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.
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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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× 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 Betsi Cadwaladr 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
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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 standardised resuscitation trolleys and drug provision across acute sites in line with national standards.
Verbatim wording from the response “• A standardised approach to resuscitation trolleys and drug provision is in place across our acute sites, aligned to national standards;” Source location Response from Betsi Cadwaladr 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 Update the Resuscitation Policy to strengthen expectations for checking, stocking and laying out resuscitation equipment.
Verbatim wording from the response “• The Health Board has recently updated its Resuscitation Policy, which includes strengthened expectations in relation to the checking, stocking and layout of resuscitation equipment; and” Source location Response from Betsi Cadwaladr 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 Review local resuscitation trolley and drug arrangements against the concerns identified.
Verbatim wording from the response “• Local arrangements have been reviewed by our Resuscitation Service and relevant clinical leads in light of the issues identified;” Source location Response from Betsi Cadwaladr 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 Full standardisation of resuscitation trolley configuration across all settings is difficult in practice and may not address all identified contributory factors.
Verbatim wording from the response “In considering further action, the Health Board supports the principle of improving consistency in the availability and location of key resuscitation drugs. However, consistent with the national work undertaken to date, we consider that full standardisation of resuscitation trolley configuration across all settings will be difficult in practice and may not address all of the contributory factors identified particularly given our need to work the NHS in north-west England.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 7 Insufficient staffing of the gastroenterology and endoscopy service View source Failure to include endoscopy and gastroenterology service risks on the corporate risk register View source Delays in endoscopy for routine referrals View source Delays in endoscopy for urgent non-suspected cancer referrals View source Failure to provide adequate gastroenterology and endoscopy infrastructure View source Delays in endoscopy for urgent suspected cancer referrals View source Lack of a fully networked endoscopy and gastroenterology service View source See 4 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
Rory Colin 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
Rory Colin Williams was referred for urgent suspected cancer investigations in May 2023 after experiencing dysphagia and weight loss, but did not attend a scheduled outpatient appointment and later missed a recommended repeat endoscopy. Adenocarcinoma was identified in July 2024, and he died in hospital on 10 August 2024 after being admitted with severe abdominal pain. The report raised concerns about delays, staffing shortages, inadequate infrastructure, lengthy waiting times, and inadequate corporate risk recognition within the gastroenterology and endoscopy service.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing of the gastroenterology and endoscopy service
Wider context from the report “It was accepted by the Health Board that there had been a delay between April 2024 and July 2024 in undertaking the endoscopy. Whilst this did not impact on the outcome for Rory Williams it did highlight a number of ongoing concerns with the gastroenterology / endoscopy service:-
a. Staffing – the evidence at Inquest was that the Health Board was struggling to maintain this most basic service at Ysbyty Glan Clwyd due to staffing issues which included lack of consultants, endoscopists and other essential healthcare staff . There is currently only one full time equivalent consultant and 3 locums . The service is currently considered to be ‘absolutely dependent on locums’ . It was noted that recruitment into gastroenterology is a challenge yet these issues have been ongoing for many considerable years, potentially since 2018.
b. Infrastructure – evidence was heard that this requires significant investment and improvement within the service, and despite business cases having been made there have not been significant steps to improve this. It is not known why.
c. The Health Board’s target for urgent suspected cancer referrals to endoscopy (that is from GP referral to endoscopy) is 21 days. Today, this stands at 8 weeks.
d. The Health Board’s current wait time for urgent referrals (non-suspected cancer) to endoscopy is currently 89 weeks. This figure has increased since 2023.
e. The Health Board’s current wait time for routine referrals to endoscopy is currently 148 weeks. This figure has increased since 2023.
f. I am concerned that there is no fully networked service for endoscopy / gastroenterology where this and the above concerns do not appear on the corporate risk register. Whilst they appear on the local risk register it is extremely concerning that corporately it does not appear as a risk. Evidence was heard that at one point the risk score for the service was reduced from 25 to 20. The reason is not known.
g. The overall impression is that the service is not fit for purpose and that all of these concerns, many of which have existed for several years, signify a risk of harm and death of patients into the future as a result.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to include endoscopy and gastroenterology service risks on the corporate risk register
Wider context from the report “It was accepted by the Health Board that there had been a delay between April 2024 and July 2024 in undertaking the endoscopy. Whilst this did not impact on the outcome for Rory Williams it did highlight a number of ongoing concerns with the gastroenterology / endoscopy service:-
a. Staffing – the evidence at Inquest was that the Health Board was struggling to maintain this most basic service at Ysbyty Glan Clwyd due to staffing issues which included lack of consultants, endoscopists and other essential healthcare staff. There is currently only one full time equivalent consultant and 3 locums. The service is currently considered to be ‘absolutely dependent on locums’. It was noted that recruitment into gastroenterology is a challenge yet these issues have been ongoing for many considerable years, potentially since 2018.
b. Infrastructure – evidence was heard that this requires significant investment and improvement within the service, and despite business cases having been made there have not been significant steps to improve this. It is not known why.
c. The Health Board’s target for urgent suspected cancer referrals to endoscopy (that is from GP referral to endoscopy) is 21 days. Today, this stands at 8 weeks.
d. The Health Board’s current wait time for urgent referrals (non-suspected cancer) to endoscopy is currently 89 weeks. This figure has increased since 2023.
e. The Health Board’s current wait time for routine referrals to endoscopy is currently 148 weeks. This figure has increased since 2023.
f. I am concerned that there is no fully networked service for endoscopy / gastroenterology where this and the above concerns do not appear on the corporate risk register . Whilst they appear on the local risk register it is extremely concerning that corporately it does not appear as a risk . Evidence was heard that at one point the risk score for the service was reduced from 25 to 20. The reason is not known.
g. The overall impression is that the service is not fit for purpose and that all of these concerns, many of which have existed for several years, signify a risk of harm and death of patients into the future as a result.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in endoscopy for routine referrals
Wider context from the report “It was accepted by the Health Board that there had been a delay between April 2024 and July 2024 in undertaking the endoscopy. Whilst this did not impact on the outcome for Rory Williams it did highlight a number of ongoing concerns with the gastroenterology / endoscopy service:-
a. Staffing – the evidence at Inquest was that the Health Board was struggling to maintain this most basic service at Ysbyty Glan Clwyd due to staffing issues which included lack of consultants, endoscopists and other essential healthcare staff. There is currently only one full time equivalent consultant and 3 locums. The service is currently considered to be ‘absolutely dependent on locums’. It was noted that recruitment into gastroenterology is a challenge yet these issues have been ongoing for many considerable years, potentially since 2018.
b. Infrastructure – evidence was heard that this requires significant investment and improvement within the service, and despite business cases having been made there have not been significant steps to improve this. It is not known why.
c. The Health Board’s target for urgent suspected cancer referrals to endoscopy (that is from GP referral to endoscopy) is 21 days. Today, this stands at 8 weeks.
d. The Health Board’s current wait time for urgent referrals (non-suspected cancer) to endoscopy is currently 89 weeks. This figure has increased since 2023.
e. The Health Board’s current wait time for routine referrals to endoscopy is currently 148 weeks. This figure has increased since 2023.
f. I am concerned that there is no fully networked service for endoscopy / gastroenterology where this and the above concerns do not appear on the corporate risk register. Whilst they appear on the local risk register it is extremely concerning that corporately it does not appear as a risk. Evidence was heard that at one point the risk score for the service was reduced from 25 to 20. The reason is not known.
g. The overall impression is that the service is not fit for purpose and that all of these concerns, many of which have existed for several years, signify a risk of harm and death of patients into the future as a result.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in endoscopy for urgent non-suspected cancer referrals
Wider context from the report “It was accepted by the Health Board that there had been a delay between April 2024 and July 2024 in undertaking the endoscopy. Whilst this did not impact on the outcome for Rory Williams it did highlight a number of ongoing concerns with the gastroenterology / endoscopy service:-
a. Staffing – the evidence at Inquest was that the Health Board was struggling to maintain this most basic service at Ysbyty Glan Clwyd due to staffing issues which included lack of consultants, endoscopists and other essential healthcare staff. There is currently only one full time equivalent consultant and 3 locums. The service is currently considered to be ‘absolutely dependent on locums’. It was noted that recruitment into gastroenterology is a challenge yet these issues have been ongoing for many considerable years, potentially since 2018.
b. Infrastructure – evidence was heard that this requires significant investment and improvement within the service, and despite business cases having been made there have not been significant steps to improve this. It is not known why.
c. The Health Board’s target for urgent suspected cancer referrals to endoscopy (that is from GP referral to endoscopy) is 21 days. Today, this stands at 8 weeks.
d. The Health Board’s current wait time for urgent referrals (non-suspected cancer) to endoscopy is currently 89 weeks. This figure has increased since 2023.
e. The Health Board’s current wait time for routine referrals to endoscopy is currently 148 weeks. This figure has increased since 2023.
f. I am concerned that there is no fully networked service for endoscopy / gastroenterology where this and the above concerns do not appear on the corporate risk register. Whilst they appear on the local risk register it is extremely concerning that corporately it does not appear as a risk. Evidence was heard that at one point the risk score for the service was reduced from 25 to 20. The reason is not known.
g. The overall impression is that the service is not fit for purpose and that all of these concerns, many of which have existed for several years, signify a risk of harm and death of patients into the future as a result.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate gastroenterology and endoscopy infrastructure
Wider context from the report “It was accepted by the Health Board that there had been a delay between April 2024 and July 2024 in undertaking the endoscopy. Whilst this did not impact on the outcome for Rory Williams it did highlight a number of ongoing concerns with the gastroenterology / endoscopy service:-
a. Staffing – the evidence at Inquest was that the Health Board was struggling to maintain this most basic service at Ysbyty Glan Clwyd due to staffing issues which included lack of consultants, endoscopists and other essential healthcare staff. There is currently only one full time equivalent consultant and 3 locums. The service is currently considered to be ‘absolutely dependent on locums’. It was noted that recruitment into gastroenterology is a challenge yet these issues have been ongoing for many considerable years, potentially since 2018.
b. Infrastructure – evidence was heard that this requires significant investment and improvement within the service , and despite business cases having been made there have not been significant steps to improve this . It is not known why.
c. The Health Board’s target for urgent suspected cancer referrals to endoscopy (that is from GP referral to endoscopy) is 21 days. Today, this stands at 8 weeks.
d. The Health Board’s current wait time for urgent referrals (non-suspected cancer) to endoscopy is currently 89 weeks. This figure has increased since 2023.
e. The Health Board’s current wait time for routine referrals to endoscopy is currently 148 weeks. This figure has increased since 2023.
f. I am concerned that there is no fully networked service for endoscopy / gastroenterology where this and the above concerns do not appear on the corporate risk register. Whilst they appear on the local risk register it is extremely concerning that corporately it does not appear as a risk. Evidence was heard that at one point the risk score for the service was reduced from 25 to 20. The reason is not known.
g. The overall impression is that the service is not fit for purpose and that all of these concerns, many of which have existed for several years, signify a risk of harm and death of patients into the future as a result.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in endoscopy for urgent suspected cancer referrals
Wider context from the report “It was accepted by the Health Board that there had been a delay between April 2024 and July 2024 in undertaking the endoscopy. Whilst this did not impact on the outcome for Rory Williams it did highlight a number of ongoing concerns with the gastroenterology / endoscopy service:-
a. Staffing – the evidence at Inquest was that the Health Board was struggling to maintain this most basic service at Ysbyty Glan Clwyd due to staffing issues which included lack of consultants, endoscopists and other essential healthcare staff. There is currently only one full time equivalent consultant and 3 locums. The service is currently considered to be ‘absolutely dependent on locums’. It was noted that recruitment into gastroenterology is a challenge yet these issues have been ongoing for many considerable years, potentially since 2018.
b. Infrastructure – evidence was heard that this requires significant investment and improvement within the service, and despite business cases having been made there have not been significant steps to improve this. It is not known why.
c. The Health Board’s target for urgent suspected cancer referrals to endoscopy (that is from GP referral to endoscopy) is 21 days. Today, this stands at 8 weeks.
d. The Health Board’s current wait time for urgent referrals (non-suspected cancer) to endoscopy is currently 89 weeks. This figure has increased since 2023.
e. The Health Board’s current wait time for routine referrals to endoscopy is currently 148 weeks. This figure has increased since 2023.
f. I am concerned that there is no fully networked service for endoscopy / gastroenterology where this and the above concerns do not appear on the corporate risk register. Whilst they appear on the local risk register it is extremely concerning that corporately it does not appear as a risk. Evidence was heard that at one point the risk score for the service was reduced from 25 to 20. The reason is not known.
g. The overall impression is that the service is not fit for purpose and that all of these concerns, many of which have existed for several years, signify a risk of harm and death of patients into the future as a result.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of a fully networked endoscopy and gastroenterology service
Wider context from the report “It was accepted by the Health Board that there had been a delay between April 2024 and July 2024 in undertaking the endoscopy. Whilst this did not impact on the outcome for Rory Williams it did highlight a number of ongoing concerns with the gastroenterology / endoscopy service:-
a. Staffing – the evidence at Inquest was that the Health Board was struggling to maintain this most basic service at Ysbyty Glan Clwyd due to staffing issues which included lack of consultants, endoscopists and other essential healthcare staff. There is currently only one full time equivalent consultant and 3 locums. The service is currently considered to be ‘absolutely dependent on locums’. It was noted that recruitment into gastroenterology is a challenge yet these issues have been ongoing for many considerable years, potentially since 2018.
b. Infrastructure – evidence was heard that this requires significant investment and improvement within the service, and despite business cases having been made there have not been significant steps to improve this. It is not known why.
c. The Health Board’s target for urgent suspected cancer referrals to endoscopy (that is from GP referral to endoscopy) is 21 days. Today, this stands at 8 weeks.
d. The Health Board’s current wait time for urgent referrals (non-suspected cancer) to endoscopy is currently 89 weeks. This figure has increased since 2023.
e. The Health Board’s current wait time for routine referrals to endoscopy is currently 148 weeks. This figure has increased since 2023.
f. I am concerned that there is no fully networked service for endoscopy / gastroenterology where this and the above concerns do not appear on the corporate risk register. Whilst they appear on the local risk register it is extremely concerning that corporately it does not appear as a risk. Evidence was heard that at one point the risk score for the service was reduced from 25 to 20. The reason is not known.
g. The overall impression is that the service is not fit for purpose and that all of these concerns, many of which have existed for several years, signify a risk of harm and death of patients into the future as a result.
” 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 escalation and governance arrangements for gastroenterology-related risks within local and corporate risk management.
Verbatim wording from the response “As part of this work, the Health Board is reviewing the escalation and governance of gastroenterology-related risks to ensure that they are appropriately reflected within local and corporate risk management arrangements and subject to ongoing executive oversight.” Source location Response from Betsi Cadwaladr 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 Roll out capsule sponge endoscopy across the Health Board for suitable diagnostic circumstances.
Verbatim wording from the response “Active recruitment to substantive posts continues across the Health Board with advertisements now being for the whole Health Board rather than individual sites to help strengthen resilience. In parallel, work is underway to develop more sustainable workforce models, including greater use of multidisciplinary roles, cross-site working, and alternative pathways designed to reduce pressure on consultant capacity whilst maintaining patient safety. Capsule sponge endoscopy has been introduced at Wrexham Maelor; this is less invasive than endoscopy and can be used in certain diagnostic circumstances. This will be rolled out across the Health Board.” Source location Response from Betsi Cadwaladr 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 Integrated Digestive Disease Service with shared leadership, standardised pathways, coordinated workforce planning and strengthened governance.
Verbatim wording from the response “Work is therefore progressing on the development of an Integrated Digestive Disease Service, with shared clinical leadership, standardised pathways, coordinated workforce planning and strengthened governance. This programme of work is being taken forward under executive sponsorship, with follow-up reviews scheduled to monitor progress and ensure delivery of agreed actions.” Source location Response from Betsi Cadwaladr 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 Continue clerical and clinical validation of patients awaiting endoscopy to refine referral pathways.
Verbatim wording from the response “The Health Board has been working closely with national colleagues over the last three months to ensure both clerical and clinical validation of those awaiting endoscopy. Over 1000 referrals have been reviewed and approx. 40% have been removed from the waiting list either because it is felt that scope was not clinically indicated or that a further review or test may help decide whether the scope, or a different form of treatment, was needed. This work will be continued and is pivotal in the design of effective referral pathways.” Source location Response from Betsi Cadwaladr 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 Standardise referral, triage and prioritisation pathways across the Health Board.
Verbatim wording from the response “Actions underway to address this include the standardisation of referral and triage pathways across the Health Board, strengthened referral management (including the introduction of specialist nurse triage for all urgent cancer referrals) and prioritisation processes, whole-system capacity and demand modelling, and interim capacity-enhancing measures to improve access to care while longer-term solutions are developed.” Source location Response from Betsi Cadwaladr 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 referral management by introducing specialist nurse triage for all urgent cancer referrals.
Verbatim wording from the response “Actions underway to address this include the standardisation of referral and triage pathways across the Health Board, strengthened referral management (including the introduction of specialist nurse triage for all urgent cancer referrals) and prioritisation processes, whole-system capacity and demand modelling, and interim capacity-enhancing measures to improve access to care while longer-term solutions are developed.” Source location Response from Betsi Cadwaladr 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 a temporary endoscopy unit at Ysbyty Gwynedd to provide additional diagnostic capacity.
Verbatim wording from the response “As an immediate mitigating action, a temporary endoscopy unit has been established at Ysbyty Gwynedd, planned to be operational from mid-March 2026 for an anticipated period of approximately five months. This facility has been introduced to increase diagnostic capacity and is expected to enable the delivery of in excess of 1,500 additional endoscopy procedures, supporting patients who have been waiting longer than intended for investigation. We are also progressing whether further contracts for additional outsourcing activity are required for the new financial year.” Source location Response from Betsi Cadwaladr 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 a Rapid Quality Review of Gastroenterology Services to identify risks and agree mitigating actions.
Verbatim wording from the response “In response to a series of quality, performance and workforce concerns raised during 2024 and 2025, I convened a Rapid Quality Review of Gastroenterology Services on 13 February 2026.” Source location Response from Betsi Cadwaladr 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 Recruit substantive gastroenterology and endoscopy staff through Health Board-wide advertisements.
Verbatim wording from the response “The Health Board acknowledges the challenges associated with recruiting and retaining gastroenterology consultants and endoscopists, an issue experienced across the UK. In our Health Board, these challenges have affected service resilience, particularly at Ysbyty Glan Clwyd, where staffing gaps have necessitated reliance on locum support.” Source location Response from Betsi Cadwaladr 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 sustainable workforce models using multidisciplinary roles, cross-site working and alternative diagnostic pathways.
Verbatim wording from the response “Active recruitment to substantive posts continues across the Health Board with advertisements now being for the whole Health Board rather than individual sites to help strengthen resilience. In parallel, work is underway to develop more sustainable workforce models, including greater use of multidisciplinary roles, cross-site working, and alternative pathways designed to reduce pressure on consultant capacity whilst maintaining patient safety. Capsule sponge endoscopy has been introduced at Wrexham Maelor; this is less invasive than endoscopy and can be used in certain diagnostic circumstances. This will be rolled out across the Health Board.” Source location Response from Betsi Cadwaladr 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 endoscopy and gastroenterology infrastructure business cases against current service risks and priorities.
Verbatim wording from the response “Alongside this, existing and previously submitted business cases relating to endoscopy and gastroenterology infrastructure are being reviewed collectively to ensure that future investment decisions are informed by current service risks and priorities.” Source location Response from Betsi Cadwaladr 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 Assess whether further outsourcing contracts are required for the new financial year.
Verbatim wording from the response “As an immediate mitigating action, a temporary endoscopy unit has been established at Ysbyty Gwynedd, planned to be operational from mid-March 2026 for an anticipated period of approximately five months. This facility has been introduced to increase diagnostic capacity and is expected to enable the delivery of in excess of 1,500 additional endoscopy procedures, supporting patients who have been waiting longer than intended for investigation. We are also progressing whether further contracts for additional outsourcing activity are required for the new financial year.” Source location Response from Betsi Cadwaladr 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 Model whole-system capacity and demand to inform endoscopy access and service planning.
Verbatim wording from the response “Actions underway to address this include the standardisation of referral and triage pathways across the Health Board, strengthened referral management (including the introduction of specialist nurse triage for all urgent cancer referrals) and prioritisation processes, whole-system capacity and demand modelling, and interim capacity-enhancing measures to improve access to care while longer-term solutions are developed.” Source location Response from Betsi Cadwaladr 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 Implement interim capacity-enhancing measures to improve access while longer-term solutions develop.
Verbatim wording from the response “Actions underway to address this include the standardisation of referral and triage pathways across the Health Board, strengthened referral management (including the introduction of specialist nurse triage for all urgent cancer referrals) and prioritisation processes, whole-system capacity and demand modelling, and interim capacity-enhancing measures to improve access to care while longer-term solutions are developed.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 2 Delays in progressing referrals View source Failure to make additional enquiries to locate missing referral information View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Caitlin Rachel Imber ("Caiti") · 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
Caitlin Rachel Imber (“Caiti”) died on 13 December 2022; the recorded cause of death was hanging. The report raises concern about a 42-day delay in progressing a CAMHS referral after missing contact information was not followed up, although it states that this was not contributory to Caiti’s 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in progressing referrals
Wider context from the report “On the 9th of May 2022, CAMHS received a referral from a community paediatrician dated the 19th of April 2022. This identified the need for support care and treatment to be provided to a traumatized, vulnerable child, however as the referral did not contain any contact numbers, the referral was closed without any additional enquiries being made to further the matter.
A further referral was received on the 31st of May 2022 and was then accepted by CAMHS, representing a delay of 42 days from the original paediatrician’s referral to any action being taken.
Whilst this was not contributory to Caiti’s death, I am concerned by the apparent lack of effort to locate missing information and progress a referral and I consider that if this situation continues to prevail, then there is a risk that future deaths could occur.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to make additional enquiries to locate missing referral information
Wider context from the report “On the 9th of May 2022, CAMHS received a referral from a community paediatrician dated the 19th of April 2022. This identified the need for support care and treatment to be provided to a traumatized, vulnerable child, however as the referral did not contain any contact numbers, the referral was closed without any additional enquiries being made to further the matter .
A further referral was received on the 31st of May 2022 and was then accepted by CAMHS, representing a delay of 42 days from the original paediatrician’s referral to any action being taken.
Whilst this was not contributory to Caiti’s death, I am concerned by the apparent lack of effort to locate missing information and progress a referral and I consider that if this situation continues to prevail, then there is a risk that future deaths could occur.
” 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 Audit CAMHS practice to confirm the revised referral procedure is embedded.
Verbatim wording from the response “The service is also undertaking an audit to confirm the changes that have been made are embedded in practice.” Source location Response from Betsi Cadwaladr 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 Change the CAMHS operating procedure to offer appointments when referral contact numbers are missing.
Verbatim wording from the response “I can confirm that CAMHS have changed their standard operating procedure, and an appointment is now offered even where contact numbers are not provided. This change was made following completion of the investigation and ensures all referrals receive an appointment.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
21 May 2025 Etta-Lili Stockwell-Parry · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 4 Insufficient contextual sharing of investigation findings View source Failure to conduct sufficiently thorough neonatal investigations View source Failure to contextualise learning in staff memoranda View source Inadequate sharing of incident learning with uninvolved staff 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
Etta-Lili Stockwell-Parry · 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
Etta-Lili Stockwell-Parry was born in poor condition on 3 July 2023 and died four days later after transfer for specialist neonatal care. The report identified missed opportunities to recognise static growth and fetal distress, inadequate monitoring and incomplete records during labour, and concerns that the neonatal investigation and sharing of learning were insufficiently thorough and contextualised.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient contextual sharing of investigation findings
Wider context from the report “b. There was no sufficiently full contextual sharing of the investigation or its findings from a neonatal or maternity perspective. Some witnesses had only received and read the report several weeks prior to the Inquest.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct sufficiently thorough neonatal investigations
Wider context from the report “a. The neonatal investigation was not thorough. The investigator did not obtain or request statements from doctors directly involved in Etta’s resuscitation, nor did they meet with them to understand what had occurred. The investigation was based on records alone. The records themselves, identified as part of the investigation, were often incomplete or included retrospective entries. Despite this, the investigator nor the panel involved considered speaking to or obtaining statements from crucial individuals.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to contextualise learning in staff memoranda
Wider context from the report “c. The memoranda sent to staff highlighting the learning did not include context or narrative around the circumstances of investigation. Therefore, those not directly involved would not have been fully aware of the context of what had occurred.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Inadequate sharing of incident learning with uninvolved staff
Wider context from the report “Having issued Reports to the Health Board regarding quality of investigation previously, this concern remains. Specifically, I have concerns that the neonatal element of the investigation was not thorough enough such that without this genuine learning and change will not and cannot occur. Even where learning has been shared, I am concerned that this is not contextualised sufficiently. I am also concerned that staff not involved in the incident will not learn fully enough from events where there is inadequate sharing of learning from an incident.
” 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 Direct women’s-services investigations to use the Integrated Concerns Policy framework and templates.
Verbatim wording from the response “Finally, I am also aware the Executive Director of Nursing and Midwifery has instigated a number of immediate safety changes following your notice. The first is a clear direction that investigations across women’s services and neonatal services will have a single investigation officer (as opposed to the practice that occurred in Etta’s case where” Source location Response from Betsi Cadwaladr 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 Lead the Foundations for the Future programme to integrate women’s and neonatal services and improve investigations and learning across them.
Verbatim wording from the response “I am also leading work to improve how the organisation functions as part of a programme called Foundations for the Future, and this will have a range of interventions of which the closer integration of women’s services and neonatal services will be an outcome. This will also improve the way investigations and learning is conducted across these two deeply interconnected services).” Source location Response from Betsi Cadwaladr 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 Direct that investigations across women’s and neonatal services use a single investigation officer.
Verbatim wording from the response “Finally, I am also aware the Executive Director of Nursing and Midwifery has instigated a number of immediate safety changes following your notice. The first is a clear direction that investigations across women’s services and neonatal services will have a single investigation officer (as opposed to the practice that occurred in Etta’s case where” Source location Response from Betsi Cadwaladr 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 Implement the Integrated Concerns Policy as a single approach to incident, complaint and mortality reviews and investigations.
Verbatim wording from the response “In relation to investigations, as you know this is an area of improvement I have prioritised. Last year, a new Integrated Concerns Policy was approved in June 2024 by the Board” Source location Response from Betsi Cadwaladr 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 a quality governance officer to neonatal services to provide specialist investigation and review capacity.
Verbatim wording from the response “separate reviews were undertaken and then brought together). This will directly address quality and consistency, in line with how all other services operate. In addition, a directive has been issued that investigations across women’s services will use the framework and templates within the Integrated Concerns Policy (as opposed to the PMRT tool which was used for Etta’s case). The national tool will continue to be used however investigations will follow the established Health Board format. We have also appointed a new quality governance officer into neonatal services which will ensure access to local specialist skills and capacity for investigations and reviews.” Source location Response from Betsi Cadwaladr 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 and test a searchable learning repository, evaluate it with staff, and roll it out across the Health Board.
Verbatim wording from the response “Furthermore, work is being finalised to improve how learning is shared once a review or investigation is completed. A learning repository is being developed which is a key digital initiative designed to support our journey toward becoming a learning and self-improving organisation. This is believed to be the first of its kind in Wales.” Source location Response from Betsi Cadwaladr 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 Implement a programme for investigating officers.
Verbatim wording from the response “and implemented in September 2024. This new policy provides a single, integrated approach to incident, complaint and mortality reviews and investigations. The patient safety, complaint and mortality review teams are now working together as a more integrated hub to coordinate investigations, supported by a daily hub review meeting and a weekly clinical executive led meeting. A new programme for investigating officers has been implemented. The new policy also requires that all those involved in an incident are engaged in the process including receiving the sharing of information.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 2 Failure to assess relevant patient-care information before accepting transfer View source Failure to ensure receipt of all relevant patient-care information before transfer View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patricia Ann Catterall · 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 Ann Catterall’s care was transferred to a nursing home on 11 June 2024 after 207 days at Mold Community Hospital. Her blood sugar levels, previously checked three times daily, were checked once daily at the nursing home; her condition deteriorated and she was admitted to hospital on 19 June with HHS and sepsis, dying a few days later. The principal concern was that the nursing home’s pre-transfer assessment was not sufficiently robust and did not identify all relevant care information, including the frequency of her blood sugar monitoring.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to assess relevant patient-care information before accepting transfer
Wider context from the report “That the process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had been received and assessed prior to the patient being received into their care .
Evidence was received that in the majority of cases (post Covid) there are no face to face assessments prior to patient transfer and that the assessment is therefore dependent on the documentation supplied to the Nursing Home by the Health Board which in some cases may result in not all relevant information being provided.
In this instance evidence was given that the Nursing Home did not know that the deceased’s blood sugar levels were monitored three times per days whilst in the care of 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure receipt of all relevant patient-care information before transfer
Wider context from the report “That the process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had been received and assessed prior to the patient being received into their care.
Evidence was received that in the majority of cases (post Covid) there are no face to face assessments prior to patient transfer and that the assessment is therefore dependent on the documentation supplied to the Nursing Home by the Health Board which in some cases may result in not all relevant information being provided .
In this instance evidence was given that the Nursing Home did not know that the deceased’s blood sugar levels were monitored three times per days whilst in the care of Health Board.
” 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 the care-home discharge plan form to define observation and medication frequencies clearly.
Verbatim wording from the response “In response to the notice, our senior nursing team in the East Integrated Health Community have led work to understand the issue across the Health Board. This work has identified that whilst there is a standardised form for discharge plans into care homes, the level of detail is varied.” Source location Response from Betsi Cadwaladr 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 audit questions, complete peer-review monitoring, and report findings through monthly Matron Reports to local quality groups.
Verbatim wording from the response “Audit questions will be developed to monitor these changes which will be completed by Ward Managers and Matrons and included in the peer reviews across our services. The audit findings will be included in the monthly Matron Reports into local quality groups for assurance.” Source location Response from Betsi Cadwaladr 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 a Task and Finish Group of Community Hospital Matrons and Discharge Nurses to review the care-home discharge plan form.
Verbatim wording from the response “A Task and Finish Group has been set up (consisting of Community Hospital Matrons and Discharge Nurses) to review the current form for suitability, and this work will specifically ensure that frequency of observations and medication is clearly defined within the document.” Source location Response from Betsi Cadwaladr 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 Share the finalized and approved form changes with the North Wales Care Home Forum.
Verbatim wording from the response “Changes to the form, once finalised and approved, will be shared with the North Wales Care Home Forum, with support from the Quality Development Team (this team supports improvements in quality across commissioned care home services).” Source location Response from Betsi Cadwaladr 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 Share the new form and supporting examples with teams through Team Meeting Safety Briefs.
Verbatim wording from the response “The new form, and examples to support learning, will be shared with teams and will be included on Team Meeting Safety Briefs.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 6 Failure to document Single Point of Access triage discussions, decisions and actions in patient health records View source Insufficient permanent perinatal health visitor coverage across all three Health Board areas View source Failure to document Single Point of Access meeting records and decisions View source Insufficient awareness of the Perinatal Mental Health Service among health professionals View source Inadequate staffing of the Perinatal Mental Health Service View source Insufficient awareness of the Perinatal Mental Health Service among health professionals View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Leanne Marie Carroll · 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
Leanne Marie Carroll, aged 27, died on 29 June 2024 after excessive consumption of prescribed and non-prescribed medications. She had experienced anxiety and deteriorating OCD following the birth of her first child and had been referred to mental health support, but not to the Perinatal Mental Health Service. The report raises concerns about inadequate awareness and staffing of that service and the lack of written records of Single Point of Access discussions and 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to document Single Point of Access triage discussions, decisions and actions in patient health records
Wider context from the report “3. The Single Point of Access meetings which occur on a daily basis by way of triaging referrals do not provide written records of the discussions had and decisions made . This means that there is no written justification for decisions made or written actions and therefore these discussions and decisions do not form part of any health record for the patient which would be relevant to the overall management of 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient permanent perinatal health visitor coverage across all three Health Board areas
Wider context from the report “2. There are only 2 temporary perinatal health visitors across the 3 Health Board areas and not one in the Eastern area of the Health Board . By not having permanent perinatal health visitors across all three Health Board areas then those who need to access support will suffer
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to document Single Point of Access meeting records and decisions
Wider context from the report “4. I am concerned that deaths will occur into the future as awareness of the Service is not at all adequate to health professionals, the Service is not adequately staffed and records of meetings and decisions made in the Single Point of Access are not documented .
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient awareness of the Perinatal Mental Health Service among health professionals
Wider context from the report “1. The Perinatal Mental Health Service was established across the Health Board around 5 years ago. It was accepted in evidence that there is insufficient awareness of the Service by health professionals including midwives, health visitors and GP’s . Whilst attempts have been made to raise awareness and encourage direct referrals to the Service (rather than via the Single Point of Access) this remains inadequate . If health professionals are unaware of the Service then mothers-to-be and mothers who require assistance will not be fully supported.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing of the Perinatal Mental Health Service
Wider context from the report “4. I am concerned that deaths will occur into the future as awareness of the Service is not at all adequate to health professionals, the Service is not adequately staffed and records of meetings and decisions made in the Single Point of Access are not documented.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient awareness of the Perinatal Mental Health Service among health professionals
Wider context from the report “4. I am concerned that deaths will occur into the future as awareness of the Service is not at all adequate to health professionals , the Service is not adequately staffed and records of meetings and decisions made in the Single Point of Access are not documented.
” 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 and disseminate perinatal mental health awareness training across relevant Health Board teams.
Verbatim wording from the response “Currently, mandatory perinatal mental health training is delivered to midwifery colleagues, student health visitors, obstetricians and gynaecologists, Community Mental Health Teams (CMHT’s) and Home Treatment Teams (HTT). As extended members of the team, specialist perinatal health visitors provide training relating to the “Ask, Assess and Act Assessment Framework” whilst promoting the role of the Perinatal Mental Health Service. In addition, Institute of Health Visiting perinatal training is offered six times per year to the Health Visiting Teams, and members of the Mental Health Perinatal Team have undertaken train the trainer modules to disseminate this training further across the Health Board.” Source location Response from BCUHB
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 the SPOAA Referral Checklist across the division for all SPOAA meetings.
Verbatim wording from the response “As an outcome of the inquest and subsequent notice, we have identified that consistency across the whole division is required in terms of the documentation used to record the summary and outcome of SPOAA Meetings.” Source location Response from BCUHB
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 Health Visiting Services and wider perinatal provision to identify access gaps and make recommendations.
Verbatim wording from the response “With regard to Perinatal Health Visitors and the equity of access across North Wales, I can confirm that a review of Health Visiting Services at the Health Board that relate to wider perinatal services will be undertaken to determine whether gaps in service are evident. This will include consideration of access to specialist Perinatal Mental Health Services and the Mental Health Perinatal Service Manager will be involved within this process. An action plan will be developed to address any identified areas of need in order to ensure that there is equitable and appropriate access to perinatal services. Consideration will be given to the role and function of the Perinatal Health Visitor posts currently in place in the central and west areas on a temporary basis. This review will be undertaken with recommendations for the Health Board to consider by the end of July 2025.” Source location Response from BCUHB
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 Integrate perinatal mental health awareness training across the acute mental health care pathway, including inpatient services.
Verbatim wording from the response “Moving forwards, the long-term plan is to integrate perinatal mental health training across the whole of the mental health acute care pathway to include in-patient services in addition to HTT, Psychiatric Liaison, and CMHTs. This is being processed through the Mental Health and Learning Disabilities Training and Development Group and it is expected that the perinatal awareness training will be fully ratified at the end of July 2025.” Source location Response from BCUHB
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 perinatal mental health training for North Wales GPs covering illness recognition, assessment, support and referral.
Verbatim wording from the response “Alongside this, the Health Board’s Perinatal Consultant Psychiatrist, ████████, is leading on the development of training for GPs across North Wales. This training intends to increase knowledge of perinatal mental illness and the role and referral process for access to perinatal mental health assessment and support. ████████ is in the process of liaising with GP colleagues with the aim of having initial training dates agreed by the beginning of September 2025.” Source location Response from BCUHB
Open published response
Concerns raised 2 Lack of a formal documented process for referrals and subsequent advice View source Lack of records of discussions between Glan Clwyd and the tertiary centre View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ann Margaret Cotgrave · 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
Ann Margaret Cotgrave was admitted to Glan Clwyd Hospital on 31 March 2022 for investigation of jaundice, underwent ERCP on 19 April, sustained a perforation, and died on 3 May 2022. The principal concern was that discussions and advice between Glan Clwyd and a tertiary centre were not documented, and there was no formal documented process for such referrals and advice.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal documented process for referrals and subsequent advice
Wider context from the report “That there was no record of any discussions which took place between Glan Clwyd and the tertiary centre and no formal documented process in relation to such referrals and the subsequent advice which was provided and thereafter acted upon .
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of records of discussions between Glan Clwyd and the tertiary centre
Wider context from the report “That there was no record of any discussions which took place between Glan Clwyd and the tertiary centre and no formal documented process in relation to such referrals and the subsequent advice which was provided and thereafter acted upon.
” 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 Develop an Outline Business Case for the integrated digital records solution.
Verbatim wording from the response “In addition, it is important we recognise the challenges our clinical staff have with our current record keeping arrangements, which includes some paper records and some electronic records (which can be disjointed). As you know, the Health Board is actively progressing an integrated digital solution and we believe this will significantly improve the quality of patient records – the Health Board is at the forefront of this work across Wales. We have developed an Outline Business Case and this is due for approval at our Board in June 2025, before submission to the Welsh Government in July 2025.” Source location Response from Betsi Cadwaladr 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 Seek Board approval for the Outline Business Case and submit it to the Welsh Government on the stated timetable.
Verbatim wording from the response “In addition, it is important we recognise the challenges our clinical staff have with our current record keeping arrangements, which includes some paper records and some electronic records (which can be disjointed). As you know, the Health Board is actively progressing an integrated digital solution and we believe this will significantly improve the quality of patient records – the Health Board is at the forefront of this work across Wales. We have developed an Outline Business Case and this is due for approval at our Board in June 2025, before submission to the Welsh Government in July 2025.” Source location Response from Betsi Cadwaladr 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 Progress an integrated digital records solution to improve the quality and coherence of patient records.
Verbatim wording from the response “In addition, it is important we recognise the challenges our clinical staff have with our current record keeping arrangements, which includes some paper records and some electronic records (which can be disjointed). As you know, the Health Board is actively progressing an integrated digital solution and we believe this will significantly improve the quality of patient records – the Health Board is at the forefront of this work across Wales. We have developed an Outline Business Case and this is due for approval at our Board in June 2025, before submission to the Welsh Government in July 2025.” Source location Response from Betsi Cadwaladr 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 case summary presentation addressing documentation of discussions when seeking tertiary-centre opinions.
Verbatim wording from the response “However, we felt that the absolute necessity for the documentation of discussions between clinicians, particularly when seeking opinion from a tertiary centre, is an important learning point to widely share.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 1 Failure to access and consider full medical records and risk assessments when prescribing medication changes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret Joy Daly · 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
Margaret Joy Daly was an in-patient at Wrexham Maelor Hospital and, despite being assessed as at significant risk of falling, received lorazepam after a doctor prescribed it without reviewing her full records. She later had an unwitnessed fall and sustained the injury that resulted in her death; the principal concern was that sedative prescribing could occur without consideration of the patient’s full medical records and risk 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to access and consider full medical records and risk assessments when prescribing medication changes
Wider context from the report “The clinician who prescribed a sedative, did so, without reference to any of Mrs Daly’s notes other than her prescription chart and as a result was unaware of her enhanced falls risk or any other behavioural issues. Whilst I recognise that medication changes may be necessary without the doctor being able to review a patient in person, I am concerned that this may occur without the doctor having access to and considering her full medical records and risk assessments .
” 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 Progress development of integrated electronic health records through business cases, Welsh Government-supported mental health work, and collaboration with early implementers and other Welsh organisations.
Verbatim wording from the response “The longer term, and more sustainable solution is the development of an integrated electronic health record and I know our Chief Executive has discussed these developments with you.” Source location Response from BCUHB
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 Establish a prescribing safety process requiring access to patient notes, communication of falls risk, and escalation or assessment when safe prescribing is uncertain.
Verbatim wording from the response “Having considered the learning, a new process is being established by the East Medical Director to improve safety whilst recognising medication changes may be necessary without the doctor being able to review a patient in person.” Source location Response from BCUHB
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 Roll out the electronic Prescribing and Medication Administration System across most acute and community specialties, including staff training and access to medication information.
Verbatim wording from the response “The Health Board is also working to roll out an Electronic Prescribing and Medication Administration System (ePMA).” Source location Response from BCUHB
Open published response
Concerns raised 3 Delays in acting on identified learning and actions View source Failure to involve responsible staff in investigations of care failings View source Lack of accountability for staff breaches of safe-care policies and procedures View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Anthony Roberts · 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
Paul Anthony Roberts took an overdose and inflicted multiple stab wounds in February 2023, after which he received no further mental health support. On 14 August 2023, he attended an emergency department because of deteriorating mental health, but psychiatric assessment was delayed and he left before it took place; he subsequently harmed himself and died on 15 August 2023 from a knife injury to the heart. The substantive concerns were failures in mental health referral and emergency-department care, insufficient accountability for staff actions or omissions, and delays in implementing identified safety measures.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in acting on identified learning and actions
Wider context from the report “An investigation by the Health Board had identified that there were failings in relation to the care afforded to Mr Roberts both following the February mental health referral and at ED on the 14th of August, however the evidence at inquest indicated that the persons with responsibility for these issues had not been spoken to, nor played a part in the investigation process (respectively being the team manager of LPMHSS and the nurse in charge of ED).
Furthermore an action plan provided by the health board advised that by the end of May 2024 a leaflet would be available and would be given to patients attending ED with mental health issues and would be provided to them at the time of triage to provide advice, support and an indication of likely waiting times there are any psychiatric assessment took place.
My concerns are therefore as follows :
1. There do not appear to be any consequences for staff members whose actions or omissions result in a failure to adhere to the policies and procedures which the health board impose for the safe care and treatment of patients and in my opinion this lack of accountability perpetuates future risk to patients.
2. The failure to act in a timely manner when learning and actions have been identified (especially when the timetable has been set by the organisation itself ) is incomprehensible and as a result there is a failure to mitigate the risk to patients .
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to involve responsible staff in investigations of care failings
Wider context from the report “An investigation by the Health Board had identified that there were failings in relation to the care afforded to Mr Roberts both following the February mental health referral and at ED on the 14th of August, however the evidence at inquest indicated that the persons with responsibility for these issues had not been spoken to, nor played a part in the investigation process (respectively being the team manager of LPMHSS and the nurse in charge of ED).
Furthermore an action plan provided by the health board advised that by the end of May 2024 a leaflet would be available and would be given to patients attending ED with mental health issues and would be provided to them at the time of triage to provide advice, support and an indication of likely waiting times there are any psychiatric assessment took place.
My concerns are therefore as follows :
1. There do not appear to be any consequences for staff members whose actions or omissions result in a failure to adhere to the policies and procedures which the health board impose for the safe care and treatment of patients and in my opinion this lack of accountability perpetuates future risk to patients.
2. The failure to act in a timely manner when learning and actions have been identified (especially when the timetable has been set by the organisation itself) is incomprehensible and as a result there is a failure to mitigate the risk to patients.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of accountability for staff breaches of safe-care policies and procedures
Wider context from the report “An investigation by the Health Board had identified that there were failings in relation to the care afforded to Mr Roberts both following the February mental health referral and at ED on the 14th of August, however the evidence at inquest indicated that the persons with responsibility for these issues had not been spoken to, nor played a part in the investigation process (respectively being the team manager of LPMHSS and the nurse in charge of ED).
Furthermore an action plan provided by the health board advised that by the end of May 2024 a leaflet would be available and would be given to patients attending ED with mental health issues and would be provided to them at the time of triage to provide advice, support and an indication of likely waiting times there are any psychiatric assessment took place.
My concerns are therefore as follows :
1. There do not appear to be any consequences for staff members whose actions or omissions result in a failure to adhere to the policies and procedures which the health board impose for the safe care and treatment of patients and in my opinion this lack of accountability perpetuates future risk to patients .
2. The failure to act in a timely manner when learning and actions have been identified (especially when the timetable has been set by the organisation itself) is incomprehensible and as a result there is a failure to mitigate the risk to patients.
” 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 Develop and launch investigator training incorporating learning from the inquest and responsibilities for escalating care concerns.
Verbatim wording from the response “In addition to this, new training for investigating officers is being developed by the Health Board. The learning from Mr Roberts’ inquest will be incorporated into this training, ensuring that investigators are aware of their responsibility to escalate concerns in relation to action or omissions in care and treatment to the managers of staff. This will then prompt consideration of professional and workforce processes. This training is scheduled to be launched at the end of October 2024.” Source location Response from BCUHB
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 rolling Datix audits to verify that divisions record, manage and evidence closure of Learning and Improvement Plan actions.
Verbatim wording from the response “As part of the new policy, there are clear accountabilities now set on divisions to deliver the improvement and action plans. The Patient Safety Team, Complaints Team and” Source location Response from BCUHB
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 Adapt and launch the patient information leaflet in the Ysbyty Wrexham Maelor and Ysbyty Gwynedd Emergency Departments.
Verbatim wording from the response “With regard to your concerns about the failure to implement improvement actions in a timely manner, I can assure you that the outstanding Patient Information Leaflet is now in place within the Ysbyty Glan Clwyd Emergency Department and is given to patients at the point of triage. Adaptations are currently being made to launch the patient leaflet in both Ysbyty Wrexham Maelor and Ysbyty Gwynedd Emergency Departments. Completion of this will be monitored via the MHLD Learning and Action Group with an expected completion date of 25th September 2024.” Source location Response from BCUHB
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 open action-plan progress and escalate delays through the MHLD Learning and Action Group.
Verbatim wording from the response “The MHLD Learning and Action Group is responsible for the dissemination of learning attained via multiple routes such as investigations, inspections, inquests and mortality reviews. Moving forward this group will review the progression of open action plans and provide timely escalation to facilitate completion.” Source location Response from BCUHB
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 the patient information leaflet at triage in the Ysbyty Glan Clwyd Emergency Department.
Verbatim wording from the response “With regard to your concerns about the failure to implement improvement actions in a timely manner, I can assure you that the outstanding Patient Information Leaflet is now in place within the Ysbyty Glan Clwyd Emergency Department and is given to patients at the point of triage. Adaptations are currently being made to launch the patient leaflet in both Ysbyty Wrexham Maelor and Ysbyty Gwynedd Emergency Departments. Completion of this will be monitored via the MHLD Learning and Action Group with an expected completion date of 25th September 2024.” Source location Response from BCUHB
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 the new investigation template directing investigators to involve care staff and escalate concerns about care and treatment to managers.
Verbatim wording from the response “As part of the new policy, there is new guidance, training and templates. The new template includes clear guidance for the investigator that directs them to include staff immediately involved in the care and treatment. This will ensure that staff delivering care are active contributors to learning investigations moving forward; it will also prompt the escalation of concerns about care and treatment to the managers of staff to ensure that any actions or omissions are addressed with staff appropriately. This template will be in use from 15 September 2024 as part of the new policy implementation.” Source location Response from BCUHB
Open published response
Concerns raised 3 Lack of an electronic laboratory-to-emergency-department alert system for abnormal results View source Failure to act on abnormal blood results View source Failure to document abnormal blood results in emergency department records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Eric Thompson · 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
Eric Thompson presented with confusion and poor mobility and was found to have high potassium levels. The results were not initially documented or escalated, he did not receive treatment for hyperkalaemia, and he subsequently suffered cardiac arrest and died; the report identified concerns about reliance on person-to-person communication without an electronic alert system for abnormal laboratory results.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of an electronic laboratory-to-emergency-department alert system for abnormal results
Wider context from the report “The abnormal blood results were telephoned through to the emergency department as required by the current system within an hour of the blood being taken to highlight the abnormal results. The results were available on the system; but they were not initially documented by the emergency department following the telephone call. They were not actioned, nor were they noted until many hours later until a clinician actively considered the electronic emergency department medical records for Mr Thompson.
There is no electronic or IT method or system by which the laboratory can send the results to the emergency department quickly and efficiently with an alert to indicate abnormal results. Instead, the system relies on person-to-person discussions and for this to then be escalated, as necessary.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to act on abnormal blood results
Wider context from the report “The abnormal blood results were telephoned through to the emergency department as required by the current system within an hour of the blood being taken to highlight the abnormal results. The results were available on the system; but they were not initially documented by the emergency department following the telephone call. They were not actioned , nor were they noted until many hours later until a clinician actively considered the electronic emergency department medical records for Mr Thompson.
There is no electronic or IT method or system by which the laboratory can send the results to the emergency department quickly and efficiently with an alert to indicate abnormal results. Instead, the system relies on person-to-person discussions and for this to then be escalated, as necessary.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to document abnormal blood results in emergency department records
Wider context from the report “The abnormal blood results were telephoned through to the emergency department as required by the current system within an hour of the blood being taken to highlight the abnormal results. The results were available on the system; but they were not initially documented by the emergency department following the telephone call . They were not actioned, nor were they noted until many hours later until a clinician actively considered the electronic emergency department medical records for Mr Thompson.
There is no electronic or IT method or system by which the laboratory can send the results to the emergency department quickly and efficiently with an alert to indicate abnormal results. Instead, the system relies on person-to-person discussions and for this to then be escalated, as necessary.
” 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 Review, revise and update telephone-alert procedures across all three emergency departments, establishing a clear mechanism for receiving and acting on abnormal laboratory results.
Verbatim wording from the response “To that end, our three hospital Medical Directors will work with all of our three ED teams to review, revise and update the processes in place to ensure there is a clear mechanism for telephone alerts to be received and acted upon. That work will include ensuring the learning from this case is cascaded, that procedures are considered and updated, and importantly that staff are aware of those procedures.” Source location Response from Betsi Cadwaladr 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 Cascade learning from the case across all three emergency departments and ensure staff are aware of the updated telephone-alert procedures.
Verbatim wording from the response “To that end, our three hospital Medical Directors will work with all of our three ED teams to review, revise and update the processes in place to ensure there is a clear mechanism for telephone alerts to be received and acted upon. That work will include ensuring the learning from this case is cascaded, that procedures are considered and updated, and importantly that staff are aware of those procedures.” Source location Response from Betsi Cadwaladr 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 Telephone alerts remain an adequate safety arrangement and are unlikely to be replaced by a future electronic alert system.
Verbatim wording from the response “In specific relation to the issue of abnormal results being communicated to the emergency department (ED) quickly, our Medical Directors have discussed this with senior clinicians and they have identified the telephone alert process is standard in most EDs. This method of alert is more likely to bring the abnormal result to the attention of the department than an IT related alert, due to the dynamic nature of the ED and the fact that most clinicians will be working agile and with patients rather than by a computer. Therefore, the arrangement of phone alerts would still have a valuable role in safety and is not likely to be replaced by any future electronic system (although we acknowledge such systems may provide improved access to information).” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 2 Failure to book urgent vascular surgery transfers with the Adult Critical Care Service Cymru View source Lack of knowledge of the use and operation of the Adult Critical Care Service Cymru View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maureen Elizabeth Owens · 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
Maureen Elizabeth Owens developed a condition requiring urgent vascular surgery while a patient at Maelor Hospital Wrexham on 6 December 2022. Her transfer was delayed, and she deteriorated after subsequent surgery before dying at Glan Clwyd Hospital on 9 December 2022; concerns included incorrect booking of the urgent transfer and inadequate knowledge across the Health Board about the relevant transport service.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to book urgent vascular surgery transfers with the Adult Critical Care Service Cymru
Wider context from the report “An investigation by the Health Board indicated that the transport request for urgent transfer for vascular surgery should have been booked by the ward with the Adult Critical Care Service Cymru (ACCTS) and not WAST and evidence was received in the course of the inquest which suggests that there is inadequate knowledge of the use of ACCTS and its operation across the whole of the Health Board, including clinical site managers as well as clinicians and nursing 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of the use and operation of the Adult Critical Care Service Cymru
Wider context from the report “An investigation by the Health Board indicated that the transport request for urgent transfer for vascular surgery should have been booked by the ward with the Adult Critical Care Service Cymru (ACCTS) and not WAST and evidence was received in the course of the inquest which suggests that there is inadequate knowledge of the use of ACCTS and its operation across the whole of the Health Board, including clinical site managers as well as clinicians and nursing staff .
” 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 Re-share the agreed transfer process with all Integrated Health Communities and obtain confirmation that it has been cascaded.
Verbatim wording from the response “1. | Re-share with all Integrated Health Communities (IHCs) the agreed transfer process and seek confirmation from them this has been cascaded | 13/05/2024 (Complete)” Source location Response from Betsi Cadwaladr 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 Confirm site management teams at all acute sites as the single contact point for emergency transfers.
Verbatim wording from the response “2. | All acute sites to confirm site management teams as the single point of contact for emergency transfers from their respective sites | 10/06/2024” Source location Response from Betsi Cadwaladr 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 Patient Transfer Procedure (NU19) led by the Head of Nursing and Head of Patient Safety.
Verbatim wording from the response “4. | Review the Patient Transfer Procedure (NU19) – this work is already underway led by a Head of Nursing and the Head of Patient Safety | 01/08/2024” Source location Response from Betsi Cadwaladr 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 ACCTS is commissioned only for patients requiring critical care; non-critical ward-to-ward transfers should be referred to the Welsh Ambulance Service Trust.
Verbatim wording from the response “The ACCTS service is currently only commissioned to transfer patients with critical care requirements. Therefore, the referral was correctly made to the Welsh Ambulance Service Trust and the clinical urgency of the transfer should have determined the speed of response and transfer.” Source location Response from Betsi Cadwaladr 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 Mrs Owens did not meet current ACCTS referral or transfer criteria because the proposed transfer was ward-to-ward without identified critical care needs.
Verbatim wording from the response “They confirm that it is correct that the ACCTS were not contacted about the transfer of Mrs Owens, and from their review confirm Mrs Owens did not meet the current criteria for ACCTS referral or transfer since the proposed transfer was a ward to ward transfer and there were no critical care needs identified.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 1 Failure of the bleep system to convey information electronically View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jennifer Ann Trigger · 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
Jennifer Ann Trigger was admitted to Wrexham Maelor Hospital on 29 January 2020 after suffering an acute stroke and was prescribed beriplex, a time-critical treatment, which was not administered until the following morning. The report identified miscommunication and limitations in the bleep system as contributing to delays in prioritising and administering the treatment, followed by deterioration in her condition and her death on 31 January 2020.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of the bleep system to convey information electronically
Wider context from the report “There was a miscommunication or misunderstanding when a ward nurse bleeped a junior doctor with a view to action being taken in relation to the administration of the beriplex infusion. This resulted in a delay in the doctor attending as she did not prioritise a task which was time critical and the subsequent delays resulted in an unrecoverable deterioration in the patient’s condition.
Evidence was received in the course of the inquest that the current bleep system did not enable information to be conveyed electronically and that this in turn created a risk of misunderstanding as to work requirements and hence impacted upon prioritisation of tasks and therefore potential delays , the effects of which (as in this case) could be catastrophic in terms of patient safety.
Evidence was also given that alternative systems existed that had the potential for mitigating or eliminating such risk by way of the electronic transfer of information and requests to doctors.
” 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 Replace Ysbyty Gwynedd’s on-site paging with an integrated critical messaging service.
Verbatim wording from the response “The project involves the replacement of existing on-site paging at Ysbyty Gwynedd in Bangor with an integrated critical messaging service, as part of an overall solution with Ysbyty Glan Clwyd in Bodelwyddan and Wrexham Maelor Hospital.” Source location Response from Betsi Cadwaladr 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 Test WiFi telephones and smartphone messaging applications with frontline clinicians to assess future communication options.
Verbatim wording from the response “The new Multitone iMessage critical messaging system will improve resilience and will provide standardisation across the 3 general hospitals and switchboards, and will allow for inter-site paging and cross cover arrangements.” Source location Response from Betsi Cadwaladr 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 Upgrade critical messaging services at Ysbyty Glan Clwyd and Wrexham Maelor Hospital.
Verbatim wording from the response “The Health Board has been working on a paging system replacement and upgrade project for 12 months.” Source location Response from Betsi Cadwaladr 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 Decide the specific future communication solution using the results of technical testing with frontline clinicians.
Verbatim wording from the response “The ongoing improvements in our systems will improve on site communication for staff to support patient referral, transfers, treatment and discharge and improve efficiencies. A number of technical options are being tested to achieve this, with the testing informing a decision on the specific future solution. These options include WiFi telephones (being tested with ward managers and matrons at Ysbyty Gwynedd) and smart phone devices with the Microsoft Teams and Cisco apps to enable calls and instant messaging through our network (being tested with 34 medical staff in Ysbyty Gwynedd). As with any new technology, it is vital we test the options with front line clinicians to inform the best solution and to ensure patient safety.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
28 Feb 2024 Nesta Jones · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 4 Failure to encourage junior doctors to challenge or discuss differing findings with consultant colleagues View source Failure to undertake full investigations into patient deaths View source Inadequate systems and processes for responding to urgent complaints and concerns View source Failure to formally consider immediate actions and learning to reduce harm and risk of death 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
Nesta 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
Nesta Jones died in hospital on 8 May 2017 after being admitted with suspected septic arthritis of a prosthetic left knee. The report describes concerns about delayed consideration and treatment of septic arthritis, junior doctors not being encouraged to challenge consultant opinions, inadequate handling of the family’s urgent complaint, and the lack of a full investigation into the 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to encourage junior doctors to challenge or discuss differing findings with consultant colleagues
Wider context from the report “a. Nesta Jones was seen by a number of orthopaedic doctors of varying grades including consultants. There was a concern during the evidence that junior doctors may not reach a different opinion to their consultant colleagues where the consultants have seen patients prior, and that this opinion is then followed through the patient’s journey. If junior doctors are not encouraged to challenge or discuss their findings (which may be different) to their consultant colleagues or have professional discussions, then there is a risk of missing diagnoses.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake full investigations into patient deaths
Wider context from the report “c. There was no full investigation undertaken by the Health Board into Nesta’s death other than a desktop report, the quality of which was questionable , as the Police were investigating. This means that there were no formal considerations as to immediate actions or learning required to reduce harm and the risk of death. In oral evidence I was informed that there is a new governance process being considered and likely to be in force by April 2024. I have made previous Reports on this precise point and yet the new and improved process is still not 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Inadequate systems and processes for responding to urgent complaints and concerns
Wider context from the report “b. The family wrote a detailed urgently marked letter to the Chief Executive on 3 May 2017 whilst Nesta was still in hospital. This requested consideration by him of her care as ‘a matter of life or death urgency’. There was no response. The Health Board did not have adequate and appropriate systems and processes for dealing with such complaints and concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to formally consider immediate actions and learning to reduce harm and risk of death
Wider context from the report “c. There was no full investigation undertaken by the Health Board into Nesta’s death other than a desktop report, the quality of which was questionable, as the Police were investigating. This means that there were no formal considerations as to immediate actions or learning required to reduce harm and the risk of death. In oral evidence I was informed that there is a new governance process being considered and likely to be in force by April 2024. I have made previous Reports on this precise point and yet the new and improved process is still not in place.
” 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 Review incident and complaint processes and create an integrated framework covering incidents, complaints and mortality.
Verbatim wording from the response “In relation to the complaint process, I can confirm that since Mrs Jones' death the process in the Complaints Team has now changed. A new Complaints Procedure was introduced in March 2022. This procedure includes an escalation process. However, I acknowledge that further improvement is still needed and we are currently undertaking a full review of the complaint process alongside the review of the incident process detailed below. We will create a new, integrated framework that covers incidents, complaints and mortality. This work is underway at present with a view to completion in the next two months.” Source location Response from Betsi Cadwaladr 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 the NHS Wales National Executive quality team to support improvement work on incident and complaint processes.
Verbatim wording from the response “The Chief Executive is now personally driving this work which will include a new, integrated framework that covers incidents, complaints and mortality as I have detailed above. The Chief Executive is also personally overseeing performance in relation to overdue incidents and complaints with that area being escalated for close executive scrutiny. As a result, we expect to see significant improvement in the process, and the quality and timeliness of investigations, over the coming months as changes are implemented. We are also engaging the support of the NHS Wales National Executive quality team to support us in this improvement work.” Source location Response from Betsi Cadwaladr 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 Issue and distribute a safety alert sharing learning and reinforcing listening to differing professional views, including junior clinicians’ concerns.
Verbatim wording from the response “We are issuing a Safety Alert to share the learning from this case and to highlight and support the improvement of listening to differing professional views and concerns including those from more junior clinicians. This will be shared across the organisation by the end of April 2024.” Source location Response from Betsi Cadwaladr 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 Roll out the Call 4 Concern service to general hospital sites, providing patients and families access to urgent clinical support.
Verbatim wording from the response “In addition, as mentioned at the inquest, the Health Board has also launched a new service to allow patients or relatives to escalate their clinical concerns, called Call 4 Concern. The Call 4 Concern Service was launched in Ysbyty Gwynedd during 2022 and following a pilot is now being rolled out at our other general hospital sites this year.” Source location Response from Betsi Cadwaladr 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 revised Complaints Procedure, including an escalation process.
Verbatim wording from the response “In relation to the complaint process, I can confirm that since Mrs Jones' death the process in the Complaints Team has now changed. A new Complaints Procedure was introduced in March 2022. This procedure includes an escalation process. However, I acknowledge that further improvement is still needed and we are currently undertaking a full review of the complaint process alongside the review of the incident process detailed below. We will create a new, integrated framework that covers incidents, complaints and mortality. This work is underway at present with a view to completion in the next two months.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
14 Feb 2024 Teresa Ann Bennett · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 4 Lack of a standard medication review practice View source Failure to conduct regular medication reviews when prescribing medicines that can depress the central nervous system View source Failure to issue patients specific advice about associated medication risks View source Failure to meet the target frequency for monthly medication reviews 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
Teresa Ann Bennett · 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
Teresa Ann Bennett, who had significant comorbidities and was taking multiple medications including Fentanyl, was found deceased at home on 1 December 2021. The inquest recorded multi-organ failure due to fatty liver and combined drug toxicity, with toxicological analysis identifying Fentanyl in the toxic and fatal range. Concerns included missed regular medication reviews, the absence of a standardised review process, and the risk of inadvertent overdose when medicines that depress the central nervous system are prescribed without regular reviews or specific advice.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard medication review practice
Wider context from the report “(2) No standard practice for medication reviews leading to a lack assurance that all pertinent matters will be covered and the approach varying between clinicians and practices .
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct regular medication reviews when prescribing medicines that can depress the central nervous system
Wider context from the report “(3) The risk of inadvertent overdose in individuals like Ms Bennett, where medication that can cause e.g drowsiness and fatigue, is prescribed alongside strong opiates and other drugs that have the ability to depress the central nervous system when such medicines are prescribed without regular reviews nor specific advice in respect of the associated risks issued to patients e.g in Ms Bennett’s case, she was instructed to simply “remove old patch and apply new patch every 72 hours”
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to issue patients specific advice about associated medication risks
Wider context from the report “(3) The risk of inadvertent overdose in individuals like Ms Bennett, where medication that can cause e.g drowsiness and fatigue, is prescribed alongside strong opiates and other drugs that have the ability to depress the central nervous system when such medicines are prescribed without regular reviews nor specific advice in respect of the associated risks issued to patients e.g in Ms Bennett’s case, she was instructed to simply “remove old patch and apply new patch every 72 hours”
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to meet the target frequency for monthly medication reviews
Wider context from the report “(1) Lack of compliance with the target of 12-15 monthly medication reviews in Health Board managed GP practices.
” 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 Establish a managed Practice Quality and Governance Group covering North Wales services.
Verbatim wording from the response “Practices will report their progress against medication review targets at assurance meetings that will be held regularly (every 2 months). These will be reported at a newly formed managed Practice Quality and Governance Group which will cover all North Wales services.” Source location Response from Betsi Cadwaladr 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 Add the Faculty of Pain Medicine opioid leaflet to the clinical system and provide it to patients at opioid reviews, initiation, or dose changes.
Verbatim wording from the response “Health Board Managed Practices will, from 01 May 2024, add the Faculty of Pain Medicine opioid leaflet onto the clinical system. This will be printed and given to patients on opioids at their medication review, or when opioids are started or doses changed. A copy of this leaflet is attached as an appendix.” Source location Response from Betsi Cadwaladr 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 a Health Board policy defining medication-review standards and risk-priority levels for managed practices.
Verbatim wording from the response “A pan Health Board policy is now being developed to outline the standards for medication review within our managed practices. This will be completed by 30 June 2024.” Source location Response from Betsi Cadwaladr 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 Put practice-specific standard operating procedures in place for medication-review responsibilities and governance.
Verbatim wording from the response “Standard Operating Procedures will then be put in place at each practice to add the detail of responsibility and governance of the process; this will differ at each practice due to staffing skill mix.” Source location Response from Betsi Cadwaladr 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 Risk-stratify patients lacking recent medication reviews to prioritise review according to medication-related risk.
Verbatim wording from the response “We have commenced benchmarking work on 21 February 2024 for all Health Board managed practices to identify all patients on regular repeat medication who have not got a medication review documented in the notes in the last 12-15 months. This work will be completed by 31 May 2024. These patients will then be risk stratified for medication review. This will occur parallel to implementing new procedures as outlined below.” Source location Response from Betsi Cadwaladr 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 Require practices to report medication-review progress against targets through regular assurance meetings.
Verbatim wording from the response “Practices will report their progress against medication review targets at assurance meetings that will be held regularly (every 2 months). These will be reported at a newly formed managed Practice Quality and Governance Group which will cover all North Wales services.” Source location Response from Betsi Cadwaladr 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 medication-risk warnings on pharmacy labels and patient information leaflets with advice for relevant opioid and patch-related scenarios.
Verbatim wording from the response “Addressing the concerns regards patient information and their awareness of risks, additional warnings are included on pharmacy labels on the outside of medication boxes, which reference the risks of drowsiness. In addition, patient information leaflets are included in every box which outlines what to do in various scenarios e.g., increased drowsiness, if patches no longer giving pain relief, and if a patch falls off.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 4 Lack of joint discharge planning between the Health Board and out-of-area psychiatric facilities View source Failure to share relevant clinical information between the Health Board and out-of-area psychiatric facilities View source Delays and failures in transferring and acting on discharge clinical documentation View source Lack of agreed minimum information-sharing standards between the Health Board and private psychiatric facilities View source See 1 more concern
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
Philip David Taylor · 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
Philip David Taylor had mental health difficulties, was admitted to a private psychiatric unit outside the NHS North Wales area, and died by suicide at home on 23 August 2023 after discharge to the Home Treatment Team. The concerns included inadequate information sharing and coordination between the Health Board and the private unit, including delayed or missing discharge documentation and no agreed written standards for communication and documentation.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of joint discharge planning between the Health Board and out-of-area psychiatric facilities
Wider context from the report “b. There was no joined up planning or joint meeting between the Health Board and Ty Grosvenor prior to the deceased’s 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant clinical information between the Health Board and out-of-area psychiatric facilities
Wider context from the report “a. The Health Board utilises facilities out of area for acute psychiatric care when there are no available beds in the NHS in North Wales. I was informed that the patients, however, remain the responsibility of the Health Board. During the deceased’s time at Ty Grosvenor it does not appear that any/all relevant information was shared between the two organisations e.g. deceased’s progress, medication, treatment etc, except for few telephone conversations.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays and failures in transferring and acting on discharge clinical documentation
Wider context from the report “c. The prescription and administration record together with a copy of the pre-admission paperwork were only sent to the Health Board two days after the deceased was discharged .
d. The discharge summary was emailed to the Health Board three days after discharge, but this was either not received by the Health Board or received and not acted upon . In fact, it is the deceased’s wife who had informed the Home Treatment Team that the deceased had been discharged. On knowing this, no one sought to request the discharge summary from Ty Grosvenor , even where there was a change in medication dosage.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of agreed minimum information-sharing standards between the Health Board and private psychiatric facilities
Wider context from the report “e. There was no evidence at Inquest of any written agreement or standard operating procedure or similar between the Health Board and private facility as to minimum standard requirements or expectations between both organisations e.g. what documentation should be shared, how it is to be shared, when documentation should be shared, the timeliness of sharing documentation etc.
f. It is concerning that such minimum standards are not set out and agreed between the Health Board and this private psychiatric unit in a situation where many patients are likely to be treated there. It is not known whether or not such minimum standards or Agreement exists with other out of area private units.
g. In the event that patients are to be treated in private units out of the area then there will be a risk of future deaths if such minimum standards regarding sharing of information and communication are not set and agreed between the Health Board and private facility. There had been no consideration of this as part of the actions arising from the Health Board’s own investigation.
” 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 Hold formal weekly multidisciplinary out-of-area monitoring meetings with documented actions, escalation and oversight of repatriation, clinical activity and discharge planning.
Verbatim wording from the response “All areas have stood up a formal weekly out of area monitoring meeting. The purpose of this meeting is to promote timely repatriation where possible, assurance that key clinical activity and standards are being met and that discharge plans are being implemented and actioned. These meetings are underpinned by terms of reference, agenda, minutes and a log of actions to be completed. Membership includes the multidisciplinary team, including Health and Social Care, Consultant and Medical staffing, Occupational Therapy, Home Treatment Team and Care Coordinators. Outcomes from the meetings are provided to Divisional Putting Things Right meetings and the weekly Divisional Senior Leadership meeting to ensure appropriate escalation arrangements can be put in place where required.” Source location Response from Betsi Cadwaladr 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 Launch and implement the fully ratified standard operating procedure for out-of-area acute placements.
Verbatim wording from the response “A multi-disciplinary task and finish group has been established, chaired by the Head of Integrated strategy and development, who is leading on the development of the SoP in collaboration with both operational and clinical teams. Progress will be overseen by the MHLD Policy and Procedure Group. Following ratification, the Task and Finish Group will oversee the launch and implementation of the SoP and compliance with the SoP will be monitored through established local and divisional Putting Things Right Meetings. I am advised that the SoP will be fully ratified by the end of August 2024.” Source location Response from Betsi Cadwaladr 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 a standard operating procedure governing information sharing, repatriation and discharge planning, and key documentation for out-of-area acute placements.
Verbatim wording from the response “The learning from the inquest of Mr Taylor has identified that a standard operating procedure is required (SoP) and must include the requirements for sharing information, joined up planning for repatriation and/or discharge and standards for the development and sharing of key documentation.” Source location Response from Betsi Cadwaladr 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 Monitor compliance with the standard operating procedure through local and divisional Putting Things Right meetings.
Verbatim wording from the response “A multi-disciplinary task and finish group has been established, chaired by the Head of Integrated strategy and development, who is leading on the development of the SoP in collaboration with both operational and clinical teams. Progress will be overseen by the MHLD Policy and Procedure Group. Following ratification, the Task and Finish Group will oversee the launch and implementation of the SoP and compliance with the SoP will be monitored through established local and divisional Putting Things Right Meetings. I am advised that the SoP will be fully ratified by the end of August 2024.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 3 Lack of assurance regarding changes and learning from identified matters View source Failure to investigate matters arising from lost follow-up View source Failure to raise Datix reports for identified matters View source
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
Thomas Grenville Hammersley Ithell · 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
Thomas Ithell, aged 77, died in hospital on 20 November 2022 after prostate cancer progressed and caused his death. He had become lost to follow-up, with PSA monitoring and clinical review not occurring for about 10 months after November 2021. Concerns included the absence of a Datix report and Health Board investigation, lack of assurance about learning or changes, and staff time constraints affecting incident reporting.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of assurance regarding changes and learning from identified matters
Wider context from the report “During the course of the evidence it was identified that:-
1. There was no Datix raised by anyone when the error (Mr Ithell being lost to follow up) was identified, either at the time of the appointment on 22 October 2022 when the error was identified or at any point thereafter;
2. There has been no investigation by the Health Board into how Mr Ithell came lost for follow up after his appointment on 5 November 2021;
3. There have been no assurances as to what, if any, changes and learning have been identified other than a tracking system for PSA monitoring ;
4. Evidence was heard at the Inquest that time restraints on hospital staff had meant that Datix was not completed and that the system was not user-friendly.
I have raised a number of Prevention of Future Death reports with the Health Board previously around investigation processes. I remain incredibly concerned that where matters are not raised in accordance with internal Health Board processes that assurances given to me previously in Prevention of Future Death Reports cannot be supported . Furthermore, I am concerned that Datix reports will not be raised if time constraints prevent such, where the Health Board themselves often identified the Datix reporting system as the initiation of governance / investigation processes.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate matters arising from lost follow-up
Wider context from the report “During the course of the evidence it was identified that:-
1. There was no Datix raised by anyone when the error (Mr Ithell being lost to follow up) was identified, either at the time of the appointment on 22 October 2022 when the error was identified or at any point thereafter;
2. There has been no investigation by the Health Board into how Mr Ithell came lost for follow up after his appointment on 5 November 2021 ;
3. There have been no assurances as to what, if any, changes and learning have been identified other than a tracking system for PSA monitoring;
4. Evidence was heard at the Inquest that time restraints on hospital staff had meant that Datix was not completed and that the system was not user-friendly.
I have raised a number of Prevention of Future Death reports with the Health Board previously around investigation processes. I remain incredibly concerned that where matters are not raised in accordance with internal Health Board processes that assurances given to me previously in Prevention of Future Death Reports cannot be supported. Furthermore, I am concerned that Datix reports will not be raised if time constraints prevent such, where the Health Board themselves often identified the Datix reporting system as the initiation of governance / investigation processes.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to raise Datix reports for identified matters
Wider context from the report “During the course of the evidence it was identified that:-
1. There was no Datix raised by anyone when the error (Mr Ithell being lost to follow up) was identified, either at the time of the appointment on 22 October 2022 when the error was identified or at any point thereafter ;
2. There has been no investigation by the Health Board into how Mr Ithell came lost for follow up after his appointment on 5 November 2021;
3. There have been no assurances as to what, if any, changes and learning have been identified other than a tracking system for PSA monitoring;
4. Evidence was heard at the Inquest that time restraints on hospital staff had meant that Datix was not completed and that the system was not user-friendly.
I have raised a number of Prevention of Future Death reports with the Health Board previously around investigation processes. I remain incredibly concerned that where matters are not raised in accordance with internal Health Board processes that assurances given to me previously in Prevention of Future Death Reports cannot be supported. Furthermore, I am concerned that Datix reports will not be raised if time constraints prevent such , where the Health Board themselves often identified the Datix reporting system as the initiation of governance / investigation processes.
” 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 the incident process further with support from the NHS Wales National Executive Quality Team.
Verbatim wording from the response “I can also advise that the Patient Safety Team have reviewed the incident process and intend to make changes to that process from April 2024. The team have been working with services to co-design the changes taking into account feedback from front line clinicians and looking at best practice across Wales. Over the coming months, we plan further reviews into this process with support from the NHS Wales National Executive Quality Team.” Source location Response from Betso Cadwaladr 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 Redesign the incident process with services using frontline feedback and Welsh best practice.
Verbatim wording from the response “I can also advise that the Patient Safety Team have reviewed the incident process and intend to make changes to that process from April 2024. The team have been working with services to co-design the changes taking into account feedback from front line clinicians and looking at best practice across Wales. Over the coming months, we plan further reviews into this process with support from the NHS Wales National Executive Quality Team.” Source location Response from Betso Cadwaladr 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 Raise an incident report for the identified follow-up error.
Verbatim wording from the response “I can confirm that an Incident Report has now been raised in regards to the error identified and a Make it Safe Rapid Review was undertaken. This review was completed on 05 March 2023. A decision was made to conduct a full investigation and this is underway at present. The incident has been confirmed as a Nationally Reportable Incident (NRI). The investigation report is due to be completed by 09 May 2024 and will include a full action plan to address any areas of learning.” Source location Response from Betso Cadwaladr 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 revised Datix training programme through recurring team sessions, local training, videos and guidance.
Verbatim wording from the response “I am aware you have raised your concerns with regards to incident reporting and management previously. Since those earlier concerns, a revised training programme has been put in place for our Datix incident reporting system. This includes training offered by our Quality Systems Team on the Datix system twice monthly, training specifically on incident reporting and reviewing delivered by our Patient Safety Team weekly, and local training delivered by our locally based quality teams (in our East Integrated Health Community for example, there are weekly dates offered). This range of training means there is a mix of opportunities for staff to access training. A number of training videos and “how to guides” are available on our staff intranet.” Source location Response from Betso Cadwaladr 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 Complete a Make it Safe Rapid Review of the incident.
Verbatim wording from the response “I can confirm that an Incident Report has now been raised in regards to the error identified and a Make it Safe Rapid Review was undertaken. This review was completed on 05 March 2023. A decision was made to conduct a full investigation and this is underway at present. The incident has been confirmed as a Nationally Reportable Incident (NRI). The investigation report is due to be completed by 09 May 2024 and will include a full action plan to address any areas of learning.” Source location Response from Betso Cadwaladr 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 a detailed action plan responding to the investigation findings.
Verbatim wording from the response “I can confirm that an Incident Report has now been raised in regards to the error identified and a Make it Safe Rapid Review was undertaken. This review was completed on 05 March 2023. A decision was made to conduct a full investigation and this is underway at present. The incident has been confirmed as a Nationally Reportable Incident (NRI). The investigation report is due to be completed by 09 May 2024 and will include a full action plan to address any areas of learning.” Source location Response from Betso Cadwaladr 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 Form the Quality Systems Group to provide integrated oversight of quality systems and user feedback.
Verbatim wording from the response “Within the Health Board, in November 2023, we formed a new Quality Systems Group to provide greater oversight of our quality systems in a more integrated approach. This group’s remit includes collecting, assessing and acting upon user feedback. Over the coming months we will be conducting a survey of our staff experiences in using the Datix system and we will use these findings to make recommendations nationally on improvements or enhancements to the system (recognising any changes we suggest will be subject to all-Wales agreement).” Source location Response from Betso Cadwaladr 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 the full investigation into how the patient was lost to follow-up.
Verbatim wording from the response “I can confirm that an Incident Report has now been raised in regards to the error identified and a Make it Safe Rapid Review was undertaken. This review was completed on 05 March 2023. A decision was made to conduct a full investigation and this is underway at present. The incident has been confirmed as a Nationally Reportable Incident (NRI). The investigation report is due to be completed by 09 May 2024 and will include a full action plan to address any areas of learning.” Source location Response from Betso Cadwaladr University Health Board
Open published response
Concerns raised 12 Unavailability of out-of-hours emergency endoscopy View source Upper GI Bleeding Management and Principles of Care guidance no longer fit for purpose View source Lack of clarity about when to call the Emergency Treatment Team View source Insufficient Emergency Department space for patient demand View source Insufficient doctors and nurses for Emergency Department patient demand View source Failure to adequately share investigation learning with practitioners View source Failure to sufficiently identify and action issues from investigation findings View source Failure to record triage of ambulance arrivals at the Emergency Department View source Failure to maintain consistent investigation report content View source Failure to admit ambulance patients promptly and return ambulances to active duty View source Ineffective triage of ambulance arrivals at the Emergency Department View source Lack of clarity about when to engage the Major Haemorrhage Pathway View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what this recipient says about the concern when it does not describe a specific action. 7
Position
The NEWS chart clearly identifies when clinicians should call the Medical Emergency Team.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Glan Clwyd Hospital lacks sufficient demand to support a 24/7 emergency endoscopy service under NICE guidance.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Position
Resuscitation, haemorrhage management, critical care monitoring and escalation pathways can stabilise most upper gastrointestinal bleeding until endoscopy.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
The upper gastrointestinal bleeding guideline was updated, follows NICE and British Society of Gastroenterology guidance, and is scheduled for review.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Workforce challenges at Wrexham Maelor Hospital prevent continuation of cross-site cover for urgent upper gastrointestinal bleeds.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action. View source
Position
The Major Haemorrhage Pathway is available to all staff, visibly displayed, and supported by experienced senior staff.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Position
Existing Manchester Triage, continuous nursing cover, senior ambulance triage and electronic recording address emergency department triage concerns.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source See 6 more positions
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AI-generated summary
Vivienne Greener · 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
Vivienne Greener was taken by ambulance to Glan Clwyd Hospital after vomiting blood and died there on 20 March 2018 following a massive upper gastrointestinal haemorrhage. The report identified concerns including delayed admission and triage, delayed provision of blood products, failures to escalate and trigger haemorrhage pathways, insufficient staffing and the lack of out-of-hours emergency endoscopy.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Unavailability of out-of-hours emergency endoscopy
Wider context from the report “1. An out of hours emergency endoscopy is still not available at Glan Clwyd Hospital or in this area of North Wales as the provision has ‘collapsed’ at Wrexham Maelor Hospital, so no referrals can be made;
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Upper GI Bleeding Management and Principles of Care guidance no longer fit for purpose
Wider context from the report “6. The Health Board’s Upper GI Bleeding Management and Principles of Care 2022 is no longer fit for purpose ;
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about when to call the Emergency Treatment Team
Wider context from the report “4. There is not a clear understanding of when the Emergency Treatment Team should be called ;
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient Emergency Department space for patient demand
Wider context from the report “2. There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department ;
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient doctors and nurses for Emergency Department patient demand
Wider context from the report “2. There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department;
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately share investigation learning with practitioners
Wider context from the report “7. Any learning from the Health Board’s Investigation Report is not adequately shared with its practitioners ;
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to sufficiently identify and action issues from investigation findings
Wider context from the report “8. A part of the Health Board’s Investigation Report changed in different versions and obscured the reason why the provision of blood products was delayed meaning issues are not sufficiently identified and actioned ;
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to record triage of ambulance arrivals at the Emergency Department
Wider context from the report “3. There is an ineffective triage and record of triage of patients arriving at Glan Clwyd Emergency Department by ambulance ;
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain consistent investigation report content
Wider context from the report “8. A part of the Health Board’s Investigation Report changed in different versions and obscured the reason why the provision of blood products was delayed meaning issues are not sufficiently identified and actioned;
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to admit ambulance patients promptly and return ambulances to active duty
Wider context from the report “9. Ambulances and paramedics are being kept at the Emergency Department as an extension of the hospital and its staff , due to WAST being unable to get their patients admitted into the Emergency Department and back on active duty .
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Ineffective triage of ambulance arrivals at the Emergency Department
Wider context from the report “3. There is an ineffective triage and record of triage of patients arriving at Glan Clwyd Emergency Department by ambulance ;
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about when to engage the Major Haemorrhage Pathway
Wider context from the report “5. There is not a clear understanding of when the Major Haemorrhage Pathway should be engaged ;
” 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 and increase the Emergency Department nurse staffing roster template through the annual staffing review.
Verbatim wording from the response “The YGC ED department along with the other two sites are in the process of being reviewed as part of the 2023/2024 annual nurse staffing review cycle and have they have proposed that the current staffing roster template is increased.” Source location Response from Betso Cadwaladr 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 Manchester Triage Tool and electronic Symphony records for ambulance handovers and triage decisions.
Verbatim wording from the response “Within the ED at YGC, the Manchester Triage Tool is in place (which staff have been trained in) which highlights prioritisation of patients. A waiting room member of the nursing team is in place 24 hours a day, 7 days a week and the triage registered nurse and nurse in charge will address stroke, chest pain and silver trauma – this is for walk in patients prior to formalised triage assessment. All ambulance handovers are triaged by a senior nurse. Triage outcomes and decisions are recorded electronically on Symphony system, which is a relatively new system that was introduced on 30th March 2022.” Source location Response from Betso Cadwaladr 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 a new incident process for sharing investigation learning with clinicians.
Verbatim wording from the response “In relation to your concern that incident investigation reports are not shared with clinicians, I can confirm that following concerns from other coroners, a new incident process is being developed and will be implemented in April 2024.” Source location Response from Betso Cadwaladr 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 Display the Major Haemorrhage Pathway in all clinical areas, including the Emergency Department resuscitation area.
Verbatim wording from the response “Any member of staff can trigger the Major Haemorrhage Pathway and it is printed on the wall in all clinical areas, including the resuscitation area in ED, and is clearly visible to all. Senior staff who are all very familiar with the pathway are always available and support all resuscitation cases, and can advise if agency staff are unsure or unfamiliar with the pathway.” Source location Response from Betso Cadwaladr 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 expanding consultant staffing in the Emergency Department, now providing 8.6 whole-time-equivalent consultants plus one locum.
Verbatim wording from the response “The Emergency Department at YGC is fully staffed with junior doctors, in line with the budgeted provision, and appropriate staffing levels are put in place through rota management each month, with mitigation in place for management of sickness and unplanned absence. In addition, staffing levels have been mitigated with the expansion of Consultant numbers since Mrs Greener’s death, and there are now 8.6 whole time equivalent Consultants plus 1 whole time equivalent locum. Our senior consultants, are also available 24/7 to attend to and support such cases as this, and all core clinical consultant shifts are covered.” Source location Response from Betso Cadwaladr 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 Display the Medical Emergency Team call process on NEWS charts for clinicians assessing observations.
Verbatim wording from the response “With regards to understanding when to call the Medical Emergency Team (MET), evidence of the MET call process is included on the National Early Warning Score (NEWS) chart and is clearly visible to all clinicians assessing and reviewing patient recorded observations. For clarity, the Emergency Treatment Team is now known as the Medical Emergency Team.” Source location Response from Betso Cadwaladr 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 suitable out-of-hours endoscopy rota.
Verbatim wording from the response “Provision of out of hours endoscopy remains under review given the historical and on-going concerns and the teams will be working towards the development of a suitable rota.” Source location Response from Betso Cadwaladr 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 Update the Upper GI Bleeding Management and Principles of Care guideline to align with NICE and British Society of Gastroenterology guidance.
Verbatim wording from the response “I can confirm this was updated in July 2023 and will be reviewed again in April 2024. This guideline follows the appropriate NICE guidelines and the acute upper GI bleed care bundle from the British Society of Gastroenterology.” Source location Response from Betso Cadwaladr 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 Scope and formalise additional Emergency Department capacity, including a dedicated speciality waiting area.
Verbatim wording from the response “Processes are taking place in respect of patient flow to release capacity, however, we are reviewing the opportunity to create additional capacity in terms of infrastructure changes and a review of our current START clinical area. This would create a dedicated speciality waiting area with cubicles for review. This scoping is work in progress, and will be formalised.” Source location Response from Betso Cadwaladr 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 the Emergency Department resource required to meet demand and national recommendations.
Verbatim wording from the response “The Emergency Department are continuously reviewing staffing in relation to increasing the core numbers to meet national recommendations within the funding envelope available, and work is ongoing to map the resource required to meet demands.” Source location Response from Betso Cadwaladr 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 Implement the new incident process in April 2024.
Verbatim wording from the response “In relation to your concern that incident investigation reports are not shared with clinicians, I can confirm that following concerns from other coroners, a new incident process is being developed and will be implemented in April 2024.” Source location Response from Betso Cadwaladr 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 Add a newly appointed gastroenterologist to the upper gastrointestinal rota from April 2024.
Verbatim wording from the response “A new Gastroenterologist has been appointed in YGC and will start in April 2024 and they will be part of an upper GI rota.” Source location Response from Betso Cadwaladr 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 a report template identifying the final approved investigation version and distinguishing it from drafts.
Verbatim wording from the response “Finally, regarding your concern that the investigation report changed in different versions and obscured the reason why the provision of blood products was delayed, I understand ████████, IHC Medical Director provided a statement regarding this. Our new incident process mentioned above will introduce a new report template making it clear which version is the final, approved version of the report avoiding any confusion between the final approved version and any draft versions.” Source location Response from Betso Cadwaladr 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 The NEWS chart clearly identifies when clinicians should call the Medical Emergency Team.
Verbatim wording from the response “With regards to understanding when to call the Medical Emergency Team (MET), evidence of the MET call process is included on the National Early Warning Score (NEWS) chart and is clearly visible to all clinicians assessing and reviewing patient recorded observations. For clarity, the Emergency Treatment Team is now known as the Medical Emergency Team.” Source location Response from Betso Cadwaladr 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 Glan Clwyd Hospital lacks sufficient demand to support a 24/7 emergency endoscopy service under NICE guidance.
Verbatim wording from the response “Out of hours emergency endoscopy not available at Glan Clwyd Hospital or in this area of North Wales” Source location Response from Betso Cadwaladr 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 Resuscitation, haemorrhage management, critical care monitoring and escalation pathways can stabilise most upper gastrointestinal bleeding until endoscopy.
Verbatim wording from the response “Optimal resuscitation measures, excellent major haemorrhage management, close critical care monitoring (and use in extremis of the Sengstaken tube for variceal bleeds) can stabilise most Upper GI bleeding until endoscopy can be done at the earliest next opportunity. On very rare occasions when patients cannot be stabilised, and patients display evidence of ongoing life threatening bleeding such as overt large volume bleeding, haemodynamic compromise, shock, NEWS scores >8, or high Glasgow Blatchford scores the following key staff should be contacted - the on Call Consultant Physician, Surgeon, ITU team, and ED consultant to lead on the management and coordinate care.” Source location Response from Betso Cadwaladr 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 The upper gastrointestinal bleeding guideline was updated, follows NICE and British Society of Gastroenterology guidance, and is scheduled for review.
Verbatim wording from the response “Upper GI Bleeding Management and Principles of Care 2022 is no longer fit for purpose” Source location Response from Betso Cadwaladr 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 Workforce challenges at Wrexham Maelor Hospital prevent continuation of cross-site cover for urgent upper gastrointestinal bleeds.
Verbatim wording from the response “As you identified, Wrexham Maelor Hospital (WMH) would previously take over patients with urgent upper gastrointestinal bleeds, once they were stabilised at YGC. This cross-site cover has stopped due to workforce challenges at WMH. Currently the clinicians will adopt the recommendations set out in the Upper GI Bleeding – Management and Principles of Care at YGC ‘pathway. The pathway outlines the following:” Source location Response from Betso Cadwaladr 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 The Major Haemorrhage Pathway is available to all staff, visibly displayed, and supported by experienced senior staff.
Verbatim wording from the response “Any member of staff can trigger the Major Haemorrhage Pathway and it is printed on the wall in all clinical areas, including the resuscitation area in ED, and is clearly visible to all. Senior staff who are all very familiar with the pathway are always available and support all resuscitation cases, and can advise if agency staff are unsure or unfamiliar with the pathway.” Source location Response from Betso Cadwaladr 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 Existing Manchester Triage, continuous nursing cover, senior ambulance triage and electronic recording address emergency department triage concerns.
Verbatim wording from the response “Within the ED at YGC, the Manchester Triage Tool is in place (which staff have been trained in) which highlights prioritisation of patients. A waiting room member of the nursing team is in place 24 hours a day, 7 days a week and the triage registered nurse and nurse in charge will address stroke, chest pain and silver trauma – this is for walk in patients prior to formalised triage assessment. All ambulance handovers are triaged by a senior nurse. Triage outcomes and decisions are recorded electronically on Symphony system, which is a relatively new system that was introduced on 30th March 2022.” Source location Response from Betso Cadwaladr University Health Board
Open published response
Concerns raised 1 Lack of an approved, documented system of work for communication with patients’ consultants before pooled-list surgery View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Catherine Lisa 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
Catherine Lisa Jones died at Wrexham Maelor Hospital on 10 November 2016 from widespread metastatic ovarian cancer contributed to by pseudomembranous colitis. The report describes concerns that a biopsy had been wrongly classified as benign, that a lesion was not identified during subsequent surgery or on a scan, and that surgery conducted through pooled lists was not supported by a documented, approved system of work, potentially resulting in a lack of cohesive care and treatment.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of an approved, documented system of work for communication with patients’ consultants before pooled-list surgery
Wider context from the report “It was indicated that for many departments within the health board, surgery was conducted on the basis of “pooled lists” and although evidence was given that the common practice of one of the surgeons was to ensure that they had some form of communication with the patient’s consultant prior to surgery (by phone and/or email), there was no evidence that this practice was part of an approved system of work which was documented within the health board’s protocols .
In the absence of this being a part of an adopted practice and procedure guidance , I am concerned that there may be a lack of cohesive care and treatment for patients undergoing surgery and that future death may occur as a result.
” 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 a clear, consistent organisation-wide policy through a task group involving Integrated Health Communities and Regional Specialist Services.
Verbatim wording from the response “Upon receiving the notice, I asked my deputy executive medical director, ████████
████████ to review and assess practice across the Health Board. This work has been completed and has identified the need to develop a clear and consistent policy for the entire organisation.” Source location Response from Betsi Cadwaladr 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 a Health Board-wide review and assessment of pooled surgical-list practice to identify required policy improvements.
Verbatim wording from the response “Upon receiving the notice, I asked my deputy executive medical director, ████████
████████ to review and assess practice across the Health Board. This work has been completed and has identified the need to develop a clear and consistent policy for the entire organisation.” Source location Response from Betsi Cadwaladr 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 Obtain Planned Care Board approval for the new policy to establish operational and clinical ownership.
Verbatim wording from the response “The new policy will be approved at the Planned Care Board to ensure operational and clinical ownership. This group will also oversee the progress of the task group.” Source location Response from Betsi Cadwaladr 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 Implement the new policy under divisional medical director leadership and report implementation progress to the task group.
Verbatim wording from the response “Implementation of this new policy will then be led by the medical directors for our divisions and reported back into the group.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 3 Inadequate management of patients with food intolerances and allergies View source Failure to ensure staff complete Datix reports when required and know how to complete them View source Failure to investigate patient safety incidents through adequate governance processes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Hazel Pearson · 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
Hazel Pearson, who had known coeliac disease, consumed Weetabix in hospital on 26 November 2021, then vomited, aspirated and developed respiratory deterioration before dying from aspiration pneumonia on 30 November 2021. The report raised concerns about inadequate management of food intolerances and allergies, the lack of investigation into the incident, and failures to complete incident reports for other instances of gluten ingestion.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Inadequate management of patients with food intolerances and allergies
Wider context from the report “1. Despite the deceased passing away just shy of 2 years ago, there have been inadequate improvements to manage patients with food intolerances and allergies . The Health Board has been working with other organisations in Wales to create an e-learning module and implement the use of red wrist bands for food intolerances / allergies, but this has taken far too long . The e-learning training module was uploaded to BCUHB system the day prior to the Inquest. It is strongly suspected that this was due to the impending Inquest.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff complete Datix reports when required and know how to complete them
Wider context from the report “3. There were other incidences of gluten ingestion at Ysbyty Maelor and Deeside Community Hospital. On the at least 4 occasions at Deeside Community Hospital there were no Datix reports completed at the time . I was provided with no evidence that additional training, refresher training or induction training deals with when such reports should be made . I cannot be satisfied and reassured that all staff are aware of when to make a Datix report and how to complete this .
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate patient safety incidents through adequate governance processes
Wider context from the report “2. The Health Board has not investigated the incident at all . A Medical Examiner Report was prepared following the death in November 2021 highlighting the ingestion of gluten in a coeliac patient. I have raised and continue to raise a number of concerns around the inadequacy of governance and poor investigation processes .
” 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 full Health Board incident-process review through staff co-design.
Verbatim wording from the response “On the second and third points around incident reporting and investigations, I know we have written to you recently regarding these points. To summarise our earlier responses, as you know we are undertaking a full review of the incident process in the Health Board, in co-design with our staff, and will introduce a new process and procedure for April 2024. This new process will include a revised training programme for staff on conducting investigations. A revised training programme for incident reporting is in place for all staff with dates confirmed across North Wales for the next quarter alongside “how to” guides and videos for staff to access at any time via the BetsiNet intranet.” Source location Response from Betsi Cadwaladr 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 and revise the governance escalation structure to ensure timely escalation from incident review meetings to the INCHS Group.
Verbatim wording from the response “The documents that underpinned the use of red wrist bands were all agreed and signed off through the relevant governance groups 8-9 months from the task and finish group being established. It is acknowledged that there were gaps in the escalation process from the Make it Safe incident review meetings to the Improving Nutrition, Catering and Hydration Standards (INCHS) Group and the governance structure underneath that group has been reviewed and changes are being made to ensure escalation processes are robust and timely.” Source location Response from Betsi Cadwaladr 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 volunteer training requirements and provide the necessary training links and materials.
Verbatim wording from the response “assigned to undertake this training. This will be mandated for them and will automatically appear on their ESR compliance page. Those staff will be all frontline staff who have an involvement in meal provision, with catering staff having an advanced level of training, which is already in place. In addition, agency staff and students will be required to undertake the training and this has been communicated with the agencies and local universities in January 2024. Training for volunteers is also being reviewed in January 2024, and the necessary training links and materials will be made available for the voluntary staff in February 2024. I have enclosed a copy of the communication to all staff via our BetsiNet intranet.” Source location Response from Betsi Cadwaladr 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 Implement red wrist-band use and approve the supporting documents through the relevant governance groups.
Verbatim wording from the response “assigned to undertake this training. This will be mandated for them and will automatically appear on their ESR compliance page. Those staff will be all frontline staff who have an involvement in meal provision, with catering staff having an advanced level of training, which is already in place. In addition, agency staff and students will be required to undertake the training and this has been communicated with the agencies and local universities in January 2024. Training for volunteers is also being reviewed in January 2024, and the necessary training links and materials will be made available for the voluntary staff in February 2024. I have enclosed a copy of the communication to all staff via our BetsiNet intranet.” Source location Response from Betsi Cadwaladr 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 commissioning formal food-standards expertise from the local authority and seek the funding required to support it.
Verbatim wording from the response “To support ongoing improvement, we are also exploring how the Health Board can access expert advice in relation to compliance. Wrexham Council, acting as the Primary Authority for North Wales, have been providing some formal guidance to the Health Board in relation to food safety, specifically food hygiene. The same arrangement for food standards, where food allergens sits, is not in place. The Health Board are considering commissioning this support going forward and will require some funding to support this. The Local Authority have been providing some advice to the Health Board but not in any formal capacity.” Source location Response from Betsi Cadwaladr 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 mandated allergy and food-intolerance training for relevant frontline, catering, agency and student staff, with completion recorded in ESR.
Verbatim wording from the response “Following the inquest, further meetings have taken place in December 2023 to communicate the roll out of the red wrist bands, which has now happened via the BetsiNet intranet page accessible by all staff and the training is live, with agreed staff groups being” Source location Response from Betsi Cadwaladr 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 a new incident reporting and investigation process and procedure, including revised investigation training, for April 2024.
Verbatim wording from the response “On the second and third points around incident reporting and investigations, I know we have written to you recently regarding these points. To summarise our earlier responses, as you know we are undertaking a full review of the incident process in the Health Board, in co-design with our staff, and will introduce a new process and procedure for April 2024. This new process will include a revised training programme for staff on conducting investigations. A revised training programme for incident reporting is in place for all staff with dates confirmed across North Wales for the next quarter alongside “how to” guides and videos for staff to access at any time via the BetsiNet intranet.” Source location Response from Betsi Cadwaladr 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 revised incident-reporting training and provide staff with accessible how-to guides and videos through the BetsiNet intranet.
Verbatim wording from the response “On the second and third points around incident reporting and investigations, I know we have written to you recently regarding these points. To summarise our earlier responses, as you know we are undertaking a full review of the incident process in the Health Board, in co-design with our staff, and will introduce a new process and procedure for April 2024. This new process will include a revised training programme for staff on conducting investigations. A revised training programme for incident reporting is in place for all staff with dates confirmed across North Wales for the next quarter alongside “how to” guides and videos for staff to access at any time via the BetsiNet intranet.” Source location Response from Betsi Cadwaladr 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 Commissioning formal food-allergen standards advice will require funding, limiting the Health Board’s ability to obtain that support.
Verbatim wording from the response “To support ongoing improvement, we are also exploring how the Health Board can access expert advice in relation to compliance. Wrexham Council, acting as the Primary Authority for North Wales, have been providing some formal guidance to the Health Board in relation to food safety, specifically food hygiene. The same arrangement for food standards, where food allergens sits, is not in place. The Health Board are considering commissioning this support going forward and will require some funding to support this. The Local Authority have been providing some advice to the Health Board but not in any formal capacity.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
24 Oct 2023 Jennifer Lydia Campbell · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 6 Lack of clarity about which incidents require investigation View source Patient referrals remaining paper based View source Failure to audit for other lost patient referrals View source Failure to formally investigate lost referrals View source Failure to establish awareness and action on Medical Examiner concerns View source Failure to implement learning and improvement after incidents View source See 3 more concerns
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. 8
Action
Implement referral safeguards requiring endoscopy referrals to be scanned, recorded on WPAS, and routed through booking clerks.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2023. View source
Action
Review the Health Board incident process through staff co-design.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 November 2023. View source
Action
Introduce a revised incident process and staff training programme, including triangulation of information from all sources, by April 2024.
Stated plannedThe respondent said that this action was planned when they made their response on 1 November 2023. View source
Action
Work with Digital Health and Care Wales to develop an electronic ERCP internal referral form within the Welsh Clinical Portal.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 November 2023. View source
Action
Audit referral forms received between 1 October 2021 and 30 November 2023 for missing forms.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2023. View source
Action
Implement a process for reviewing complaints, medical examiner reports, incidents and other matters, and sharing appropriate lessons.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2023. View source
Action
Triage medical examiner forms, send them to clinical services and upload them to Datix within two weeks, referring potential incident triggers to the Patient Safety Team.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2023. View source
Action
Develop a strategic outline business case for an Electronic Patient Record system with Welsh Government and Digital Health and Care Wales.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 November 2023. View source See 5 more actions
×
AI-generated summary
Jennifer Lydia Campbell · 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
Jennifer Lydia Campbell, aged 73, died on 24 February 2022 after an ERCP referral for obstructing gallstones was not received by the endoscopy department. She became severely unwell and died from infection and pneumonia associated with the obstructing gallstones. The principal concerns were the absence of an investigation into the lost referral, lack of learning or audit to prevent recurrence, and continued reliance on paper-based referrals.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about which incidents require investigation
Wider context from the report “a. There was no evidence of any formal investigation having been undertaken into how the referral for ERCP became lost. It appears that only during the course of Inquest proceedings did the issue relating to the lost referral become known to the Health Board. Even once it became known to them in 2022 there was still no investigation undertaken. It is not understood at all which incidents that occur are to be investigated. I have issued a number of Prevention of Future Death Reports relating to investigations and governance and yet these concerns continue. I am not in any way satisfied that improvements have occurred.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Patient referrals remaining paper based
Wider context from the report “e. Evidence was heard relating to electronic notes and referrals. Such referrals remain paper based and there is no indication as yet when these will be fully electronic . I am aware that this national strategy is ongoing but the time it is taking is putting patients’ 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to audit for other lost patient referrals
Wider context from the report “c. There was no evidence that any audits had taken place to review whether any other patients’ referrals had become ‘lost’.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to formally investigate lost referrals
Wider context from the report “a. There was no evidence of any formal investigation having been undertaken into how the referral for ERCP became lost. It appears that only during the course of Inquest proceedings did the issue relating to the lost referral become known to the Health Board. Even once it became known to them in 2022 there was still no investigation undertaken. It is not understood at all which incidents that occur are to be investigated. I have issued a number of Prevention of Future Death Reports relating to investigations and governance and yet these concerns continue. I am not in any way satisfied that improvements have occurred.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to establish awareness and action on Medical Examiner concerns
Wider context from the report “d. Matters relating to the ERCP which did not take place were identified by the Medical Examiners in their report dated 4 days after the deceased’s death. There was no evidence as to whether the Health Board had been made aware of the concerns therein and if so, what action they had undertaken as a result.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to implement learning and improvement after incidents
Wider context from the report “b. Given that no investigation was conducted to understand how the issue may have occurred there has been no learning, change or improvement to ensure it is not repeated . I have been provided with no assurances in this regard.
” 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 referral safeguards requiring endoscopy referrals to be scanned, recorded on WPAS, and routed through booking clerks.
Verbatim wording from the response “Following this incident, I can however confirm there has been learning and we have made improvements. A new standing operating procedure for all endoscopy referrals has been implemented in November 2023 to ensure all paper referrals are scanned into the endoscopy email inbox, even if received in a paper format by the endoscopy booking clerks. An audit has been completed of referral forms dating 01 October 2021 to 30 November 2023 to ensure no other forms have been lost.” Source location Response from Betsi Cadwaladr 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 Health Board incident process through staff co-design.
Verbatim wording from the response “Turning to the first concern, we fully acknowledge that no incident was reported regarding the missing referral form and as such the incident review process did not take place. We are taking steps to ensure staff are aware of the need to report an incident in these situations through awareness and reminders. We are also undertaking a full review of the incident process in the Health Board, in co-design with our staff, and will introduce a new process and procedure for April 2024. This new process will include a revised training programme for staff.” Source location Response from Betsi Cadwaladr 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 a revised incident process and staff training programme, including triangulation of information from all sources, by April 2024.
Verbatim wording from the response “Turning to the first concern, we fully acknowledge that no incident was reported regarding the missing referral form and as such the incident review process did not take place. We are taking steps to ensure staff are aware of the need to report an incident in these situations through awareness and reminders. We are also undertaking a full review of the incident process in the Health Board, in co-design with our staff, and will introduce a new process and procedure for April 2024. This new process will include a revised training programme for staff.” Source location Response from Betsi Cadwaladr 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 Work with Digital Health and Care Wales to develop an electronic ERCP internal referral form within the Welsh Clinical Portal.
Verbatim wording from the response “In parallel with the operational work above, the Health Board are working with Digital Health and Care Wales (DHCW) on the development of an electronic form as part of the Welsh Clinical Portal (WCP) that clinicians can use to do an internal referral specifically and exclusively for ERCP. It is not clear when this national work will be delivered and we are chasing them on it.” Source location Response from Betsi Cadwaladr 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 Audit referral forms received between 1 October 2021 and 30 November 2023 for missing forms.
Verbatim wording from the response “Following this incident, I can however confirm there has been learning and we have made improvements. A new standing operating procedure for all endoscopy referrals has been implemented in November 2023 to ensure all paper referrals are scanned into the endoscopy email inbox, even if received in a paper format by the endoscopy booking clerks. An audit has been completed of referral forms dating 01 October 2021 to 30 November 2023 to ensure no other forms have been lost.” Source location Response from Betsi Cadwaladr 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 Implement a process for reviewing complaints, medical examiner reports, incidents and other matters, and sharing appropriate lessons.
Verbatim wording from the response “We do however accept that we have improvements to be made to our own process, and the West Integrated Health Community have developed and implemented a process in November 2023 to ensure that any complaints, medical examiner reports, incidents and other matters are adequately reviewed to ensure we are able to provide patients and families the best response and outcome, and to ensure lessons learnt are appropriate and shared.” Source location Response from Betsi Cadwaladr 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 Triage medical examiner forms, send them to clinical services and upload them to Datix within two weeks, referring potential incident triggers to the Patient Safety Team.
Verbatim wording from the response “At an organisational level, our Mortality Review Team have developed and introduced a process whereby medical examiner forms are triaged upon receipt and will be sent to our clinical services and uploaded to our Datix quality management system within 2 weeks, ensuring they are available for access by those undertaking investigations. Following this triage, the team will also send a copy to the Patient Safety Team if anything is identified which may need to trigger the incident process. This provides a further safety net and was introduced over the summer of 2023 as a result of your earlier concerns.” Source location Response from Betsi Cadwaladr 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 strategic outline business case for an Electronic Patient Record system with Welsh Government and Digital Health and Care Wales.
Verbatim wording from the response “In relation to electronic records, we are currently developing a strategic outline business case for an Electronic Patient Record (EPR) system in conjunction with Welsh Government and Digital Health and Care Wales (DHCW). This business case will require significant investment and the Health Board hope to present it to Welsh Government in early 2024 and would expect significant time taken to secure approval. Once funds are secured, the timelines for delivering such a significant transformation project, as is required in the case of the Health Board, will be at least three years. This is based on an independent assessment made of our business need in terms of people, practice and technology by Ethical Healthcare Consulting who have been assisting us with this business case.” Source location Response from Betsi Cadwaladr 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 The Health Board did not receive medical examiner concerns before the inquest because no scrutiny document had been created at the time.
Verbatim wording from the response “In relation to a lack of action on concerns from the medical examiner, whilst I acknowledge your own concerns, the Health Board only received the report from the medical examiner on the day of the inquest as a result of your inquiries (and I understand you are aware of this issue at the inquest). The Senior Medical Examiner Officer for North” Source location Response from Betsi Cadwaladr 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 Electronic patient record implementation depends on substantial investment and approval, with delivery taking at least three years after funding is secured.
Verbatim wording from the response “In relation to electronic records, we are currently developing a strategic outline business case for an Electronic Patient Record (EPR) system in conjunction with Welsh Government and Digital Health and Care Wales (DHCW). This business case will require significant investment and the Health Board hope to present it to Welsh Government in early 2024 and would expect significant time taken to secure approval. Once funds are secured, the timelines for delivering such a significant transformation project, as is required in the case of the Health Board, will be at least three years. This is based on an independent assessment made of our business need in terms of people, practice and technology by Ethical Healthcare Consulting who have been assisting us with this business case.” Source location Response from Betsi Cadwaladr 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 The independent medical examiner service is provided nationally by NHS Wales Shared Services Partnership, to which the issue was reported.
Verbatim wording from the response “Wales has confirmed no scrutiny document was created at the time of the death by them, and therefore the Health Board was not in receipt of the concerns they had. The medical examiner service is independent to the Health Board and provided nationally by NHS Wales Shared Services Partnership. We have reported this issue to them.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 2 Unsustainable pressure on emergency department clinicians and other staff View source Insufficient or ineffective strategic planning and support for reducing emergency department pressures View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret Gertrude Kelly · 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
Margaret Gertrude Kelly underwent elective hernia repair on 28 March 2022, after which her bowel was probably damaged. She attended the Emergency Department the following day but was not seen by a surgical doctor for several hours; emergency surgery was undertaken on 30 March, and she died at Glan Clwyd Hospital on 31 March 2022. The report raises concerns about unsustainable pressure on staff, delays in treatment, and insufficient or ineffective strategic planning and support to reduce pressures within the department.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Unsustainable pressure on emergency department clinicians and other staff
Wider context from the report “Evidence was given at the inquest that when the deceased attended the emergency department it was at level 4 escalation (the highest level which they would escalate to), that this was far from unusual and that between March 2022 and the present day, the department would usually be operating between levels 3 & 4.
I am concerned that the pressure on clinicians and other staff is unsustainable and that delays in treatment will result in deaths. I do not consider that the operating practices within the department are a direct cause for concern (and as a result I do not require hearing the views of any clinicians in respect thereof), however I am concerned that insufficient or ineffective strategic planning and support is being undertaken and I would therefore wish to hear from those responsible at an executive/managerial level as to the steps which are being taken to reduce pressures within the department at Glan Clwyd.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient or ineffective strategic planning and support for reducing emergency department pressures
Wider context from the report “Evidence was given at the inquest that when the deceased attended the emergency department it was at level 4 escalation (the highest level which they would escalate to), that this was far from unusual and that between March 2022 and the present day, the department would usually be operating between levels 3 & 4.
I am concerned that the pressure on clinicians and other staff is unsustainable and that delays in treatment will result in deaths. I do not consider that the operating practices within the department are a direct cause for concern (and as a result I do not require hearing the views of any clinicians in respect thereof), however I am concerned that insufficient or ineffective strategic planning and support is being undertaken and I would therefore wish to hear from those responsible at an executive/managerial level as to the steps which are being taken to reduce pressures within the department at Glan Clwyd.
” 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 Improve the information technology systems used for same-day emergency care.
Verbatim wording from the response “• Our Operational Management Team are working on two key areas around SDEC improvement: Improving the IT systems used by staff and using new telephony systems to support more referrals from GPs and WAST into the SDEC service.” Source location Response from Betsi Cadwaladr Unviersity 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 Re-establish fortnightly strategic meetings with the Welsh Ambulance Service to review demand, conveyances and demand-reduction actions.
Verbatim wording from the response “• The IHC have re-established fortnightly strategic meetings with WAST to review demand and conveyances and actions that can be taken to reduce demand.” Source location Response from Betsi Cadwaladr Unviersity 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 Present ambulance performance data at emergency department governance meetings to review required actions and support zero-tolerance handover performance.
Verbatim wording from the response “• On 12 October 2023, IHC Directors presented current ambulance performance data at the monthly ED Governance Meeting to review actions required and identify the support needed to achieve zero tolerance of 4 Hour Ambulance Handover from 1st November 2023.” Source location Response from Betsi Cadwaladr Unviersity 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 the YGC acute medical model, including its rota and working patterns, to provide timely senior decision-making and appropriate specialty care.
Verbatim wording from the response “• Work is underway to improve the YGC acute medical model. Operational teams are developing the model, rota and working patterns to support this. The objectives of the new model are to deliver timely patient care, provide senior decision-making support to the ED, and ensuring patients are cared for by the best medical specialty and in the right place.” Source location Response from Betsi Cadwaladr Unviersity 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 more efficient board-round system to expedite discharge and improve patient flow.
Verbatim wording from the response “• Developing a more efficient board round system will expedite patients home in a timely manner, improving patient flow and relieving pressures upstream in the emergency department.” Source location Response from Betsi Cadwaladr Unviersity 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 Implement the 8 Steps Project to improve emergency department patient flow and monitor performance through daily huddles and dashboards.
Verbatim wording from the response “• The 8 Steps Project is aiming to improve each of the steps that patients take through their ED journey, creating efficiencies and therefore reducing the waiting time within the ED. Performance is being continuously monitored through a dashboard and to identify improvements to working practice. The 8 steps include:” Source location Response from Betsi Cadwaladr Unviersity 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 a dedicated project team to develop and deliver urgent and emergency care improvements.
Verbatim wording from the response “Urgent & emergency care provision is one of the main priorities for the Central IHC and requires significant support and focus to deliver improvements. We have recognised that a programme management approach is required, and have established a dedicated project team to support the development and delivery of our improvement work related to urgent and emergency care. This additional capacity is vital in supporting operational teams to drive the programmes forward at pace and embed the change as we go.” Source location Response from Betsi Cadwaladr Unviersity 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 a Quality Check mock inspection to provide an objective update on emergency department improvement progress.
Verbatim wording from the response “The ED at Ysbyty Glan Clwyd continues to face significant pressure. You will be aware that Healthcare Inspectorate Wales designated it a Service Requiring Significant Improvement. We have supported the ED to develop and deliver considerable improvement plans in response to three HIW inspections since February 2022, and during the summer of 2023 we supported a “mock inspection” (called a Quality Check) to provide an objective progress update. Our Executive Director of Nursing and Midwifery is overseeing the continuing actions arising from this process.” Source location Response from Betsi Cadwaladr Unviersity 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 Scrutinise emergency department improvement plans and performance and provide executive support for their delivery.
Verbatim wording from the response “As an Executive Team, we are fully committed to supporting the ED through the Central IHC to develop and deliver its improvement plans, which are outlined above. We will scrutinise those plans and performance, and provide support.” Source location Response from Betsi Cadwaladr Unviersity 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 Oversee continuing actions arising from the emergency department inspection and improvement process.
Verbatim wording from the response “The ED at Ysbyty Glan Clwyd continues to face significant pressure. You will be aware that Healthcare Inspectorate Wales designated it a Service Requiring Significant Improvement. We have supported the ED to develop and deliver considerable improvement plans in response to three HIW inspections since February 2022, and during the summer of 2023 we supported a “mock inspection” (called a Quality Check) to provide an objective progress update. Our Executive Director of Nursing and Midwifery is overseeing the continuing actions arising from this process.” Source location Response from Betsi Cadwaladr Unviersity 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 Undertake a Monday-to-Friday daytime see-and-treat test to support staff learning and evaluate its effect on emergency department performance.
Verbatim wording from the response “• A test of a Monday to Friday 9am-5pm ‘see and treat’ model will also be undertaken during November for staff learning and to evaluate impact on non-admitted performance and de-compressing ED.” Source location Response from Betsi Cadwaladr Unviersity 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 department rota and skill mix to address identified doctor shortages.
Verbatim wording from the response “• An ED rota review, including skill mix is scheduled for November as we have identified doctor shortages compared to attendances on Monday’s and Tuesday’s (two busiest days).” Source location Response from Betsi Cadwaladr Unviersity 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 Return the GP Out of Hours Service to Ysbyty Glan Clwyd and co-locate it with emergency services.
Verbatim wording from the response “• We are currently finalising plans to return the GP Out of Hours Service to the YGC. This is in line with Peer Review recommendations and will ensure co-located GP services to ED for nearly 70% of the week (6.30pm-8am Mon – Fri and all day Saturday and Sunday). We are currently working with operational leads to implement this provision before winter pressures this year. Patients presenting in YGC ED with primary care presentations during week day hours will be advised how they can access local primary care services (GP / Optometry / Community Pharmacy / Dental).” Source location Response from Betsi Cadwaladr Unviersity 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 Support delivery of emergency department improvement plans responding to Healthcare Inspectorate Wales inspections.
Verbatim wording from the response “The ED at Ysbyty Glan Clwyd continues to face significant pressure. You will be aware that Healthcare Inspectorate Wales designated it a Service Requiring Significant Improvement. We have supported the ED to develop and deliver considerable improvement plans in response to three HIW inspections since February 2022, and during the summer of 2023 we supported a “mock inspection” (called a Quality Check) to provide an objective progress update. Our Executive Director of Nursing and Midwifery is overseeing the continuing actions arising from this process.” Source location Response from Betsi Cadwaladr Unviersity 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 telephony systems to support additional GP and ambulance-service referrals to same-day emergency care.
Verbatim wording from the response “• Our Operational Management Team are working on two key areas around SDEC improvement: Improving the IT systems used by staff and using new telephony systems to support more referrals from GPs and WAST into the SDEC service.” Source location Response from Betsi Cadwaladr Unviersity Health Board
Open published response
Concerns raised 3 Failure to provide a finalised and widely shared transfer-of-care process View source Failure of investigations to address how transfer of care did not occur View source Unavailability of electronic mental-health patient notes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard Geraint Griffiths · 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
Richard Geraint Griffiths moved to the Conwy area in October 2022 to live with his mother, and the transfer of his care from the South Gwynedd Community Mental Health Team did not occur. He was found suspended on 26 March 2023 and was pronounced deceased at the location; the inquest concluded suicide. Concerns included deficiencies in the Health Board’s investigation, an unfinished transfer-of-care process, and delays in implementing electronic mental-health patient notes.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a finalised and widely shared transfer-of-care process
Wider context from the report “b. The Health Board’s Transfer of Care document at the time the transfer occurred did not include any detail or process as to how the transfer should occur . The amended policy has still not been finalised and there remains a concern that deaths will continue to occur if the process is not finalised and shared widely within the Health Board to 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to address how transfer of care did not occur
Wider context from the report “a. The Investigation undertaken by the Health Board was deficient in that it did not contain pertinent points relating to how the transfer of care did not occur . I have previously issued a number of Prevention of Future Death Reports relating to quality and timeliness of investigation.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Unavailability of electronic mental-health patient notes
Wider context from the report “c. Patient notes for mental health are still not electronic; they are paper based. I have issued several Prevention of Future Death Reports specifically relating to this. There has been considerable delay in actioning this and yet there is still not anticipated timescale for this to occur . As such, deaths will continue to occur or may occur into the future with the risk that notes are paper based only . The risk relates to only one department or individual having access to them at once when there is wider support for the patient .
” 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 Share the addendum investigation report when completed.
Verbatim wording from the response “The investigation is underway, and the investigating officer (IO) has undertaken interviews with staff directly and indirectly involved in Mr Griffiths’ care and treatment. The IO has considered the transfer process that was in place at the time Mr Griffiths was receiving care, the improvements that have been made since, and the review of the Transfer and Discharge of Care Protocol. The addendum report is currently progressing through the Health Board’s approval process and I will be happy to share this with you on its completion in the coming weeks.” Source location Response from Betsi Cadwaladr 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 Require investigating officers to meet involved staff and share investigation outcomes with them.
Verbatim wording from the response “On the 15th September 2023, the Quality Governance team contacted the Heads of Operations and Heads of Nursing throughout MH&LD to share the concerns you raised about the quality of the investigation report. The Quality Governance team requested that in future, IOs meet with the staff involved in the delivery of care and treatment to explore in detail the decision-making and actions taken when delivering care and that the” Source location Response from Betsi Cadwaladr 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 Health Board-wide Strategic Outline Case for electronic patient records addressing fragmented care records.
Verbatim wording from the response “In addition I am pleased to report that a Strategic Outline Case for an Electronic Patient Record system(s) is being developed on a Health Board wide level to address the issue of fragmented care records; the deadline for the strategic outline case is the end of January 2024. MH&LD are taking a key role in shaping the outline case to ensure that the Division’s needs are considered as part of the Health Board wide proposal.” Source location Response from Betsi Cadwaladr 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 Complete the addendum investigation and progress its report through Health Board approval.
Verbatim wording from the response “████████, the Director of MH&LD Division, reported to you on the 14th September 2023 that an addendum investigation would be undertaken to expand on the pertinent points relating to how the transfer of care of Mr Griffiths did not happen.” Source location Response from Betsi Cadwaladr 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 Progress the revised Transfer and Discharge of Care Protocol through Health Board ratification.
Verbatim wording from the response “The Transfer and Discharge of Care Protocol has been revised to include explicit guidance relating to transfers of care between community teams. This includes the steps to be taken by the care coordinator, supporting administrative staff and the single point of access service (SPOA). Progression of this protocol through the Health Board ratification process is being led by the MH&LD Deputy Director of Nursing and progress is overseen by the MH&LD Policy and Procedure Group. The revised protocol is due at MH&LD Policy and Procedure Group in December 2023 after which it will progress through the Health Board’s revised ratification process. I anticipate that the protocol will be ratified by the end of January 2024.” Source location Response from Betsi Cadwaladr 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 the Chief Information Officer to consider options for a more timely MH&LD digital-records solution.
Verbatim wording from the response “Whilst MH&LD are keen to support and progress the processes outlined above, we are mindful of the scale of the task for agreeing a national solution and are therefore working with BCUHBs Chief Information Officer to consider options which may bring MH&LD a more timely solution. This remains a major priority for the Division and is supported by the Health Board.” Source location Response from Betsi Cadwaladr 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 Engage in regional and local-authority discussions to agree a preferred digital patient-records option for North Wales.
Verbatim wording from the response “Regional meetings are now taking place across Wales to discuss the options that have been presented to them by WG as alternative to WCCIS Care Direct Version 5. BCUHB has met with Local Authorities to discuss implications across health and social care services in order to come to an agreement on the preferred option for North Wales.” Source location Response from Betsi Cadwaladr 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 Check during report quality assurance whether investigating officers have explored staff decision-making and actions.
Verbatim wording from the response “outcome of reports are shared with the staff involved. The Quality Governance team now also check for this aspect during the quality assurance of reports. This will ensure more detailed investigations that get to heart of the contributory factors and the root causes of incidents.” Source location Response from Betsi Cadwaladr 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 National digital patient-record implementation depends on decisions about the national system made by Welsh Government.
Verbatim wording from the response “Within the notice, you also raised your continued concerns about the implementation of digital patient records for MH&LD. In previous correspondence with you, the Health Board has reported significant delays with the development and implementation of a suitable system at a national level. I understand that you have raised your concerns about the delays with the Health Minister directly. We now know that following a decision made by WG the national system will not be progressing in the way that was previously expected. This has significantly altered MH&LD divisional plans for digital transformation as these were dependent upon the use of the WCCIS Care Director Version 5 product, with a pilot having been due to start in September 2023, and the expectation that a wider adoption across all applicable MH&LD services would follow.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
8 Sep 2023 Lynsey Sarah Smalley · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 5 Investigation reports containing conflicting evidence View source Lack of strategic planning and collaboration in governance processes View source Risk of full or partial loss of paper medical notes during transfer View source Failure of paper-based medical records to provide all relevant care information to involved individuals and organisations View source Delays in identifying and completing proposed actions 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
Lynsey Sarah Smalley · 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
Lynsey Sarah Smalley, aged 42, set fire to her bed at home during an acute psychotic episode on 8 April 2021. She suffered inhalation injuries, was admitted to intensive care, and died at Ysbyty Gwynedd, Bangor on 16 May 2021. The substantive concerns were conflicting investigation reports, disjointed patient-safety and governance processes, delays in completing actions, and risks arising from paper-based medical records that may impede continuity of care.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Investigation reports containing conflicting evidence
Wider context from the report “a. The Health Board provided 3 investigation reports into the death, two of which contained conflicting evidence . One responded to Lynsey’s brother’s complaint. It is clear that there was no strategic plan or collaboration in governance processes. Furthermore, there were a number of proposed actions which took nearly two years to identify and complete. The time it took to identify and complete actions, together with governance processes are matters which I have raised previously with the Health Board in previous Prevention of future Death Reports. If there are such disjointed patient safety and governance processes learning will not be effective and deaths will continue to occur or will occur into 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of strategic planning and collaboration in governance processes
Wider context from the report “a. The Health Board provided 3 investigation reports into the death, two of which contained conflicting evidence. One responded to Lynsey’s brother’s complaint. It is clear that there was no strategic plan or collaboration in governance processes . Furthermore, there were a number of proposed actions which took nearly two years to identify and complete. The time it took to identify and complete actions, together with governance processes are matters which I have raised previously with the Health Board in previous Prevention of future Death Reports. If there are such disjointed patient safety and governance processes learning will not be effective and deaths will continue to occur or will occur into 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Risk of full or partial loss of paper medical notes during transfer
Wider context from the report “b. A number of individuals and organisations are involved in the care of those under mental health teams or at times have contact with patients e.g. CMHT, Home Treatment Teams, Psychiatrists, Occupational therapists, Care Coordinators, out of hours crisis service (local authority based in Gwynedd), Police, Ambulance Service etc. As medical records remain paper based not all individuals or organisations who need to understand a patient’s circumstances/care/treatment are privy to all aspects of care/treatment. In addition, where a CMHT patient is receiving in-patient mental heath treatment the paper notes are transferred to the hospital setting. There is a risk that notes will become lost in full / in part. Having medical records electronically will not only allow full access to all notes to those who require which will inform future care/treatment but will also ensure effective continuity of care, without the risk of missing or lost notes. I have previously issued a Prevention of Future Deaths Report on this point, a copy of which was also sent to ████████, Health Minister.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of paper-based medical records to provide all relevant care information to involved individuals and organisations
Wider context from the report “b. A number of individuals and organisations are involved in the care of those under mental health teams or at times have contact with patients e.g. CMHT, Home Treatment Teams, Psychiatrists, Occupational therapists, Care Coordinators, out of hours crisis service (local authority based in Gwynedd), Police, Ambulance Service etc. As medical records remain paper based not all individuals or organisations who need to understand a patient’s circumstances/care/treatment are privy to all aspects of care/treatment. In addition, where a CMHT patient is receiving in-patient mental heath treatment the paper notes are transferred to the hospital setting. There is a risk that notes will become lost in full / in part. Having medical records electronically will not only allow full access to all notes to those who require which will inform future care/treatment but will also ensure effective continuity of care, without the risk of missing or lost notes. I have previously issued a Prevention of Future Deaths Report on this point, a copy of which was also sent to ████████, Health Minister.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in identifying and completing proposed actions
Wider context from the report “a. The Health Board provided 3 investigation reports into the death, two of which contained conflicting evidence. One responded to Lynsey’s brother’s complaint. It is clear that there was no strategic plan or collaboration in governance processes. Furthermore, there were a number of proposed actions which took nearly two years to identify and complete . The time it took to identify and complete actions, together with governance processes are matters which I have raised previously with the Health Board in previous Prevention of future Death Reports. If there are such disjointed patient safety and governance processes learning will not be effective and deaths will continue to occur or will occur into 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 Monitor evidence supporting completion of investigation and complaint actions through the divisional governance forum.
Verbatim wording from the response “which is chaired by the deputy director of nursing, and any delays or breaches in timescales are highlighted. In June 2023, the Quality Governance team also began monitoring the receipt of evidence for completed actions via this forum. The Divisional PTR meeting reports to the Divisional SLT on a weekly basis and into the Divisional Quality Delivery Group on a monthly basis escalating any delays in the progress of reviews or actions. The expectation is that all complaints and incidents will be reviewed in line with the timescales set out by The National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 and any delays are escalated each week to the Divisional SLT.” Source location Response from Betsi Cadwaladr 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 the Chief Information Officer to consider options for a more timely MHLD digital-record solution.
Verbatim wording from the response “Whilst MHLD are keen to support and progress the processes outlined above, we are mindful of the scale of the task for agreeing a national solution and are therefore working with BCUHBs Chief Information Officer to consider options which may bring MHLD a more timely solution. This remains a major priority for the Division and is supported by the Health Board.” Source location Response from Betsi Cadwaladr 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 Participate in regional and local-authority discussions to assess alternative digital patient-record options for North Wales.
Verbatim wording from the response “Regional meetings are now taking place across Wales to discuss the options that have been presented to them by WG as alternative to WCCIS Care Direct Version 5. BCUHB has met with Local Authorities to discuss implications across health and social care services in order to come to an agreement on the preferred option for North Wales.” Source location Response from Betsi Cadwaladr 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 weekly coordination meetings between divisional nursing, governance and Healthcare Law leads to strengthen timely submission of reports and action evidence.
Verbatim wording from the response “The MHLD Division has a close working relationship with the Healthcare Law Team who coordinate inquest activity for the Health Board. The Divisional Heads of Nursing meet each week with the Healthcare Law Team and the Head of Governance. This has further strengthened the timely submission of reports and evidence of completed actions.” Source location Response from Betsi Cadwaladr 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 and co-design a new incident investigation and action-planning process, including governance review, staff training and planned implementation.
Verbatim wording from the response “The Health Board is now fully reviewing the incident process to identify where it can be improved and strengthened. A workshop was held on the 23rd October 2023 to identify current issues and to begin the work of revising our process. The concerns you have identified in this notice, and in other notices, are being directly fed into this work. We are working in co-designing the process with staff and patient representatives, such as the independent Llais organisation, to implement a completely new and improved approach where the focus is on learning and improvement. During November 2023 we are meeting with the IHCs and Divisions for their collaboration and engagement in developing the process.” Source location Response from Betsi Cadwaladr 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 a Health Board strategic outline case for electronic patient records, incorporating MHLD requirements to address fragmented care records.
Verbatim wording from the response “In addition I am pleased to report that a Strategic Outline Case for an Electronic Patient Record system(s) is being developed on a Health Board wide level to address the issue of fragmented care records; the deadline for the strategic outline case is the end of January 2024. MHLD are taking a key role in shaping the outline case to ensure that the Division’s needs are considered as part of the Health Board wide proposal.” Source location Response from Betsi Cadwaladr 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 Implementation of the planned MHLD digital records system cannot proceed as expected because national arrangements changed following a Welsh Government decision.
Verbatim wording from the response “Within the notice, you also raised your continued concerns about the implementation of digital patient records for MHLD. In previous correspondence with you, the Health Board has reported significant delays with the development and implementation of a suitable system at a national level. I understand that you have raised your concerns about the delays with the Health Minister directly. We now know that following a decision made by WG the national system will not be progressing in the way that was previously expected. This has significantly altered MHLD divisional plans for digital transformation as these were dependent upon the use of the WCCIS Care Director Version 5 product, with a pilot having been due to start in September 2023, and the expectation that a wider adoption across all applicable MHLD services would follow.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
6 Sep 2023 JAMES JONES · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 2 Insufficient staffing levels to meet demand and safely care for patients View source Failure to review triage category 2 patients within the intended timeframe 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
JAMES 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
James Jones was taken to hospital with abdominal and chest pain, vomiting, reduced bowel movements and reduced urine output, and was later assessed as having a small bowel obstruction. He experienced delays in medical review, scanning and preparation for exploratory surgery, waiting 17.5 hours before being taken to the anaesthetic room, where he suffered a cardiac arrest. The concerns identified were pressures and insufficient staffing in the Accident and Emergency department, potentially leading to delayed reviews and missed opportunities that may prove fatal in similar cases.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing levels to meet demand and safely care for patients
Wider context from the report “(1) Continued pressures within the Accident and Emergency department at Ysbyty Gwynedd will result in:
(a) Doctors not having the capacity to review patients in line with the “aim” e.g within 10 minutes for triage category 2 patients.
(b) Missed opportunities that may prove fatal
(2) Current staffing levels being insufficient to meet demand and safely care for patients
Although the delays did not cause or contribute to death in this case, I am concerned that if there are similar delays in similar life-threatening situations in future, deaths will occur.
” 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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to review triage category 2 patients within the intended timeframe
Wider context from the report “(1) Continued pressures within the Accident and Emergency department at Ysbyty Gwynedd will result in:
(a) Doctors not having the capacity to review patients in line with the “aim” e.g within 10 minutes for triage category 2 patients.
(b) Missed opportunities that may prove fatal
(2) Current staffing levels being insufficient to meet demand and safely care for patients
Although the delays did not cause or contribute to death in this case, I am concerned that if there are similar delays in similar life-threatening situations in future, deaths will occur.
” Open source report
Concerns raised 1 Failure to include bed rail assessment in the Welsh Nursing Care Record View source
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
Malcolm Ralph Unwin · 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
Malcolm Ralph Unwin suffered an unwitnessed fall from his bed while a patient at hospital on 30 December 2022 and died at Wrexham Maelor Hospital on 6 January 2023. The report raised concern that he had not been assessed for bed rails and that the absence of bed-rail assessment from the Welsh Nursing Care Record could result in such assessments being missed in future.
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 Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to include bed rail assessment in the Welsh Nursing Care Record
Wider context from the report “There was no evidence that the deceased had been assessed for bed rails, whilst in hospital although it is probable that they were in due at the time of his fall.
Evidence was given that the bed rail assessment is not currently a part of the Welsh Nursing Care Record which staff access via iPad.
In the absence of this being a part of the WNCR I am concerned that this assessment may be missed , and that future death may occur as a result.
” 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 Finalise and introduce the updated Bed Rails Procedure.
Verbatim wording from the response “We are also in the process of finalising our updated Bed Rails Procedure which will be live within the next few weeks.” Source location Response from Betsi Cadwaladr 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 Remind ward managers, matrons and heads of nursing about paper-based bed-rail assessments and provide materials for staff safety briefings and ward display.
Verbatim wording from the response “In the interim period, I can confirm we have written to all ward managers, matrons and heads of nursing reminding them of the process for paper based assessment forms. We have provided information which can be used on ward safety briefs with staff and which can also be visibly placed in wards to remind staff.” Source location Response from Betsi Cadwaladr 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 Raise the bed-rail assessment issue nationally to expedite standardisation and inclusion in the WNCR.
Verbatim wording from the response “Following your Notice, we raised this issue nationally in order to expedite this process. The issue was discussed at the National Deputy Directors of Nursing Meeting on 07 September 2023, and in response Cwm Taf Morgannwg University Health Board has taken the lead in establishing a national working group to create a standardised bed rails assessment tool across Wales, and to propose this single version for inclusion in the WNCR.” Source location Response from Betsi Cadwaladr 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 Creation of a standardised bed-rails assessment tool is being led nationally by Cwm Taf Morgannwg University Health Board.
Verbatim wording from the response “Following your Notice, we raised this issue nationally in order to expedite this process. The issue was discussed at the National Deputy Directors of Nursing Meeting on 07 September 2023, and in response Cwm Taf Morgannwg University Health Board has taken the lead in establishing a national working group to create a standardised bed rails assessment tool across Wales, and to propose this single version for inclusion in the WNCR.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations