarely asked to participate in these investigations .
In order that lessons can be learned and opportunities identified for better partnership working around patients, it would seem appropriate that the patient’s primary care contact (especially when being supervised in the community) be involved in internal / serious incident reviews.
” Open source report
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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 Review practices governing GP involvement in Serious Incident Reviews.
Verbatim wording from the response “Further to your report, I am pleased to inform you that the Aneurin Bevan University Health Board has reviewed its practices with regard to GP involvement in Serious Incident Reviews.” Source location 2021-0086-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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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 Develop a process and pro forma to share pertinent information and invite GPs routinely to Serious Incident Reviews.
Verbatim wording from the response “Furthermore, the Mental Health and Learning Disabilities Division has devised a process and pro forma to aid the timely sharing of pertinent information, and to ensure that GPs are routinely invited to participate in reviews of Serious Incidents. Copies of both documents are enclosed for your information. Whilst I must highlight that only a small number of GP Surgeries within the Gwent area are managed by the Health Board and the vast majority are managed independently, it is hoped that this process will enable the Health Board to engage with both managed and non-managed GP surgeries when conducting Serious Incident Reviews.” Source location 2021-0086-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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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 Liaise with the Primary Care and Community Division after the trial period to review the GP notification process and take forward suggested amendments.
Verbatim wording from the response “It is suggested that this process is tried for 6 months; following which, the MH & LD Division will liaise with the Primary Care and Community Division to review the process and take forward any suggested amendments.” Source location 2021-0086-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
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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 Use the pro forma to notify GPs of relevant unexpected deaths, request salient information, and invite review participation.
Verbatim wording from the response “1. The MH & LD Division will use a pro forma to notify the GP of an unexpected death of a patient in the Division. This will be sent by email from the Division’s Quality and Patient Safety (QPS) department to the GP Practice.” Source location 2021-0086-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
9 Sep 2020 Alyn Rees · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 4 Lack of an indicated expected response time for Amber 1 calls View source Failure to advise callers of the expected emergency ambulance arrival time View source Delays in transferring patients into hospital care, preventing emergency ambulance release View source Delays in emergency ambulance response View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Alyn Rees · 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
Alyn Rees became acutely unwell on 3 December 2019, experienced breathing difficulties, deteriorated into cardiac arrest, and died after paramedics were unable to revive him. Concerns were raised about the approximately two-hour wait for an emergency ambulance, the lack of advice about the expected arrival time, the absence of an indicated response time for an Amber 1 call, and delays transferring patients into hospital care that prevented ambulances from being released.
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. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of an indicated expected response time for Amber 1 calls
Wider context from the report “However, the family raised concerns, with which I agreed, that 2 hours is a long time to wait for an emergency ambulance. At no time were the family advised of the expected time of arrival and potentially, if they had been aware of this, they may have contacted earlier the local GP.
The report did not indicate what the expected response time for an Amber 1 call should be .
I was advised that on this occasion there were significant delays (up to 3 hours) transferring patients into the care of Aneurin Bevan University Health Board Hospitals. This is also of significant concern as it prevented emergency ambulances being released.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to advise callers of the expected emergency ambulance arrival time
Wider context from the report “However, the family raised concerns, with which I agreed, that 2 hours is a long time to wait for an emergency ambulance. At no time were the family advised of the expected time of arrival and potentially, if they had been aware of this, they may have contacted earlier the local GP.
The report did not indicate what the expected response time for an Amber 1 call should be.
I was advised that on this occasion there were significant delays (up to 3 hours) transferring patients into the care of Aneurin Bevan University Health Board Hospitals. This is also of significant concern as it prevented emergency ambulances being released.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients into hospital care, preventing emergency ambulance release
Wider context from the report “However, the family raised concerns, with which I agreed, that 2 hours is a long time to wait for an emergency ambulance. At no time were the family advised of the expected time of arrival and potentially, if they had been aware of this, they may have contacted earlier the local GP.
The report did not indicate what the expected response time for an Amber 1 call should be.
I was advised that on this occasion there were significant delays (up to 3 hours) transferring patients into the care of Aneurin Bevan University Health Board Hospitals . This is also of significant concern as it prevented emergency ambulances being released .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aneurin Bevan University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in emergency ambulance response
Wider context from the report “However, the family raised concerns, with which I agreed, that 2 hours is a long time to wait for an emergency ambulance . At no time were the family advised of the expected time of arrival and potentially, if they had been aware of this, they may have contacted earlier the local GP.
The report did not indicate what the expected response time for an Amber 1 call should be.
I was advised that on this occasion there were significant delays (up to 3 hours) transferring patients into the care of Aneurin Bevan University Health Board Hospitals. This is also of significant concern as it prevented emergency ambulances being released.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations