21 Dec 2018 Diane Greenslade · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 6 Delays in medical intervention View source Failure to carry out a clinical assessment during initial call handling View source Failure to escalate calls appropriately after unsuccessful contact View source Failure to make contact with callers or their families View source Unavailability of nearby rapid response vehicles for calls outside red and amber 1 categories View source Excessive delays at hospitals View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Diane Greenslade · 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
Diane Greenslade was found moaning on her bedroom floor with a chest of drawers on top of her after ambulance responses were delayed. She suffered a cardiac arrest and died, with the inquest concluding that she died from natural causes following a fifteen-and-a-half-hour delay in ambulance intervention. The substantive concerns included the initial call categorisation without clinical assessment, failure to consider escalation or a police welfare check, high ambulance demand and hospital delays, and a nearby rapid response vehicle being unavailable because it was reserved for higher-priority calls.
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 medical intervention
Wider context from the report “(5) The delay in medical intervention must have played a significant role in Mrs Greenslade’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 carry out a clinical assessment during initial call handling
Wider context from the report “(1) The initial call was categorised Green 3 without any contact being made with Mrs Greenslade or her family and without any clinical assessment .
” 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 escalate calls appropriately after unsuccessful contact
Wider context from the report “(2) After failing to make contact, no consideration was given to either upgrading the call category or to contacting the Police to ask them to carry out a welfare check .
” 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 contact with callers or their families
Wider context from the report “(1) The initial call was categorised Green 3 without any contact being made with Mrs Greenslade or her family and without any clinical assessment.
” 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 nearby rapid response vehicles for calls outside red and amber 1 categories
Wider context from the report “(4) A rapid response vehicle had been based only eight minutes away from Mrs Greenslade’s home since at least 6.30 and had not responded to any calls as it was ring fenced for red and amber 1 calls .
” 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 Excessive delays at hospitals
Wider context from the report “(3) Demand for ambulances was high compounded by excessive delays at hospitals .
” 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 Open additional capacity to meet predicted demand and support ambulance release.
Verbatim wording from the response “We have additional doctors in the Emergency Department and on our Assessment Units to ensure more timely assessment of patients, and we have opened additional capacity in order to meet the predicted demand. There are several other initiatives to support the winter pressures to reduce demand, and improve our flow in order to release ambulances.” Source location 2018-0401-Response-by-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 Operate the Winter Resilience plan to manage winter demand and capacity pressures affecting ambulance release.
Verbatim wording from the response “The Health Board has a Winter Resilience plan which is designed to manage the peaks of demand and capacity through the winter period when services are under significant pressure. The plan was developed with stakeholders and partners to ensure actions and initiatives described within the plan are shared, agreed and delivered in partnership. The plan is monitored by all stakeholders, including WAST, on a weekly basis and also reviewed and monitored by the Health Board’s Executive Team each week. There are several initiatives included in the plan which support the timely release of ambulances at the hospital. For example, we have practitioners reviewing the WAST calls waiting to attend the hospital to ensure patients are treated in the most appropriate setting. We will shortly be implementing clinical call handlers assessing GP calls for admission to hospital.” Source location 2018-0401-Response-by-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 Have practitioners review WAST calls awaiting hospital attendance to direct patients to the most appropriate setting.
Verbatim wording from the response “The Health Board has a Winter Resilience plan which is designed to manage the peaks of demand and capacity through the winter period when services are under significant pressure. The plan was developed with stakeholders and partners to ensure actions and initiatives described within the plan are shared, agreed and delivered in partnership. The plan is monitored by all stakeholders, including WAST, on a weekly basis and also reviewed and monitored by the Health Board’s Executive Team each week. There are several initiatives included in the plan which support the timely release of ambulances at the hospital. For example, we have practitioners reviewing the WAST calls waiting to attend the hospital to ensure patients are treated in the most appropriate setting. We will shortly be implementing clinical call handlers assessing GP calls for admission to hospital.” Source location 2018-0401-Response-by-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 clinical call handlers to assess GP calls for hospital admission.
Verbatim wording from the response “The Health Board has a Winter Resilience plan which is designed to manage the peaks of demand and capacity through the winter period when services are under significant pressure. The plan was developed with stakeholders and partners to ensure actions and initiatives described within the plan are shared, agreed and delivered in partnership. The plan is monitored by all stakeholders, including WAST, on a weekly basis and also reviewed and monitored by the Health Board’s Executive Team each week. There are several initiatives included in the plan which support the timely release of ambulances at the hospital. For example, we have practitioners reviewing the WAST calls waiting to attend the hospital to ensure patients are treated in the most appropriate setting. We will shortly be implementing clinical call handlers assessing GP calls for admission to hospital.” Source location 2018-0401-Response-by-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 additional Emergency Department and Assessment Unit doctors to support timely patient assessment.
Verbatim wording from the response “We have additional doctors in the Emergency Department and on our Assessment Units to ensure more timely assessment of patients, and we have opened additional capacity in order to meet the predicted demand. There are several other initiatives to support the winter pressures to reduce demand, and improve our flow in order to release ambulances.” Source location 2018-0401-Response-by-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 the Red Release Protocol to identify an urgent patient move when an ambulance crew is needed for a red community call.
Verbatim wording from the response “The Health Board also has a Red Release Protocol for response to WAST, for when a crew is required to attend a ‘red’ call in the community. The identification of a ‘red release’ bed is discussed and agreed at each operational site meeting and a patient is identified as the urgent next move from ED, should the need to respond to a red release is called.” Source location 2018-0401-Response-by-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 Work with Welsh Ambulance Services Trust colleagues to improve hospital ambulance handover times.
Verbatim wording from the response “The ability to release ambulance crews in order to respond to community calls is of paramount importance to Aneurin Bevan University Health Board (ABUHB) and we are working closely with our Welsh Ambulance Services Trust (WAST) colleagues to improve handover delays.” Source location 2018-0401-Response-by-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 the Full Capacity Protocol to trigger patient moves that facilitate immediate ambulance handover.
Verbatim wording from the response “The Health Board has a Full Capacity Protocol which lists a number of objectives to guide staff to trigger a list of actions, with the overall objective, to secure and maintain the safety of patients and staff within the ED and Assessment Units. This is to allow patient moves which facilitate the immediate handover of ambulances.” Source location 2018-0401-Response-by-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 Emergency Department escalation protocols to manage delayed ambulance crews and create offloading capacity.
Verbatim wording from the response “As a Health Board, we have reviewed and implemented a number of key processes which should, in turn, improve the timeliness of releasing crews at the hospital. The Health Board has identified escalation protocols which are used to guide staff within the Emergency Department (ED) in the operational procedures for receiving and offloading ambulances. These include escalation when 3 or more crews are delayed for greater than 30 minutes and limited capacity exists within the hospital to off load them.” Source location 2018-0401-Response-by-University-Health-Board
Open published response
6 Mar 2018 ELLIE MAY CLARK · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 6 Lack of effective and robust long-term care planning and clinical oversight View source Delays in triaging emergency appointments resulting in insufficient attendance notice View source Failure to prominently record severe or life-threatening asthma on medical notes View source Lack of support for staff who challenge clinical decisions or seek second opinions View source Failure to ensure continuity and availability of triage information for emergency appointment clinicians View source Failure to provide clinical assessment and safeguarding advice when late patients attend emergency appointments View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
ELLIE MAY CLARK · 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
Ellie May Clark was a child with severe asthma who became seriously unwell after attending her GP surgery and was later found to have died from bronchial asthma. The report identified concerns about care planning, triage delays and systems, her being turned away from an emergency appointment without clinical assessment or safeguarding advice, the recording of her severe asthma, and staff support when challenging decisions.
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 effective and robust long-term care planning and clinical oversight
Wider context from the report “(1) The lack of an effective and robust care plan . No one clinician was allocated to oversee the long-term management and care of Ellie's medical condition . She dealt with by three different doctors at the surgery within a period of 5 days leading up to her 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 triaging emergency appointments resulting in insufficient attendance notice
Wider context from the report “(3) A delay in Ellie being triaged for an emergency appointment resulting in insufficient notice being given to ████████ to enable timely attendance at the appointment.
” 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 prominently record severe or life-threatening asthma on medical notes
Wider context from the report “(5) A note that Ellie had severe/life threatening asthma was not placed on her medical notes in a prominent position.
” 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 support for staff who challenge clinical decisions or seek second opinions
Wider context from the report “(6) Support staff did not feel they would be supported if they challenged a doctor's decision or sought a second opinion.
” 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 continuity and availability of triage information for emergency appointment clinicians
Wider context from the report “(4) The lack of an effective and robust triage system . The receptionist who spoke with ████████ on the telephone and the doctor who triaged Ellie were different to the receptionist ████████ spoke with at the surgery and the doctor with whom the emergency appointment was booked. Furthermore, the triage notes were not made available to the doctor in readiness for the emergency appointment.
” 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 clinical assessment and safeguarding advice when late patients attend emergency appointments
Wider context from the report “(2) Ellie was turned away from an emergency appointment for being late without any clinical assessment or safeguarding advice being given .
” 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 Provide asthma teaching to peers and junior staff, sharing adverse-outcome learning and reinforcing personal asthma action plan standards.
Verbatim wording from the response “3. As part of the paediatric consultant’s regular commitment to asthma teaching the team provide teaching for peers and juniors around their responsibilities, where adverse outcomes in Gwent are shared in terms of lessons learned, and the need for PAAPs as part of current standards review.” Source location 2018-0066-Response-by-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 and update the asthma-related action plan to reflect completed improvements and further assurance requirements.
Verbatim wording from the response “I can confirm that the Health Board has duly noted your recommendations and ensured a formal review of the action plan which was developed and implemented in 2015 immediately following the Health Board’s own investigation undertaken by the former Clinical Director, Primary Care Division was completed. This has been conducted in liaison with the Grange Clinic practice.” Source location 2018-0066-Response-by-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 Follow up high-risk children receiving repeated steroids or nebulisers for at least one year and children admitted to intensive care until specified stepdown or transition.
Verbatim wording from the response “5. The team recommit to following up all children who have received more than steroids and nebulisers for at least one year and any child that has been to Intensive Care Unit to follow up until transition or exacerbation-free stepdown in preventer treatment down to step 2 or less.” Source location 2018-0066-Response-by-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 Audit provision of personal asthma action plans in clinics and at discharge.
Verbatim wording from the response “The Health Board can confirm that those actions and request for assurances outlined in your correspondence have been implemented and continue to be the focus of cross divisional work with primary care and lead consultant paediatricians. I am advised by our Lead Consultant Paediatrician that the consultant leads for asthma have met to discuss Ellie May’s case and the Regulation 28 report. He confirms that the plan for the next 6 months includes:” Source location 2018-0066-Response-by-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 Independent primary care contractors are responsible for safe service delivery, professional standards, regulatory compliance and patient accessibility.
Verbatim wording from the response “It may be helpful to clarify that the Health Board does not directly manage the delivery of services or the oversight of staff employed within independent primary care contractors. Independent contractors are directly responsible for ensuring that the delivery of services is safe and also for ensuring that services conform to the expected professional standards and regulations and are appropriately accessible to patients. Nonetheless, there is a requirement for practices to provide assurance to the Health Board in respect of the adequacy of services provided. The Health Board has established processes to monitor the compliance of practices with contractual requirements and to intervene where it has concerns, contractually or professionally.” Source location 2018-0066-Response-by-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 Direct management of service delivery and oversight of independent primary care contractor staff falls outside the Health Board’s functions.
Verbatim wording from the response “It may be helpful to clarify that the Health Board does not directly manage the delivery of services or the oversight of staff employed within independent primary care contractors. Independent contractors are directly responsible for ensuring that the delivery of services is safe and also for ensuring that services conform to the expected professional standards and regulations and are appropriately accessible to patients. Nonetheless, there is a requirement for practices to provide assurance to the Health Board in respect of the adequacy of services provided. The Health Board has established processes to monitor the compliance of practices with contractual requirements and to intervene where it has concerns, contractually or professionally.” Source location 2018-0066-Response-by-University-Health-Board
Open published response
23 Mar 2017 Patricia Yvonne Donovan · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Failure of procedures to ensure provision of emergency surgery for trauma patients requiring specialist skills 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
Patricia Yvonne Donovan · 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
Patricia Yvonne Donovan was admitted after a fall causing a fractured neck of femur and was scheduled for total hip replacement. Shortly after receiving a general anaesthetic, she suffered an adverse reaction causing cardiac failure and died; the report raised concerns about emergency trauma surgery arrangements where specialist skills are needed.
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 procedures to ensure provision of emergency surgery for trauma patients requiring specialist skills
Wider context from the report “A review of the procedures in respect of the provision of emergency surgery for trauma patients where specialist skills are needed. The review should consider rescheduling elective cases and redeploying specialist staff if necessary.
” Open source report
22 Dec 2016 Mrs Georgina Lewis · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 3 Failure to put discharge plans and follow-up support in place View source Failure to provide the GP with contemporaneous notification of discharge and the assessment leading to discharge View source Failure to notify or consult family members before discharge decisions 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
Mrs Georgina Lewis · 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
Mrs Georgina Lewis was discharged from a psychiatric unit on 23 September 2013, went missing from home on 27 September, and was found dead in woods near her home on 30 September 2013. Concerns included discharge without family consultation, no discharge plan or follow-up support, and delayed notification to her GP.
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 put discharge plans and follow-up support in place
Wider context from the report “(2) Following the decision no discharge plan or follow up support was put in place .
” 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 the GP with contemporaneous notification of discharge and the assessment leading to discharge
Wider context from the report “(3) There was no contemporaneous notification to her GP of the discharge or the assessment leading to discharge , in fact the GP had still not received notification by the time of discovery of Mrs Lewis body
” 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 notify or consult family members before discharge decisions
Wider context from the report “(1) The decision to discharge was made without notification to or consultation with any family member .
” Open source report
Concerns raised 4 Inadequate monitoring of INR levels View source Inadequate communication about anticoagulation monitoring and potential therapy adjustment View source Lack of certainty whether Warfarin was being taken View source Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment 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.
×
AI-generated summary
Mrs. Mary Patricia James · 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
Mrs. Mary Patricia James had a prosthetic heart valve requiring anticoagulation, but INR monitoring was inadequate and there was uncertainty about whether she was taking Warfarin. Concerns included failures in communication between the INR Unit, care home and GP, and that she was not admitted to hospital on 15 May 2015 despite concern about a possible ischaemic leg. The inquest concluded: “Ischaemic leg contributed to by inadequate Warfarin monitoring and dosing”.
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 Inadequate monitoring of INR levels
Wider context from the report “(1) Inadequate monitoring of INR levels in a patient suffering from dementia;
” 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 communication about anticoagulation monitoring and potential therapy adjustment
Wider context from the report “(3) Inadequate communication between the INR Unit, the Care Home and the GP regarding this patient’s anticoagulation monitoring and the potential need for therapy adjustment ;
” 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 certainty whether Warfarin was being taken
Wider context from the report “(2) Lack of certainty whether Warfarin was being taken by the patient ;
” 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 admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment
Wider context from the report “(4) That against this background and the Care Home’s concern about a possible ischaemic leg , Mrs. James was not admitted to hospital on the 15th May, 2015 when there may have been a window of opportunity to have adjusted the anticoagulation therapy .
” Open source report
Concerns raised 4 Insufficient staffing of Tissue Viability Nurses View source Failure to maintain adequate repositioning charts View source Failure to maintain adequate pressure ulcer documentation View source Lack of integrated skin care across Health Boards and Primary healthcare services 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.
×
AI-generated summary
Mr. Arthur Cook · 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
Mr. Arthur Cook had poor circulation and a chronic open wound that developed into an MRSA-infected category 4 pressure ulcer while he was resident at Four Seasons Healthcare Residential Home. He failed to respond to treatment and died. Concerns included insufficient tissue viability nursing capacity, inadequate pressure-ulcer documentation and repositioning charts, and a lack of integrated skin care across services.
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 Insufficient staffing of Tissue Viability Nurses
Wider context from the report “(1) Staffing levels of Tissue Viability Nurses within the Aneurin Bevan Health Board are low and to the extent that at times this service cannot be provided according to need ;
” 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 maintain adequate repositioning charts
Wider context from the report “(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal.
” 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 maintain adequate pressure ulcer documentation
Wider context from the report “(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal.
” 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 integrated skin care across Health Boards and Primary healthcare services
Wider context from the report “(3) An apparent lack of integrated skin care within and between Health Boards and Primary healthcare services .
” Open source report
21 Jul 2015 Rachel Hollister · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 2 Failure of medical staff and porters to follow or be aware of Health Board protocols View source Major obstetric haemorrhage protocol failing to meet published clinical guidelines 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
Rachel Hollister · 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
Rachel Hollister died after suffering a cardiac arrest during surgery for removal of a retained placenta following childbirth at the Royal Gwent Hospital on 13 April 2013. Concerns included staff and porters not following or being unaware of Health Board protocols, and the major obstetric haemorrhage protocol not meeting published guidelines.
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 medical staff and porters to follow or be aware of Health Board protocols
Wider context from the report “1. Medical staff and porters either did not follow or were unaware of the Health Board’s Protocols
” 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 Major obstetric haemorrhage protocol failing to meet published clinical guidelines
Wider context from the report “2. The major obstetric haemorrhage protocol does not meet the guidelines published by the Royal College of Obstetricians and Gynaecologists
” Open source report
Concerns raised 4 Failure to advise the pharmacy of Warfarin withdrawal due to lack of INR safety testing View source Failure to develop and maintain an anti-coagulation treatment register View source Failure to use computer software to support prescription decisions View source Failure to implement notification of failed attendance for INR testing 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.
×
AI-generated summary
Mr. Alun Walters · 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
Mr. Alun Walters, who was prescribed Warfarin following receipt of a metallic heart valve, died after a gastro-intestinal haemorrhage in circumstances of suspected elevated Warfarin levels and failed INR monitoring. His prescriptions continued despite no INR tests after November 2013, and 51 prescriptions were provided without dosage assessment. Concerns included failures by the medical practice in monitoring, prescription systems and notifying the pharmacy that Warfarin had been withdrawn, while the pharmacy supplied Warfarin without a valid prescription.
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 advise the pharmacy of Warfarin withdrawal due to lack of INR safety testing
Wider context from the report “The Lawn Medical Practice -
(1) failed to use any computer software programmes to support its prescription decisions;
(2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register;
(3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and
(4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing .
” 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 develop and maintain an anti-coagulation treatment register
Wider context from the report “The Lawn Medical Practice -
(1) failed to use any computer software programmes to support its prescription decisions;
(2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register ;
(3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and
(4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing.
” 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 use computer software to support prescription decisions
Wider context from the report “The Lawn Medical Practice -
(1) failed to use any computer software programmes to support its prescription decisions ;
(2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register;
(3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and
(4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing.
” 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 implement notification of failed attendance for INR testing
Wider context from the report “The Lawn Medical Practice -
(1) failed to use any computer software programmes to support its prescription decisions;
(2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register;
(3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing ; and
(4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing.
” Open source report
23 Jan 2014 DESGRAE REGINA TUCKER · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 3 Lack of recording of anti-embolic stocking use in patient notes View source Failure to prescribe anti-coagulant medication on discharge View source Failure to consider discharge home with anti-embolic stockings 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
DESGRAE REGINA TUCKER · 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
Desgrae Regina Tucker was admitted with abdominal pain, underwent gall bladder removal surgery, was discharged home, and died at home six days later. Concerns included inadequate recording and consideration of anti-embolic stockings and no anti-coagulant medication being prescribed on discharge.
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 recording of anti-embolic stocking use in patient notes
Wider context from the report “(1) The lack of recording in the patient's notes as to whether the patient was wearing the anti-embolic stockings prescribed .
(2) No consideration given as to whether the patient should be discharged home with anti-embolic stockings.
(3) No anti-coagulant medication prescribed to the patient upon discharge.
” 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 prescribe anti-coagulant medication on discharge
Wider context from the report “(1) The lack of recording in the patient's notes as to whether the patient was wearing the anti-embolic stockings prescribed.
(2) No consideration given as to whether the patient should be discharged home with anti-embolic stockings.
(3) No anti-coagulant medication prescribed to the patient upon discharge .
” 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 discharge home with anti-embolic stockings
Wider context from the report “(1) The lack of recording in the patient's notes as to whether the patient was wearing the anti-embolic stockings prescribed.
(2) No consideration given as to whether the patient should be discharged home with anti-embolic stockings .
(3) No anti-coagulant medication prescribed to the patient upon discharge.
” 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