Concerns raised 1 Failure of investigations to identify care and treatment concerns comprehensively and promptly 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
Philip Martin Evans · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Philip Martin Evans, aged 38, consumed approximately 200 tablets at home and later went into cardiac arrest at hospital, dying shortly afterwards. The inquest found that missed opportunities to provide treatment probably meant that death occurred when it did. The report also raises concerns about the quality, effectiveness and timeliness of the Health Board’s investigations and the delayed identification of care issues.
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 investigations to identify care and treatment concerns comprehensively and promptly
Wider context from the report “The Health Board conducted an investigation into Philip’s death to include a review of his previous mental health care and treatment as well as Emergency Department (ED) care and treatment. This did not identify any concerns from an ED perspective (conducted by a Head of Nursing). The report had been reviewed and approved by the Director or Nursing for the Mental Health and Learning Division and the Integrated Health Council Director.
A request for a Statement as part of my investigation from an ED perspective prompted a second review of the ED care and treatment which was completed only on 10 July 2024. This was undertaken by an Emergency Department matron, approved by the Divisional Director, reviewed at an Incident Learning Panel and had Executive Approval which was completed on 10 July 2024, 8 days prior to the already listed Inquest. This identified omissions in the care and treatment.
At the Inquest an ED Consultant gave evidence to the Investigation Report with this evidence differing in parts to the second investigation report.
I am concerned that the quality, effectiveness and timeliness of the Health Board’s investigations means that issues or concerns with care and treatment are not being identified either at all or quickly enough in order to put in place additional measures or learning to prevent deaths in similar circumstances.
I have issued several Reports pertaining to this very point over a long period and yet the same concerns remain.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide new investigation guidance, training and templates through a dedicated staff intranet portal.
Verbatim wording from the response “• As part of the new policy, there is new guidance, training and templates to be used and a new portal has been created on our staff intranet to access this in one place.” 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 weekly executive oversight of commissioned investigations and rapid reviews.
Verbatim wording from the response “• A weekly executive meeting will have oversight of commissioned investigations and rapid reviews.” 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 262 previous investigations against newly developed good-practice standards through a dedicated review team and senior oversight structure.
Verbatim wording from the response “As you know, the Health Board had started actions to implement a new incident procedure from April 2024. However, in response to the increasing number of concerns you raised and our own internal concerns, the new Chief Executive commissioned a significant programme of work to review previous investigations in order to gain a deep understanding of the issues. The Learning from Investigations Programme reviewed 262 investigations against a set of good practice standards that we developed. This work commenced in January 2024 and concluded at the end of June 2024 with a dedicated review team established and an oversight panel of senior leaders reporting to an executive steering group. The findings from this programme led to a clear understanding of where the problems were occurring in our processes.” 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 Apply defined standards for investigation quality and engagement with affected and involved people.
Verbatim wording from the response “• Clear standards on what is expected in terms of investigation quality and engagement with those affected and those involved.” 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 Operate an Integrated Concerns Hub to triage and triangulate incidents, complaints and medical examiner referrals for proportionate investigation or review.
Verbatim wording from the response “• An Integrated Concerns Hub will meet daily to ensure incidents, complaints and medical examiner referrals are triaged and triangulated to ensure the right review or investigation commences (proportionate to the issue) – our approach will be to investigate once, investigate well.” 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 Set review and investigation deadlines and monitor progress through an Investigations Tracker within the ward-to-Board Quality Dashboard.
Verbatim wording from the response “• Clear deadlines are being set for each review and investigation – a new Investigations Tracker has been developed to monitor progress, which itself is part of our new Quality Dashboard providing ward to Board quality data.” Source location Response from BCUHB
Open published response
Concerns raised 8 Failure to communicate nil-by-mouth status to visitors View source Failure to document the rationale for oxygen administration and clinician discussion View source Insufficient space for nursing care and pressure-area assessment View source Insufficient nursing and clinical staffing capacity View source Lack of written nursing documentation of patient care View source Delays in allocation of hospital beds from the Emergency Department View source Delays in entry into hospital from ambulance arrival View source Failure to complete or communicate required repeat blood tests View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Philip Hawkins · 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 Hawkins, aged 97, suffered a fall at home on 18 March 2023, was transferred by ambulance to hospital, and died on 23 March 2023. Concerns included delays in being admitted and allocated a bed, insufficient staffing, inability to provide care, gaps in nursing documentation, and failures in aspects of assessment 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 Failure to communicate nil-by-mouth status to visitors
Wider context from the report “Care Concerns in the ED
4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas.
5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians.
6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician.
7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23.
8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him .
” 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 the rationale for oxygen administration and clinician discussion
Wider context from the report “Care Concerns in the ED
4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas.
5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians.
6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician .
7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23.
8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him.
” 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 space for nursing care and pressure-area assessment
Wider context from the report “Care Concerns in the ED
4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas .
5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians.
6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician.
7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23.
8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him.
” 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 nursing and clinical staffing capacity
Wider context from the report “Staffing
9. There were insufficient nursing and clinical staff to attend to the numbers of patients as outstanding nursing shifts went unfulfilled on the nursing rota .
10. Due to the presenting circumstances, staff were unable to fulfil their role in caring for Mr Hawkins.
11. Specifically, I am concerned as to the wait and delay Mr Hawkins had to endure to enter hospital and the same in respect of being provided with a bed; the inability of staff to tend to him; the lack of available staff and the lack of written record of assessment and treatment.
” 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 written nursing documentation of patient care
Wider context from the report “Care Concerns in the ED
4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas.
5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians.
6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician.
7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23 .
8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him.
” 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 allocation of hospital beds from the Emergency Department
Wider context from the report “Entry into Hospital and Delay to bed allocation
1. Mr Hawkins arrived at hospital at 13:25 on 18.03.23 and remained in the ambulance until 23:42 when he was ‘offloaded’ onto a corridor in the Emergency Department (ED).
2. He was moved to a rapid assessment room in the ED at 11:33 on 19.03.23 and then into a cubicle at 21:47, the same day.
3. Mr Hawkins was eventually allocated to a bed from the ED, at 19:17 on 20.03.23 .
” 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 entry into hospital from ambulance arrival
Wider context from the report “Entry into Hospital and Delay to bed allocation
1. Mr Hawkins arrived at hospital at 13:25 on 18.03.23 and remained in the ambulance until 23:42 when he was ‘offloaded’ onto a corridor in the Emergency Department (ED) .
2. He was moved to a rapid assessment room in the ED at 11:33 on 19.03.23 and then into a cubicle at 21:47, the same day.
3. Mr Hawkins was eventually allocated to a bed from the ED, at 19:17 on 20.03.23.
” 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 complete or communicate required repeat blood tests
Wider context from the report “Care Concerns in the ED
4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas.
5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians .
6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician.
7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23.
8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him.
” Open source report
Concerns raised 5 Unavailability of telephone communication for people requiring support View source Failure to retain and monitor correspondence relating to service users and people seeking support View source Delays in providing support sessions and counselling View source Failure to provide alcohol liaison team support to inpatients and outpatients View source Lack of systems and processes to ensure completion of alcohol liaison team referrals 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
Emily Corfield · 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
Emily Corfield, aged 41, was found deceased at home on 19 September 2021 after a history of alcohol misuse and two hospital admissions for coffee ground vomiting and alcohol withdrawal. The principal concern was the lack of evidence that the alcohol liaison team provided inpatient or outpatient support or that referrals to external organisations were made.
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 telephone communication for people requiring support
Wider context from the report “Firstly, evidence was heard during the Inquest that Emily had self-referred on a number of occasions for support to Adferiad (formerly Cais). It could not be established whether or not Emily had received written correspondence from them relating to appointments and/or offer of support as correspondence was not retained by Adferiad. Emily was on occasion closed to the service for not having responded to correspondence. The system at the time was that communicating with service users was in writing only.
It appears that more recently, policies and procedures have been established to ensure that correspondence relating to those who require support and / or contact the service is now retained though these were not provided at the Inquest. Without clear and thorough policies and procedures relating to all contact with service users or those who seek support, the organisation will not be able to adequately monitor the support processes.
Secondly, it was indicated that due to resource restrictions that communication cannot be by telephone with those requiring support / service users (in writing only) and the waiting time for support sessions / counselling is long. This will have a detrimental impact and deaths may occur if the treatment and support is not afforded in a timely manner.
” 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 retain and monitor correspondence relating to service users and people seeking support
Wider context from the report “Firstly, evidence was heard during the Inquest that Emily had self-referred on a number of occasions for support to Adferiad (formerly Cais). It could not be established whether or not Emily had received written correspondence from them relating to appointments and/or offer of support as correspondence was not retained by Adferiad . Emily was on occasion closed to the service for not having responded to correspondence. The system at the time was that communicating with service users was in writing only.
It appears that more recently, policies and procedures have been established to ensure that correspondence relating to those who require support and / or contact the service is now retained though these were not provided at the Inquest. Without clear and thorough policies and procedures relating to all contact with service users or those who seek support, the organisation will not be able to adequately monitor the support processes.
Secondly, it was indicated that due to resource restrictions that communication cannot be by telephone with those requiring support / service users (in writing only) and the waiting time for support sessions / counselling is long. This will have a detrimental impact and deaths may occur if the treatment and support is not afforded in a timely manner.
” 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 providing support sessions and counselling
Wider context from the report “Firstly, evidence was heard during the Inquest that Emily had self-referred on a number of occasions for support to Adferiad (formerly Cais). It could not be established whether or not Emily had received written correspondence from them relating to appointments and/or offer of support as correspondence was not retained by Adferiad. Emily was on occasion closed to the service for not having responded to correspondence. The system at the time was that communicating with service users was in writing only.
It appears that more recently, policies and procedures have been established to ensure that correspondence relating to those who require support and / or contact the service is now retained though these were not provided at the Inquest. Without clear and thorough policies and procedures relating to all contact with service users or those who seek support, the organisation will not be able to adequately monitor the support processes.
Secondly, it was indicated that due to resource restrictions that communication cannot be by telephone with those requiring support / service users (in writing only) and the waiting time for support sessions / counselling is long . This will have a detrimental impact and deaths may occur if the treatment and support is not afforded in a timely manner .
” 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 alcohol liaison team support to inpatients and outpatients
Wider context from the report “Emily had two inpatient admissions in the year of her death. Whilst the clinician had noted that she was for referral to the alcohol liaison team there was no evidence that Emily had in fact received any input from them either as an inpatient or as an outpatient nor any referrals to external organisations.
It is concerning that there appears to have been no evidence that Emily was receiving support from the Alcohol Liaison Team whilst an inpatient on either occasion despite her long history of alcohol misuse and need for support.
In the event that clinicians advise referral to alcohol liaison team, either as an inpatient or as an outpatient there ought to be systems and processes to ensure that this occurs.
” 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 systems and processes to ensure completion of alcohol liaison team referrals
Wider context from the report “Emily had two inpatient admissions in the year of her death. Whilst the clinician had noted that she was for referral to the alcohol liaison team there was no evidence that Emily had in fact received any input from them either as an inpatient or as an outpatient nor any referrals to external organisations .
It is concerning that there appears to have been no evidence that Emily was receiving support from the Alcohol Liaison Team whilst an inpatient on either occasion despite her long history of alcohol misuse and need for support.
In the event that clinicians advise referral to alcohol liaison team, either as an inpatient or as an outpatient there ought to be systems and processes to ensure that this occurs .
” 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 liaison psychiatry delivery framework with stakeholders and progress revisions through consultation and ratification.
Verbatim wording from the response “Although in date and operational, the MHLD Liaison Psychiatry Services in Acute Hospitals Delivery Framework will be reviewed by a working group of stakeholders, to include liaison team managers and key clinicians, led by a senior manager to ensure the referral process is clear and unambiguous.” 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 communication clarifying the referral process to liaison services and share it with clinical teams across the Health Board.
Verbatim wording from the response “During consideration of your concerns, it was identified that the liaison service did not receive a referral from the treating team located in our Integrated Health Community (East). In response to this, a communication has been produced that outlines the referral process to liaison services that will be shared with clinical teams across the Health Board to ensure there is clarity and consistency across all areas. This communication has now been issued.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
10 Jul 2023 Mary Elizabeth Jones · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 3 Delays in ambulance response and arrival View source Failure to involve Local Authorities in considerations of patient flow affected by social care deficiencies View source Inability to offload patients from ambulances into Emergency Departments in a timely manner View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mary Elizabeth 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
Mary Elizabeth Jones had an unwitnessed fall at home on 4 December 2022, followed by a 26-hour ambulance delay and a further 8-hour-23-minute wait on the ambulance outside the Emergency Department. She later deteriorated, an abdominal bleed was diagnosed, and she died on 14 January 2023. The principal concerns were the lengthy ambulance and patient offload delays, and the lack of meaningful evidence about Local Authority involvement in addressing patient-flow problems linked to social care deficiencies.
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 ambulance response and arrival
Wider context from the report “This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales.
Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones.
I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
” 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 Local Authorities in considerations of patient flow affected by social care deficiencies
Wider context from the report “This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales.
Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones.
I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies .
” 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 Inability to offload patients from ambulances into Emergency Departments in a timely manner
Wider context from the report “This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales .
Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones.
I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
” Open source report
Concerns raised 3 Delays in ambulance attendance View source Inadequate cohesive forward planning for short-term pressures and longer-term solutions View source Lack of adequate social care placements or community care for patients medically fit for hospital discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Emlyn Victor 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
Emlyn Victor Roberts called an ambulance on 13 March 2022 after sudden pain and difficulty breathing, but ambulance attendance was delayed by almost eleven and a half hours; he was found deceased at home on 14 March 2022. The principal concern was the significant and unacceptable delay in ambulance attendance, alongside concerns about continuing delays and inadequate cohesive planning for short-term pressures and longer-term solutions.
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 ambulance attendance
Wider context from the report “Whilst there was no direct evidence at the inquest to establish whether or not the outcome may have been different if Mr Roberts had received earlier medical care and attention, the delay in the attendance of the ambulance is significant and unacceptable .
It is recognised that the reasons for such delay are multifactorial and both I and my Assistant Coroners have issued multiple previous reports for the prevention of future deaths expressing similar concerns. One of my earliest such reports expressing concern regarding ambulance response times , was in relation to a death in March 2013 and yet more than ten years later this problem has become significantly worse rather than better .
It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medically fit for discharge from hospitals but without adequate placements / care in the community).
I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. winter pressures) or with a view to finding longer term solutions.
” 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 cohesive forward planning for short-term pressures and longer-term solutions
Wider context from the report “Whilst there was no direct evidence at the inquest to establish whether or not the outcome may have been different if Mr Roberts had received earlier medical care and attention, the delay in the attendance of the ambulance is significant and unacceptable.
It is recognised that the reasons for such delay are multifactorial and both I and my Assistant Coroners have issued multiple previous reports for the prevention of future deaths expressing similar concerns. One of my earliest such reports expressing concern regarding ambulance response times, was in relation to a death in March 2013 and yet more than ten years later this problem has become significantly worse rather than better.
It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medically fit for discharge from hospitals but without adequate placements / care in the community).
I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. winter pressures) or with a view to finding longer term solutions .
” 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 adequate social care placements or community care for patients medically fit for hospital discharge
Wider context from the report “Whilst there was no direct evidence at the inquest to establish whether or not the outcome may have been different if Mr Roberts had received earlier medical care and attention, the delay in the attendance of the ambulance is significant and unacceptable.
It is recognised that the reasons for such delay are multifactorial and both I and my Assistant Coroners have issued multiple previous reports for the prevention of future deaths expressing similar concerns. One of my earliest such reports expressing concern regarding ambulance response times, was in relation to a death in March 2013 and yet more than ten years later this problem has become significantly worse rather than better.
It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medically fit for discharge from hospitals but without adequate placements / care in the community ).
I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. winter pressures) or with a view to finding longer term solutions.
” Open source report
Concerns raised 4 Delays in ambulance handover at hospitals View source Failure to maintain timely ambulance availability and arrival for patients View source Insufficient social care capacity causing hospital patient-flow and ambulance offload delays View source Lack of meaningful Local Authority involvement in addressing social-care-related patient-flow deficiencies View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jean Frickel · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jean Frickel became unresponsive and died at home on 20 December 2022 after an ambulance call the previous evening and a further call the following morning. Paramedics arrived 13 hours and 3 minutes after the initial call. The report states that the delay denied her the opportunity for possible life-extending treatment and raises continuing concerns about ambulance delays, hospital patient flow, social care deficiencies, and coordination between health services and local authorities.
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 ambulance handover at hospitals
Wider context from the report “There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available.
I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals ).
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
Specifically, I require responses to the following:-
1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and
2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and
3. Extent of Strategic plan of action / improvement plan to address the above issues.
” 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 timely ambulance availability and arrival for patients
Wider context from the report “There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available .
I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals).
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
Specifically, I require responses to the following:-
1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and
2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and
3. Extent of Strategic plan of action / improvement plan to address the above issues.
” 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 social care capacity causing hospital patient-flow and ambulance offload delays
Wider context from the report “There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available.
I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals).
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
Specifically, I require responses to the following:-
1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and
2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and
3. Extent of Strategic plan of action / improvement plan to address the above issues.
” 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 meaningful Local Authority involvement in addressing social-care-related patient-flow deficiencies
Wider context from the report “There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available.
I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals).
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
Specifically, I require responses to the following:-
1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and
2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and
3. Extent of Strategic plan of action / improvement plan to address the above issues.
” Open source report
Concerns raised 3 Delays in ambulances arriving to patients View source Delays in ambulance handover at hospitals View source Inadequate social care placements or community care for patients medically fit for discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Leonard Charles Harmsworth · 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
Leonard Charles Harmsworth died on 18 June 2022 after a fall caused a fractured ankle and immobility, followed by a sudden deterioration after ankle manipulation. The report raised significant concerns about delays in ambulance arrival and hospital handover, although it stated that these delays did not cause or contribute to his death. It expressed concern that such delays were continuing and that deaths could occur in the 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 Delays in ambulances arriving to patients
Wider context from the report “Following the fall at home on 7ᵗʰ June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd Leonard Harmsworth was handed in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.
Whilst the time it took for the ambulance to arrive to Mr Harmsworth’s home and the time it took for Mr Harmsworth to be handed over to nursing staff at hospital did not cause or contribute to Mr Harmsworth’s death, the delays experienced are significant. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medical fit for discharge from hospitals but without adequate placements / care in the community).
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals.
I remain significantly concerned that delays are continuing and that deaths will continue to 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 Delays in ambulance handover at hospitals
Wider context from the report “Following the fall at home on 7ᵗʰ June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd Leonard Harmsworth was handed in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.
Whilst the time it took for the ambulance to arrive to Mr Harmsworth’s home and the time it took for Mr Harmsworth to be handed over to nursing staff at hospital did not cause or contribute to Mr Harmsworth’s death, the delays experienced are significant. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medical fit for discharge from hospitals but without adequate placements / care in the community).
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals .
I remain significantly concerned that delays are continuing and that deaths will continue to 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 Inadequate social care placements or community care for patients medically fit for discharge
Wider context from the report “Following the fall at home on 7ᵗʰ June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd Leonard Harmsworth was handed in the ambulance for 12 hours 4 minutes before being handed over to nursing staff.
Whilst the time it took for the ambulance to arrive to Mr Harmsworth’s home and the time it took for Mr Harmsworth to be handed over to nursing staff at hospital did not cause or contribute to Mr Harmsworth’s death, the delays experienced are significant. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medical fit for discharge from hospitals but without adequate placements / care in the community ).
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals.
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
” Open source report
8 Jun 2023 Eifion Wyn Huws · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 4 Delays in completing and sharing investigations into deaths View source Unavailability of all relevant notes electronically for fully informed treatment and care decisions View source Failure to identify and address electronic record availability in investigation learning and improvement View source Delays in acting on actions arising from death investigations 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
Eifion Wyn Huws · 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
Eifion Wyn Huws, aged 63, died by suicide at his daughter’s home on 10 June 2022 after being found suspended by a ligature. Concerns included the Emergency Department not having access to a very urgent mental-health referral held in hard-copy notes, and delays in completing and sharing the Health Board’s investigation and implementing resulting actions.
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 completing and sharing investigations into deaths
Wider context from the report “2. An investigation was commenced by the Health Board into Eifion’s death which appears to have been concluded in July 2022 but did not appear to be finalised and ready for sharing / disseminating until March 2023 . I have previously issued Prevention of Future Death Reports to the Health Board pertaining to the lack of timeliness of their investigations, specifically in relation to investigations from deaths in 2020 and 2021. Whilst I have previously been advised of improvements into investigation processes in respect of more recent deaths the issue of timeliness remain . Eifion died in 2022 and yet the time it took for the investigation to be completed and shared, with actions undertaken has been too long. I am concerned that deaths will occur when the actions arising are not acted upon in a timely manner.
” 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 all relevant notes electronically for fully informed treatment and care decisions
Wider context from the report “1. a. During the Inquest evidence was heard that Eifion’s GP had made a ‘very urgent’ referral to the Single Point of Access and Allocation (SPOAA) on 13 May 2022 indicating that on the background of attempts at ending his life, he was extremely concerned that Eifion was experiencing deterioration in his mental state. This document was contained within the hard copy set of notes held by the Psychiatric Liaison Team. When Eifion attended the Emergency Department the following day, on 14 May 2022, the Emergency department staff were not aware of this ‘very urgent’ referral as they only had access to the electronic notes and not the hard copy notes. Had they been aware it is likely to have further informed their decision making. It is concerning that the process of ensuring electronic notes to allow for fully informed decisions around treatment and care based on all available records, is not available to staff . It was not clear at Inquest whether the transition from paper-based notes to electronic notes was a Health Board initiative or a nationally followed initiative. Either way, any delay in ensuring all notes are available electronically is potentially harmful to patients .
b. During the evidence it was accepted that ‘a’ above was not a consideration for improvement as part of the Health Board’s investigation and so was not an action within the Action Plan upon which it could make improvements or plan to make improvements. It is surprising that the Health Board did not consider this as an issue which required further consideration and improvements in its learning and improvement.
” 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 identify and address electronic record availability in investigation learning and improvement
Wider context from the report “1. a. During the Inquest evidence was heard that Eifion’s GP had made a ‘very urgent’ referral to the Single Point of Access and Allocation (SPOAA) on 13 May 2022 indicating that on the background of attempts at ending his life, he was extremely concerned that Eifion was experiencing deterioration in his mental state. This document was contained within the hard copy set of notes held by the Psychiatric Liaison Team. When Eifion attended the Emergency Department the following day, on 14 May 2022, the Emergency department staff were not aware of this ‘very urgent’ referral as they only had access to the electronic notes and not the hard copy notes. Had they been aware it is likely to have further informed their decision making. It is concerning that the process of ensuring electronic notes to allow for fully informed decisions around treatment and care based on all available records, is not available to staff. It was not clear at Inquest whether the transition from paper-based notes to electronic notes was a Health Board initiative or a nationally followed initiative. Either way, any delay in ensuring all notes are available electronically is potentially harmful to patients.
b. During the evidence it was accepted that ‘a’ above was not a consideration for improvement as part of the Health Board’s investigation and so was not an action within the Action Plan upon which it could make improvements or plan to make improvements . It is surprising that the Health Board did not consider this as an issue which required further consideration and improvements in its learning and improvement .
” 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 acting on actions arising from death investigations
Wider context from the report “2. An investigation was commenced by the Health Board into Eifion’s death which appears to have been concluded in July 2022 but did not appear to be finalised and ready for sharing / disseminating until March 2023. I have previously issued Prevention of Future Death Reports to the Health Board pertaining to the lack of timeliness of their investigations, specifically in relation to investigations from deaths in 2020 and 2021. Whilst I have previously been advised of improvements into investigation processes in respect of more recent deaths the issue of timeliness remain. Eifion died in 2022 and yet the time it took for the investigation to be completed and shared, with actions undertaken has been too long . I am concerned that deaths will occur when the actions arising are not acted upon in a timely manner .
” 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 Continue Health Board engagement in WCCIS implementation, including reviewing functionality and supporting required development work.
Verbatim wording from the response “The Welsh Government have advocated the use of an information technology (IT) system that links health and social care through the use of an integrated care platform. The Welsh Community Care Information System (WCCIS) will enable a single integrated health and social care record. This system will help social services (adults & children) and a range of community health services (including mental health, therapies and community nursing) to ensure that care and support for individuals, families and communities are more effectively planned, co-ordinated and delivered. It will support information sharing requirements, case management and workflow for health and social care organisations across Wales. It will show where a patient is within their treatment journey and alert health professionals to key data, which will support the delivery of effective treatment.” Source location Response from Betsi Cadwaladr University Local 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 incident process to improve incident handling and learning.
Verbatim wording from the response “In my previous letter to you on 09 May 2023, I was able to inform you of the changes that have taken place within the Health Board; these included a review of the incident process, and the quality control process delivered by the quality governance teams. The Health Board have also implemented rapid learning panels and incident learning panels. The MHLD Division have prioritised the completion of overdue investigations and action plans and there has been a significant reduction in the number overdue. The Division continues to meet weekly to address any remaining overdue investigation reports and to ensure that actions are monitored for completion. I recognise the importance of ensuring this improvement is maintained and I am assured that we have the mechanisms in place to monitor this and to take further action as required.” Source location Response from Betsi Cadwaladr University Local 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 rapid learning panels and incident learning panels.
Verbatim wording from the response “In my previous letter to you on 09 May 2023, I was able to inform you of the changes that have taken place within the Health Board; these included a review of the incident process, and the quality control process delivered by the quality governance teams. The Health Board have also implemented rapid learning panels and incident learning panels. The MHLD Division have prioritised the completion of overdue investigations and action plans and there has been a significant reduction in the number overdue. The Division continues to meet weekly to address any remaining overdue investigation reports and to ensure that actions are monitored for completion. I recognise the importance of ensuring this improvement is maintained and I am assured that we have the mechanisms in place to monitor this and to take further action as required.” Source location Response from Betsi Cadwaladr University Local 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 Prioritise overdue investigations and action plans, meeting weekly to resolve remaining work and monitor actions through completion.
Verbatim wording from the response “In my previous letter to you on 09 May 2023, I was able to inform you of the changes that have taken place within the Health Board; these included a review of the incident process, and the quality control process delivered by the quality governance teams. The Health Board have also implemented rapid learning panels and incident learning panels. The MHLD Division have prioritised the completion of overdue investigations and action plans and there has been a significant reduction in the number overdue. The Division continues to meet weekly to address any remaining overdue investigation reports and to ensure that actions are monitored for completion. I recognise the importance of ensuring this improvement is maintained and I am assured that we have the mechanisms in place to monitor this and to take further action as required.” Source location Response from Betsi Cadwaladr University Local 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 and discuss the benefits of integrated IT within the investigation report and subsequent action plan.
Verbatim wording from the response “With regard to the investigation report and action plan into the care and treatment delivered to Mr Huws, the benefits of an integrated IT system should have been considered with reference to the implementation of WCCIS within the action plan and this has been discussed with the investigating officer.” Source location Response from Betsi Cadwaladr University Local Health Board
Open published response
Concerns raised 2 Lack of a documented and robust policy for future treatment and care pathways following referral to the Home Treatment Team View source Lack of a documented and robust policy for decision-making and meeting criteria for patients referred to the Home Treatment Team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew John Shambrook · 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
Andrew John Shambrook took his own life by hanging on 27 March 2022. The health board acknowledged that there was no documented or robust policy for decision-making, meeting criteria, and future treatment and care pathways when a patient was referred to the Home Treatment Team; evidence indicated that Mr Shambrook had been referred but did not meet the team’s treatment criteria.
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 documented and robust policy for future treatment and care pathways following referral to the Home Treatment Team
Wider context from the report “The health board (by their own admission through counsel) acknowledge that there is no documented or robust policy in relation to decision making/meeting criteria and thereafter future treatment and care pathways when a patient is referred to the Home Treatment Team
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of a documented and robust policy for decision-making and meeting criteria for patients referred to the Home Treatment Team
Wider context from the report “The health board (by their own admission through counsel) acknowledge that there is no documented or robust policy in relation to decision making/meeting criteria and thereafter future treatment and care pathways when a patient is referred to the Home Treatment Team
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide an interim policy addendum addressing the concerns identified at the inquest.
Verbatim wording from the response “As an interim measure, MHLD have provided an addendum to the policy to ensure the concerns noted at the inquest are addressed. The addendum to the Policy will be shared across MHLD to ensure that there is consistency across all areas and I have enclosed a copy of this for your reference.” 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 review, consultation and ratification of the Home Treatment Team Operational Policy, incorporating the coroner’s concerns and monitored through divisional and corporate governance.
Verbatim wording from the response “Firstly, I can confirm that there is an approved Home Treatment Team Operational Policy (MHLD 0035) that has been in use since April 2018. However, this operational policy has exceeded its review date and we are progressing this through the review and ratification process as a priority.” 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 Share the interim policy addendum across the Mental Health and Learning Disability Division to promote consistency across services.
Verbatim wording from the response “As an interim measure, MHLD have provided an addendum to the policy to ensure the concerns noted at the inquest are addressed. The addendum to the Policy will be shared across MHLD to ensure that there is consistency across all areas and I have enclosed a copy of this for your reference.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 4 Failure to set realistic actions arising from investigations View source Failure to complete investigation actions within their required timescales View source Delays in identifying and understanding areas for learning and training View source Lack of timely completion of internal investigations 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
Nancy Carolyn Price · 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
Nancy Carolyn Price, aged 62, presented with sudden loss of movement and sensation in both lower limbs and was diagnosed with limb ischaemia. There were delays in assessing and transferring her for vascular surgery, after which she developed multi-organ failure and died on 1 January 2021. The principal concerns were the delayed Health Board investigation, delayed sharing of learning, and unrealistic or incomplete action plans, which limited the timely identification of learning and training needs.
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 set realistic actions arising from investigations
Wider context from the report “An investigation was commenced by the Health Board into the death of Nancy Carolyn Price, a significant time after her death and was completed only on 9 June 2022, some 17 months after her death. At inquest it was identified that not all actions arising have been fully completed and the dates by when actions ought to have been completed (according to the investigation report) not adhered to. For example, the investigation report was due to be shared with vascular services to share learning by June 2022 (once approved) and yet the Report was only shared with vascular services in January 2023.
The actions arising from the investigation report are not always realistic . For example, one action was to identify any gaps in knowledge with regards to assessment and management of vascular emergencies, including recording of limb colour, sensation and movement, by the end of June 2022, approximately 3-4 weeks after the final report .
I have previously issued Prevention of Future Death Reports to the Health Board pertaining to the lack of timeliness of their investigations.
I remain significantly concerned that the strategic management of internal Health Board investigations is lacking leading to investigations that are too slow, actions are not always realistic and, as a result, identification of areas for learning and training are not understood quickly enough, such that deaths will occur or will continue to occur into the future unless rapid action is taken.
” 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 complete investigation actions within their required timescales
Wider context from the report “An investigation was commenced by the Health Board into the death of Nancy Carolyn Price, a significant time after her death and was completed only on 9 June 2022, some 17 months after her death. At inquest it was identified that not all actions arising have been fully completed and the dates by when actions ought to have been completed (according to the investigation report) not adhered to . For example, the investigation report was due to be shared with vascular services to share learning by June 2022 (once approved) and yet the Report was only shared with vascular services in January 2023 .
The actions arising from the investigation report are not always realistic. For example, one action was to identify any gaps in knowledge with regards to assessment and management of vascular emergencies, including recording of limb colour, sensation and movement, by the end of June 2022, approximately 3-4 weeks after the final report.
I have previously issued Prevention of Future Death Reports to the Health Board pertaining to the lack of timeliness of their investigations.
I remain significantly concerned that the strategic management of internal Health Board investigations is lacking leading to investigations that are too slow, actions are not always realistic and, as a result, identification of areas for learning and training are not understood quickly enough, such that deaths will occur or will continue to occur into the future unless rapid action is taken.
” 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 understanding areas for learning and training
Wider context from the report “An investigation was commenced by the Health Board into the death of Nancy Carolyn Price, a significant time after her death and was completed only on 9 June 2022, some 17 months after her death. At inquest it was identified that not all actions arising have been fully completed and the dates by when actions ought to have been completed (according to the investigation report) not adhered to. For example, the investigation report was due to be shared with vascular services to share learning by June 2022 (once approved) and yet the Report was only shared with vascular services in January 2023.
The actions arising from the investigation report are not always realistic. For example, one action was to identify any gaps in knowledge with regards to assessment and management of vascular emergencies, including recording of limb colour, sensation and movement, by the end of June 2022, approximately 3-4 weeks after the final report.
I have previously issued Prevention of Future Death Reports to the Health Board pertaining to the lack of timeliness of their investigations.
I remain significantly concerned that the strategic management of internal Health Board investigations is lacking leading to investigations that are too slow, actions are not always realistic and, as a result, identification of areas for learning and training are not understood quickly enough , such that deaths will occur or will continue to occur into the future unless rapid action is taken.
” 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 timely completion of internal investigations
Wider context from the report “An investigation was commenced by the Health Board into the death of Nancy Carolyn Price, a significant time after her death and was completed only on 9 June 2022, some 17 months after her death . At inquest it was identified that not all actions arising have been fully completed and the dates by when actions ought to have been completed (according to the investigation report) not adhered to. For example, the investigation report was due to be shared with vascular services to share learning by June 2022 (once approved) and yet the Report was only shared with vascular services in January 2023.
The actions arising from the investigation report are not always realistic. For example, one action was to identify any gaps in knowledge with regards to assessment and management of vascular emergencies, including recording of limb colour, sensation and movement, by the end of June 2022, approximately 3-4 weeks after the final report.
I have previously issued Prevention of Future Death Reports to the Health Board pertaining to the lack of timeliness of their investigations .
I remain significantly concerned that the strategic management of internal Health Board investigations is lacking leading to investigations that are too slow , actions are not always realistic and, as a result, identification of areas for learning and training are not understood quickly enough, such that deaths will occur or will continue to occur into the future unless rapid action is taken.
” 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 Engage staff to develop a new organisational learning approach, framework and toolkit.
Verbatim wording from the response “• Over the next few months, our Organisational Learning Manager is engaging with staff across the organisation to understand how we can better support learning. This will develop into a new approach to learning with a framework and toolkit, which will include the actions already mentioned.” Source location Response from Betsi Cadwaladr University Local 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 Address overdue investigations through weekly improvement and scrutiny meetings with clinical directors.
Verbatim wording from the response “• We are working to address those investigations currently overdue. A weekly improvement and scrutiny meeting, chaired by the Deputy Directors of Nursing, is held with clinical directors from our services to monitor, track and support the completion of serious incidents.” Source location Response from Betsi Cadwaladr University Local 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 local quality governance support to services for managing open and overdue investigations and evidencing completed actions.
Verbatim wording from the response “• Our divisionally-based Quality Governance Teams will support our services locally with understanding their open and overdue investigations and actions, and will support services to collate evidence of action completion. The Patient Safety Team have the role of monitoring performance and assuring the completion of actions.” Source location Response from Betsi Cadwaladr University Local 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 training for people undertaking investigations and writing action plans.
Verbatim wording from the response “• We are reviewing our training for those undertaking investigations and writing action plans and will launch new training programmes following approval of the new procedure outlined above.” Source location Response from Betsi Cadwaladr University Local Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a monthly Organisational Learning Forum to consider and share learning from incidents, complaints, mortality reviews and other processes.
Verbatim wording from the response “• A new Organisational Learning Forum has recently been established. It is chaired by the Deputy Director of Nursing who leads on the patient safety agenda. This monthly meeting considers learning from across the organisation that arises from incidents, complaints, mortality reviews and other processes and is attended by clinical directors from all services with an aim of sharing learning.” Source location Response from Betsi Cadwaladr University Local 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-evaluate the incident process and develop a procedure defining roles and responsibilities.
Verbatim wording from the response “• We are re-evaluating the incident process to identify how it can be streamlined and a new procedure document will be developed setting out roles and responsibilities. This will be complete by the end of August 2023.” Source location Response from Betsi Cadwaladr University Local Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen organisational learning capacity by appointing an Organisational Learning Manager and Director of Nursing for Quality Assurance and Learning.
Verbatim wording from the response “• We have moved resources to strengthen our approach to learning, and a new Organisational Learning Manager has been appointed. We have also appointed a Director of Nursing for Quality Assurance and Learning who is supporting the Organisational Learning Forum mentioned above.” Source location Response from Betsi Cadwaladr University Local Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen performance and accountability processes to include overdue investigations.
Verbatim wording from the response “• We will be strengthening the performance and accountability process with our services to include overdue investigations.” Source location Response from Betsi Cadwaladr University Local 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 Monitor performance and assure completion of investigation actions through the Patient Safety Team.
Verbatim wording from the response “• Our divisionally-based Quality Governance Teams will support our services locally with understanding their open and overdue investigations and actions, and will support services to collate evidence of action completion. The Patient Safety Team have the role of monitoring performance and assuring the completion of actions.” Source location Response from Betsi Cadwaladr University Local Health Board
Open published response
Concerns raised 2 Lack of strategic direction to investigations and learning View source Delays in addressing learning and actions arising from investigations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ben Christopher Harrison · 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
Ben Christopher Harrison, aged 37, was found in cardiac arrest with a ligature around his neck while a voluntary inpatient and died three days later after being transferred to intensive care. During resuscitation, an oxygen cylinder valve was not opened, so he was ventilated only on room air. Concerns included delays in addressing investigation learning and actions, and an evident lack of overall strategic direction to investigations and learning.
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 strategic direction to investigations and learning
Wider context from the report “The Health Board undertook an investigation following Ben’s death. The investigation contains an Action Plan arising as a result of the learning. It has taken the Health Board a considerable amount of time to update and provide the Action Plan, the most recent version still containing outstanding actions and yet Ben died over 2 years ago.
It is particularly concerning that learning and actions arising therefrom are not more quickly addressed. If the learning, actions and changes are taking so long then there is a risk that deaths will continue in the interim.
Overall, there is an evident lack of overall strategic direction to investigations and learning .
” 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 addressing learning and actions arising from investigations
Wider context from the report “The Health Board undertook an investigation following Ben’s death. The investigation contains an Action Plan arising as a result of the learning. It has taken the Health Board a considerable amount of time to update and provide the Action Plan, the most recent version still containing outstanding actions and yet Ben died over 2 years ago.
It is particularly concerning that learning and actions arising therefrom are not more quickly addressed . If the learning, actions and changes are taking so long then there is a risk that deaths will continue in the interim.
Overall, there is an evident lack of overall strategic direction to investigations and learning.
” Open source report
Concerns raised 5 Unavailability of a fully staffed major trauma consultant function View source Failure to follow up on radiological signs of possible bowel injury View source Failure to assess polytrauma patients as a whole across specialty boundaries View source Lack of prompt and secure delivery of radiology reports during interhospital transfers View source Failure to establish clear cross-specialty responsibility for review and escalation 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
Sara Anest 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
Sara Anest Jones died at Royal Stoke University Hospital on 2 April 2021 from complications of a bowel injury sustained in a road traffic collision on 30 March 2021. The concerns included delayed and unconfirmed delivery of a CT radiology report between hospitals, failure to follow up signs of possible bowel injury, and the absence of a protocol for prompt and secure delivery of radiology reports in such circumstances.
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 a fully staffed major trauma consultant function
Wider context from the report “The patient was admitted to Royal Stoke University Hospital, Stoke-on-Trent as a “polytrauma” patient who had sustained serious injuries in a road traffic collision. Following her admission, she was treated by doctors from several different specialisms, but it was apparent that some doctors involved in her care concentrated on only the injuries which fell within their specialty and did not consider the patient as a whole. At an important stage in her treatment the general surgeons thought that the orthopaedic surgeons would alert them to any intervention which was needed from their specialty, whilst the orthopaedic surgeons expected the general surgeons to regularly review the patient.
Partly as a result of doctors concentrating only on the injuries which fell within their specialty signs of a bowel injury which the patient had sustained were missed. The patient subsequently died as a result of complications of the undiagnosed bowel injury.
Evidence was given during the inquest that a major trauma consultant role was in the process of being developed at the Royal Stoke University Hospital, Stoke-on-Trent to address issues like this, but that the role was only 50% filled at the current time .
” 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 follow up on radiological signs of possible bowel injury
Wider context from the report “A CT scan of the deceased was undertaken at Ysbyty Gwynedd late on the evening of 30th March 2021. The deceased was then transferred to the Royal Stoke University Hospital, Stoke-on-Trent by air ambulance before the radiologist's report on the CT scan was available. Because of this the patient was transferred without the radiologist's report. The radiologist's report became available shortly before 1:00am on 31st March 2021, but was not sent to the Royal Stoke University Hospital until 5:35am that day. It was not clear that safe receipt of the report in Stoke-on-Trent was ever confirmed. Doctors in Stoke-on-Trent then failed to follow up on signs of a possible bowel injury which were indicated in the radiologist's report on the CT scan.
During the inquest I was told that the circumstances of this case were unusual and that there was not a protocol in place to ensure the prompt and secure delivery of radiology reports in circumstances like 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 assess polytrauma patients as a whole across specialty boundaries
Wider context from the report “The patient was admitted to Royal Stoke University Hospital, Stoke-on-Trent as a “polytrauma” patient who had sustained serious injuries in a road traffic collision. Following her admission, she was treated by doctors from several different specialisms, but it was apparent that some doctors involved in her care concentrated on only the injuries which fell within their specialty and did not consider the patient as a whole . At an important stage in her treatment the general surgeons thought that the orthopaedic surgeons would alert them to any intervention which was needed from their specialty, whilst the orthopaedic surgeons expected the general surgeons to regularly review the patient.
Partly as a result of doctors concentrating only on the injuries which fell within their specialty signs of a bowel injury which the patient had sustained were missed. The patient subsequently died as a result of complications of the undiagnosed bowel injury.
Evidence was given during the inquest that a major trauma consultant role was in the process of being developed at the Royal Stoke University Hospital, Stoke-on-Trent to address issues like this, but that the role was only 50% filled at the current time.
” 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 prompt and secure delivery of radiology reports during interhospital transfers
Wider context from the report “A CT scan of the deceased was undertaken at Ysbyty Gwynedd late on the evening of 30th March 2021. The deceased was then transferred to the Royal Stoke University Hospital, Stoke-on-Trent by air ambulance before the radiologist's report on the CT scan was available. Because of this the patient was transferred without the radiologist's report. The radiologist's report became available shortly before 1:00am on 31st March 2021, but was not sent to the Royal Stoke University Hospital until 5:35am that day. It was not clear that safe receipt of the report in Stoke-on-Trent was ever confirmed. Doctors in Stoke-on-Trent then failed to follow up on signs of a possible bowel injury which were indicated in the radiologist's report on the CT scan.
During the inquest I was told that the circumstances of this case were unusual and that there was not a protocol in place to ensure the prompt and secure delivery of radiology reports in circumstances like 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 establish clear cross-specialty responsibility for review and escalation
Wider context from the report “The patient was admitted to Royal Stoke University Hospital, Stoke-on-Trent as a “polytrauma” patient who had sustained serious injuries in a road traffic collision. Following her admission, she was treated by doctors from several different specialisms, but it was apparent that some doctors involved in her care concentrated on only the injuries which fell within their specialty and did not consider the patient as a whole. At an important stage in her treatment the general surgeons thought that the orthopaedic surgeons would alert them to any intervention which was needed from their specialty, whilst the orthopaedic surgeons expected the general surgeons to regularly review the patient .
Partly as a result of doctors concentrating only on the injuries which fell within their specialty signs of a bowel injury which the patient had sustained were missed. The patient subsequently died as a result of complications of the undiagnosed bowel injury.
Evidence was given during the inquest that a major trauma consultant role was in the process of being developed at the Royal Stoke University Hospital, Stoke-on-Trent to address issues like this, but that the role was only 50% filled at the current time.
” 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 Send unreported radiology reports by email and confirm safe receipt by telephone when patients leave emergency departments.
Verbatim wording from the response “We have now established a process that if a patient leaves our emergency departments without a report, which is very rare, then the report will be sent by email and its safe receipt will be confirmed by telephone.” 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 Include the unreported-report process in major trauma standard operating procedures and checklists.
Verbatim wording from the response “This process is being included in our major trauma standard operating procedure and checklists by the end of May 2023 by our Trauma Network Manager. This will ensure staff are clear on the actions they need to take.” 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 Trauma Group oversight and ongoing audit of the new unreported-report process.
Verbatim wording from the response “All trauma transfers are discussed and reviewed at our Trauma Group, so this group will have oversight of this new procedure and will ensure this new process is subject to ongoing audit to give assurance.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 2 Insufficient ambulance resource availability for timely attendance View source Delays in ambulance handover across BCUHB sites View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Colin Strachan · 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
David Strachan developed sudden chest pain, vomiting, clamminess and shortness of breath at home on 15 March 2022. After multiple 999 calls, an ambulance and paramedics arrived only later that morning; he was diagnosed with an ST elevation myocardial infarction, transferred to hospital and died on 16 March 2022. The principal concern was delayed ambulance attendance associated with resource pressures and handover delays, with the report stating that significant concerns remained.
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 ambulance resource availability for timely attendance
Wider context from the report “The causes of the ambulance delay were that all available resources were managing incidents of a higher acuity or the same category but registered prior and there were significant handover delays across all BCUHB sites.
The matters of concern herein are longstanding and multifactorial and despite proposed future action significant concerns remain. The Welsh Ambulance Service NHS Trust and Health Board maintain that they are continuing to work closely in order to address handover delays and yet any improvements appear extremely limited. Deaths are occurring and will continue to occur as a result of delayed ambulance attendances caused by these multifactorial issues .
” 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 ambulance handover across BCUHB sites
Wider context from the report “The causes of the ambulance delay were that all available resources were managing incidents of a higher acuity or the same category but registered prior and there were significant handover delays across all BCUHB sites .
The matters of concern herein are longstanding and multifactorial and despite proposed future action significant concerns remain. The Welsh Ambulance Service NHS Trust and Health Board maintain that they are continuing to work closely in order to address handover delays and yet any improvements appear extremely limited . Deaths are occurring and will continue to occur as a result of delayed ambulance attendances caused by these multifactorial issues.
” 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 Conduct joint patient-safety incident reviews with the Welsh Ambulance Service and roll out the Health Board’s handover-review model.
Verbatim wording from the response “• Joint reviews between WAST and the Health Board of any patient safety incidents identified from handover delays to support joint working alongside the improvement programmes. The process within the Health Board has been identified as the gold standard model and being rolled out across 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 the Integrated Commissioning Action Plan with partners to improve ambulance handovers.
Verbatim wording from the response “• The ICAP (Integrated Commissioning Action Plan) is a joint piece of work with WAST/NCCU and the Health Board to support actions associated with improving ambulance handovers.” 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 Some solutions to ambulance handover delays fall outside the Health Board’s control or require joint working across health and social care.
Verbatim wording from the response “The causes behind this issue are complex and long standing, exacerbated by the global COVID-19 pandemic. In many cases, the solutions sit outside of the Health Board or require joint working across the whole spectrum of health and social care.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
17 Feb 2023 Mr Twm Bryn · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 4 Insufficient Primary Mental Health Services staffing causing assessment and counselling support delays View source Interim support for mild or low-risk patients requiring self-referral View source Failure to offer or arrange interim contact or monitoring for patients awaiting counselling View source Lack of a standardised LPMHSS referral process for low-risk patients’ interim support 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
Mr Twm Bryn · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Twm Bryn died on 4 October 2021 in a shipping container near his home after suspending himself by the neck with a ligature. He had experienced mental health difficulties and was awaiting counselling after an assessment that identified a mild risk of suicide. The report raises concerns about delays and lengthy waiting lists for primary mental health support, and the lack of interim contact, monitoring or support for low-risk patients who are waiting for counselling.
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 Primary Mental Health Services staffing causing assessment and counselling support delays
Wider context from the report “(1) Continued staffing pressures within Primary Mental Health Services resulting in assessment delays and waiting lists for support e.g the waiting list for LPMHSS counselling remains at 4 – 6 months . There was no evidence that the waiting list would improve moving forward .
” 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 Interim support for mild or low-risk patients requiring self-referral
Wider context from the report “(2) Whilst awaiting counselling, the only interim support available to patients that are assessed as mild or low risk, are services that come with a requirement to self-refer , despite lack of motivation being a common symptom . The LPMHSS does not have a standardised process for referring low risk patients for interim support and no interim contact or monitoring is offered or arranged (unless patients have self-referred to an organisation providing such services).
” 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 offer or arrange interim contact or monitoring for patients awaiting counselling
Wider context from the report “(2) Whilst awaiting counselling, the only interim support available to patients that are assessed as mild or low risk, are services that come with a requirement to self-refer, despite lack of motivation being a common symptom. The LPMHSS does not have a standardised process for referring low risk patients for interim support and no interim contact or monitoring is offered or arranged (unless patients have self-referred to an organisation providing such services ).
” 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 standardised LPMHSS referral process for low-risk patients’ interim support
Wider context from the report “(2) Whilst awaiting counselling, the only interim support available to patients that are assessed as mild or low risk, are services that come with a requirement to self-refer, despite lack of motivation being a common symptom. The LPMHSS does not have a standardised process for referring low risk patients for interim support and no interim contact or monitoring is offered or arranged (unless patients have self-referred to an organisation providing such services).
” 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 Run additional assessment clinics using overtime staffing to address sickness and vacancy-related shortfalls.
Verbatim wording from the response “Assessment clinics are planned utilising overtime staff to take into account any shortfall in staffing due to sickness absence and vacancies. There is a backlog of assessments despite this with the additional work only providing a short term maintenance position that is not sustainable in the longer term. We are exploring block booking of agency staff as a short term staffing solution to bring the service back into alignment with the Mental Health Measure performance standards.” 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 the unallocated-patient waiting-list protocol through consultation, approval, distribution and team launch.
Verbatim wording from the response “Due to the variation in practice across the teams in terms of managing patients on a waiting list, an Unallocated Patient Waiting List Protocol has been developed. This draft protocol ensures that service users referred to the Health Board Community Mental Health Teams and Local Primary Mental Health Support Services are managed efficiently, equitably and consistently. The draft protocol will now progress through consultation, approval and distribution.” 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 Offer additional shifts to mental health staff in West and Central services to complete assessments.
Verbatim wording from the response “The Service Managers for Community Mental Health Services have been directed to offer additional shifts to staff working in other mental health services in West and Central to complete assessments.” 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 Run a divisional recruitment drive using an external specialist recruitment firm.
Verbatim wording from the response “Recognising the difficulty in recruiting to vacancies, as outlined earlier, a recruitment drive has been launched Divisionally using an external specialist firm, Just R Recruitment, to attract staff to the area. A review of job descriptions for LPMHSS is under way to consider what amendments would be required in order to recruit non-nursing care professionals such as Social Workers and Occupational Therapists, which would provide a wider scope of recruitment.” 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 LPMHSS job descriptions to assess amendments enabling recruitment of non-nursing care professionals.
Verbatim wording from the response “Recognising the difficulty in recruiting to vacancies, as outlined earlier, a recruitment drive has been launched Divisionally using an external specialist firm, Just R Recruitment, to attract staff to the area. A review of job descriptions for LPMHSS is under way to consider what amendments would be required in order to recruit non-nursing care professionals such as Social Workers and Occupational Therapists, which would provide a wider scope of recruitment.” 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 Discuss expanding counselling options in the West to increase capacity and reduce waiting times.
Verbatim wording from the response “Discussions are in progress regarding expanding additional counselling options made available in the West. This will create more capacity for counselling and reduce waiting times.” 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 Have 111+2 staff contact patients fortnightly to review needs and offer support while improvements are developed.
Verbatim wording from the response “We recognise many of these improvements will take some time to develop and embed, and in many cases are reliant on the recruitment of staff. In the short term, 111+2 staff will contact patients on a fortnightly basis to review needs and offer any support as required.” 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 assessment appointment scheduling and consider administrative or non-registered staff for scheduling tasks.
Verbatim wording from the response “A scoping review is underway regarding scheduling of appointments for assessment, which has been found to take up a portion of time for clinical staff. Consideration is being given to administrative or non-registered staff performing this task, which would release more clinical time for assessments and interventions.” 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 Explore block-booking agency staff as a short-term measure to reduce assessment backlogs and restore performance-standard alignment.
Verbatim wording from the response “Assessment clinics are planned utilising overtime staff to take into account any shortfall in staffing due to sickness absence and vacancies. There is a backlog of assessments despite this with the additional work only providing a short term maintenance position that is not sustainable in the longer term. We are exploring block booking of agency staff as a short term staffing solution to bring the service back into alignment with the Mental Health Measure performance standards.” 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 Unfilled vacancies and recruitment difficulties limit the ability to reduce waiting lists, caseloads and delays in access to care.
Verbatim wording from the response “Any patients currently on waiting lists are supported by the duty teams whilst awaiting allocation. The waiting lists are due to currently unfilled vacancies that have been placed into recruitment but unfortunately not all have attracted candidates and have remained unfilled despite being advertised a number of times.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
24 Oct 2022 Glenys Roberts · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 3 Failure to implement an ambulance handover plan to reduce lost hours and improve ambulance availability View source Delays in reviewing and acting on intra-hospital transfers View source Failure of the vascular emergency transfer pathway to provide direct hospital admission View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Glenys 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
Glenys Roberts was found on the floor by her front door on 23 August 2021 with leg pain and loss of sensation, and was diagnosed with a complete occlusion of the distal aorta. An ambulance transfer for vascular surgery did not take place in a timely manner or at all before she became too frail to be conveyed; she was certified deceased at 07.39 on 24 August 2021. Concerns included slow progress on intra-hospital transfers, the vascular emergency transfer pathway, and an ambulance handover plan intended to improve ambulance availability.
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 implement an ambulance handover plan to reduce lost hours and improve ambulance availability
Wider context from the report “3. Development of a pan Betsi Cadwaladr University Local Health Board ambulance handover plan to support reducing lost hours to improve performance and availability is still not in force and has been too slow
” 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 reviewing and acting on intra-hospital transfers
Wider context from the report “1. Review of and action relating to intra hospital transfers has been too slow
” 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 the vascular emergency transfer pathway to provide direct hospital admission
Wider context from the report “2. Review of the current vascular pathway to ensure vascular emergency transfers have direct admission into hospital is still not fully operational and has been too slow
” 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 Continue reviewing intra-hospital transfers, modelling service demand and developing an options appraisal to support required additional resources.
Verbatim wording from the response “The review and actions for the intra hospital process is ongoing, with support from the National Collaborative Commissioning Unit (NCCU), to assist the review in line with similar national work that has commenced. The actions for the review of the intra hospital transfer process has resulted in significant work to model the service demand and draft an options appraisal for future development, to support additional resources required. As detailed below, we have made changes to the vascular pathway and implemented a change in protocol that in the event a paramedic crew is not able to transfer the patient between hospital sites in a timely manner, then the Ambulance Critical Care Team (ACCT) will transfer the patient.” 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 Implement the agreed bolus-dose anticoagulant protocol to enable non-paramedic crews to convey patients between hospitals.
Verbatim wording from the response “• In order to avoid the need for a paramedic crew to transfer the patient between hospitals, a change in clinical protocol from an Intravenous Anticoagulant Infusion to a bolus dose has been agreed. This means that a non-paramedic crew, which are more readily available, can convey the patient.” 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 Map the emergency ischaemic limb patient journey across North Wales hospitals, identify delays and bottlenecks, and take steps to reduce them.
Verbatim wording from the response “Prior to the Inquest, the Health Board had recognised these delays in time critical pathways and work had commenced on mapping out the current Emergency Ischaemic Limb Pathway across all three hospitals in North Wales. This was a multi-disciplinary approach including Emergency Departments (EDs), diagnostic services, pharmacy” 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 Commence the vascular emergency bypass pathway for direct admission of suitable stable patients to the vascular ward and monitor its implementation until embedded.
Verbatim wording from the response “• Vascular surgeons and the emergency department clinicians have agreed to support the implementation of the South East Wales WAST Bypass Pathway. WAST crews will contact the Vascular Consultant having confirmed an emergency ischaemic limb and if the patient is stable they will be accepted and go straight to the vascular ward, by-passing ED. This is commencing from 01 December 2022 and will be monitored fortnightly through regular meetings with all key stakeholders to address issues or concerns which arise. This will continue until all parties are confident that the new pathway is fully embedded.” 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 Share the local Ysbyty Gwynedd ambulance handover plan and related emergency department and hospital protocols across Health Board sites for local adoption.
Verbatim wording from the response “The local Ysbyty Gwynedd handover plan has been shared across sites within the Health Board for local adoption, along with ED full protocols and hospital full protocols. These are aligned with the national Operational Pressures Escalation Levels (OPEL) with clear triggers to support de-escalation and reducing delays.” 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 protocol for the Ambulance Critical Care Team to transfer patients when paramedic crews cannot transfer them between hospital sites promptly.
Verbatim wording from the response “The review and actions for the intra hospital process is ongoing, with support from the National Collaborative Commissioning Unit (NCCU), to assist the review in line with similar national work that has commenced. The actions for the review of the intra hospital transfer process has resulted in significant work to model the service demand and draft an options appraisal for future development, to support additional resources required. As detailed below, we have made changes to the vascular pathway and implemented a change in protocol that in the event a paramedic crew is not able to transfer the patient between hospital sites in a timely manner, then the Ambulance Critical Care Team (ACCT) will transfer the patient.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 3 Risk of deaths associated with delayed ambulance transfer or unavailability View source Failure to make ambulance resources available for lower-priority or later-registered calls View source Delays in ambulance handovers across BCUHB sites View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Raymond Gillespie · 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
Raymond Gillespie, a care home resident with multiple comorbidities, suffered an unwitnessed fall on 8 October 2021 and waited almost 15 hours for a paramedic response after calls to the Welsh Ambulance Service Trust. The report identified delays caused by resource availability and ambulance handover delays, with a continuing risk of future deaths or harm while patients await transfer or community paramedic assistance.
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 Risk of deaths associated with delayed ambulance transfer or unavailability
Wider context from the report “(1) The first cause of the delay given was that all available resources were managing incidents of a higher acuity or same category but registered prior to this call
(2) The second cause of the delay was a handover delay across all BCUHB sites. A total of 131.1 hours were lost in delay of handovers on 9 October 2021.
(3) Whilst on the evidence it was not found that the delay contributed to Mr Gillespie’s death there remains a significant risk that deaths will continue to occur or that future deaths will occur either with patients waiting to be transferred into hospital from the ambulance or by ambulances not being available to those in the community requiring paramedic assistance and transfer to hospital .
(4) The matters of concern herein are longstanding and despite proposed future action the concerns remain.
” 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 ambulance resources available for lower-priority or later-registered calls
Wider context from the report “(1) The first cause of the delay given was that all available resources were managing incidents of a higher acuity or same category but registered prior to this call
(2) The second cause of the delay was a handover delay across all BCUHB sites. A total of 131.1 hours were lost in delay of handovers on 9 October 2021.
(3) Whilst on the evidence it was not found that the delay contributed to Mr Gillespie’s death there remains a significant risk that deaths will continue to occur or that future deaths will occur either with patients waiting to be transferred into hospital from the ambulance or by ambulances not being available to those in the community requiring paramedic assistance and transfer to hospital.
(4) The matters of concern herein are longstanding and despite proposed future action the concerns remain.
” 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 ambulance handovers across BCUHB sites
Wider context from the report “(1) The first cause of the delay given was that all available resources were managing incidents of a higher acuity or same category but registered prior to this call
(2) The second cause of the delay was a handover delay across all BCUHB sites . A total of 131.1 hours were lost in delay of handovers on 9 October 2021 .
(3) Whilst on the evidence it was not found that the delay contributed to Mr Gillespie’s death there remains a significant risk that deaths will continue to occur or that future deaths will occur either with patients waiting to be transferred into hospital from the ambulance or by ambulances not being available to those in the community requiring paramedic assistance and transfer to hospital.
(4) The matters of concern herein are longstanding and despite proposed future action the concerns remain.
” Open source report
Concerns raised 3 Failure to audit compliance with and effectiveness of introduced changes View source Delays in implementing new Standard Operating Procedures View source Failure to ensure staff acknowledgement and adoption of new safe working practices View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Trevor Reynolds · 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
Trevor Reynolds died at Glan Clwyd Hospital on 15 May 2021 after a CT scan identified a pulmonary clot that was not acted upon until 10 May, despite the result requiring immediate attention. The inquest found concerns about delays in implementing revised working practices, obtaining staff acknowledgement of the new procedure, and auditing compliance, allowing known risks to patients to continue.
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 audit compliance with and effectiveness of introduced changes
Wider context from the report “1. Although it was identified quickly that existing working practices (whereby an irregular scan report had been placed on the desk of a clinician by a secretary and due to the absence of the clinician this report had not been seen and acted upon in a timely manner), the health board did not fully implement a new Standard Operating Procedure, which was introduced to address this issue, until December 2021, seven months after the death of Mr Reynolds.
2. Furthermore an acknowledgement of the existence of the new SOP by Oncology and Haematology Secretaries was not completed until the 22nd of February 2022.
3. Finally at the time of the inquest, eleven days prior to the anniversary of Mr Reynolds’ death the health board had not completed an audit process to ensure that the changes which had been introduced were being complied with and were therefore effective .
4. I am concerned that the length of time which it takes to implement changes and to ensure that new safe working practices are introduced and adopted by staff, results in the health board allowing known risks to patients to continue and therefore presents a risk to life.
” 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 implementing new Standard Operating Procedures
Wider context from the report “1. Although it was identified quickly that existing working practices (whereby an irregular scan report had been placed on the desk of a clinician by a secretary and due to the absence of the clinician this report had not been seen and acted upon in a timely manner), the health board did not fully implement a new Standard Operating Procedure, which was introduced to address this issue, until December 2021, seven months after the death of Mr Reynolds .
2. Furthermore an acknowledgement of the existence of the new SOP by Oncology and Haematology Secretaries was not completed until the 22nd of February 2022.
3. Finally at the time of the inquest, eleven days prior to the anniversary of Mr Reynolds’ death the health board had not completed an audit process to ensure that the changes which had been introduced were being complied with and were therefore effective.
4. I am concerned that the length of time which it takes to implement changes and to ensure that new safe working practices are introduced and adopted by staff, results in the health board allowing known risks to patients to continue and therefore presents a risk to life.
” 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 acknowledgement and adoption of new safe working practices
Wider context from the report “1. Although it was identified quickly that existing working practices (whereby an irregular scan report had been placed on the desk of a clinician by a secretary and due to the absence of the clinician this report had not been seen and acted upon in a timely manner), the health board did not fully implement a new Standard Operating Procedure, which was introduced to address this issue, until December 2021, seven months after the death of Mr Reynolds.
2. Furthermore an acknowledgement of the existence of the new SOP by Oncology and Haematology Secretaries was not completed until the 22nd of February 2022 .
3. Finally at the time of the inquest, eleven days prior to the anniversary of Mr Reynolds’ death the health board had not completed an audit process to ensure that the changes which had been introduced were being complied with and were therefore effective.
4. I am concerned that the length of time which it takes to implement changes and to ensure that new safe working practices are introduced and adopted by staff , results in the health board allowing known risks to patients to continue and therefore presents a risk to life.
” 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 Roll out the newly procured electronic audit system to improve audit completion and assurance reporting.
Verbatim wording from the response “Additionally, we are currently in the process of reviewing our approach to clinical audit. We will closer align our audit programme with the risks that we have identified through issues such as serious incident reporting and inquest matters. We have also recently procured a new electronic audit system and we are in the process of rolling this out. This system will improve the digital completion of audits and the reporting of assurances.” 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 Embed the urgent radiology-results escalation procedure through staff induction, meeting agendas, training, audit and regular review.
Verbatim wording from the response “Within the Cancer Division, all clinicians and secretaries in oncology and haematology have been made aware of the Standard Operating Procedure (SOP) for the Escalation of Urgent Radiology Results Containing Unexpected Findings. The SOP has been added to the Induction Checklist for all new starters who commence within the Cancer Division and it has been added as a regular agenda item on all secretarial meetings. The learning from this matter has been shared with other health board 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 Review the clinical-audit approach and align the audit programme with identified risks, including serious incidents and inquest matters.
Verbatim wording from the response “Additionally, we are currently in the process of reviewing our approach to clinical audit. We will closer align our audit programme with the risks that we have identified through issues such as serious incident reporting and inquest matters. We have also recently procured a new electronic audit system and we are in the process of rolling this out. This system will improve the digital completion of audits and the reporting of assurances.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 3 Absence of proper medication scrutiny or review during each care home visit View source Failure of ANPs to consider patients’ medication regimes during visits View source Failure to access medication charts routinely View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nora Jane Foulkes · 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
Nora Jane Foulkes, an 87-year-old resident of a residential home, was admitted to hospital on 11 April 2021 and died on 16 April 2021. Her untreated hypothyroidism was contributory to her death, which was due to cardiorespiratory failure resulting from bronchopneumonia and an existing cardiac condition. Concerns included the failure to restart and subsequently monitor her hypothyroidism treatment, and the lack of routine medication review during ANP visits because of time constraints.
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 Absence of proper medication scrutiny or review during each care home visit
Wider context from the report “3. I am concerned that the absence of proper scrutiny or review of the medication of elderly patients in care homes during each visit presents a risk to life as it can lead to the type of error which occurred in this case not being identified .
” 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 ANPs to consider patients’ medication regimes during visits
Wider context from the report “1. Although the original failure to restart the deceased’s treatment for her hypothyroidism would appear to have been discussed and agreed between the Advance Nurse Practitioners and the care home when a medication review was conducted, the deceased was subsequently seen by ANPs on six more occasions between then and her subsequent admission to hospital and as a result there were multiple opportunities for this error to be spotted and corrected but this did not happen because at those visits there was no consideration being given by the ANPs to the patient’s medication regime to ensure that appropriate treatment was being provided .
” 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 access medication charts routinely
Wider context from the report “2. Whilst ANPs could access medication charts if required, this was not being done routinely , principally by virtue of time restraint issues .
” 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 or adapt district nursing standard operating procedures and checklists to assure medication reviews.
Verbatim wording from the response “Following this survey, all district nursing teams will develop (or review and adapt) a Standard Operating Procedure/checklist to meet the needs of their own services that provides assurance of medication reviews. This will be completed by 31 December 2022. We will discuss with our Clinical Effectiveness Team how this can be audited over a longer period of time, to ensure that we have ongoing assurance that the changes have been embedded and sustained.” 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 Survey all district nursing teams to assess compliance with consistent medication-review practice.
Verbatim wording from the response “The learning from this matter, including the medication review issues identified above, will be checked across all district nursing teams to ensure consistent practice across the Health Board. We will survey all teams to assess their level of compliance. This will be completed by 30 June 2022.” 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 Disseminate the internal investigation’s lessons to all district nursing teams.
Verbatim wording from the response “Due to the incident not being reported at the time, a formal review was not undertaken or reviewed by the Health Board’s Incident Learning Panel. We will conduct a formal internal investigation to identify root causes and lessons learned. Which will be disseminated to all district nursing teams. This will be completed by 30 June 2022.” 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 a proposal for structured medication-review collaboration between Central Community Pharmacy and the Central Community Resource Team.
Verbatim wording from the response “• A proposal has been developed (currently under review) for the Central Community Pharmacy team to work more collaboratively with the Central (Area) Community Resource Team (CRT) which will include regular structured medication reviews for nursing and residential home patients.” 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 Discuss with the Clinical Effectiveness Team how to audit medication-review changes over the longer term.
Verbatim wording from the response “Following this survey, all district nursing teams will develop (or review and adapt) a Standard Operating Procedure/checklist to meet the needs of their own services that provides assurance of medication reviews. This will be completed by 31 December 2022. We will discuss with our Clinical Effectiveness Team how this can be audited over a longer period of time, to ensure that we have ongoing assurance that the changes have been embedded and sustained.” 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 best-practice guidance for Advanced Nurse Practitioners.
Verbatim wording from the response “The best practice guidance is under review for Advanced Nurse Practitioners (ANP) and a regular quality improvement meeting for Independent Nurse Prescribing, chaired on a Health Board wide level by the Deputy Executive Director of Nursing, is held where learning is disseminated on a monthly basis. We expect the review to be completed by 30 September 2022 and the learning and any changes to practice as a consequence will be disseminated through this meeting structure and agenda.” 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 and document medication reviews at every local district nursing visit using a checklist countersigned by the care home.
Verbatim wording from the response “Concern was also noted that whilst ANPs could access medication charts if required, this was not being done routinely. I can advise changes have been made to the way the local District Nursing team in the Ruthin and Conwy locality work, which incorporates a documented medication review at each visit. A check list has been developed to prompt clinical staff to review key criteria at each visit, including medication changes/administration. The checklist is initiated by both the visiting nurse and the home manager/deputy. The checklist forms part of the patient’s individual nursing record for review and auditing.” 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 a formal internal investigation to identify root causes and lessons learned.
Verbatim wording from the response “Due to the incident not being reported at the time, a formal review was not undertaken or reviewed by the Health Board’s Incident Learning Panel. We will conduct a formal internal investigation to identify root causes and lessons learned. Which will be disseminated to all district nursing teams. This will be completed by 30 June 2022.” Source location Response from BCUHB
Open published response
Concerns raised 1 Failure to complete actions and recommendations within set timeframes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Susan Merton · 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
Susan Merton underwent a CT scan whose report did not identify a common bile duct stone. After the stone was recognised and treatment was scheduled, her condition deteriorated acutely and she died at Glan Clwyd Hospital on 23 August 2019. The report raised concerns that the Health Board had not implemented or reviewed actions from its investigation within its own timeframe, potentially putting lives at risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to complete actions and recommendations within set timeframes
Wider context from the report “1. Evidence provided to me in the course of the investigation indicated that the Health Board had conducted an investigation and had produced an Action Plan in light of the findings of their investigation. The Action Plan required that the recommendations contained therein be reviewed in a Clinical Governance Meeting on the 5th of August 2021 however for reasons which could not be explained at the inquest, this was not done.
2. On previous occasions I have issued regulation 28 reports expressing concerns that the Health Board continually fail to accomplish actions in circumstances where they have set their own timeframe .
3. I am concerned that as a result of the Health Board failing to follow through with their own actions and recommendations either in a timely manner or in this specific case at all , lives are being put at risk.
” 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 Require serious incident investigation reports to undergo Incident Learning Panel scrutiny and approval, with an action plan on the required template.
Verbatim wording from the response “As outlined in my response to the Regulation 28 regarding Mr Hurst, we changed our serious incident process in April 2021. From this date all investigation reports are submitted for scrutiny and approval at an Incident Learning Panel. This new step in the process adds an organisational level of scrutiny on all investigations completed by our clinical divisions and we have seen an improvement in the quality of reports and action plans as a result. A report without an action plan would not be accepted. I am very disappointed that our service did not complete an action plan when they should have done, nor was it completed on the right template when it was. Our new process ensures this cannot happen.” Source location 2021-0375-Response-from-BCUHB_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Track investigation actions in the Datix patient safety system and audit completion timeframes and supporting evidence.
Verbatim wording from the response “We are also now tracking actions from these investigation reports and action plans through our Datix patient safety system and auditing compliance with action completion timeframes and evidence.” Source location 2021-0375-Response-from-BCUHB_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint a clinician to review historic action plans and verify action completion and available evidence.
Verbatim wording from the response “This new process covers incidents from April 2021 onwards. We recognise the case of Ms Merton, and Mr Hurst, occurred prior to this, so we have appointed a clinician to undertake a review of historic action plans to ensure actions are completed and evidence is available. This person commenced in post in November 2021, however they have been redeployed to front line services as a result of the current COVID wave, and we hope they will be available to return back to this important work during January 2022. This work will continue until we are assured of prior action plan completion.” Source location 2021-0375-Response-from-BCUHB_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing historic action plans until prior actions are confirmed complete.
Verbatim wording from the response “This new process covers incidents from April 2021 onwards. We recognise the case of Ms Merton, and Mr Hurst, occurred prior to this, so we have appointed a clinician to undertake a review of historic action plans to ensure actions are completed and evidence is available. This person commenced in post in November 2021, however they have been redeployed to front line services as a result of the current COVID wave, and we hope they will be available to return back to this important work during January 2022. This work will continue until we are assured of prior action plan completion.” Source location 2021-0375-Response-from-BCUHB_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Historic action-plan review was temporarily interrupted because the appointed clinician was redeployed to frontline services during the COVID wave.
Verbatim wording from the response “This new process covers incidents from April 2021 onwards. We recognise the case of Ms Merton, and Mr Hurst, occurred prior to this, so we have appointed a clinician to undertake a review of historic action plans to ensure actions are completed and evidence is available. This person commenced in post in November 2021, however they have been redeployed to front line services as a result of the current COVID wave, and we hope they will be available to return back to this important work during January 2022. This work will continue until we are assured of prior action plan completion.” Source location 2021-0375-Response-from-BCUHB_Published
Open published response
Concerns raised 3 Delays in achieving safety changes within self-set timeframes View source Failure to adopt accelerated N-acetylcysteine administration into a standard operating protocol View source Failure to implement procedures mitigating risks from failure to act on diagnostic results within the stated timeframe View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kyle Nicholas James Hurst · 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
Kyle Nicholas James Hurst was admitted to Glan Clwyd Hospital on 24 January 2021 after taking an undisclosed quantity of a substance and died there later the same day despite treatment. Concerns included the lack of an adopted protocol for accelerated administration of N-Acetylcysteine and delays in implementing procedures intended to mitigate risks from failures to act on diagnostic 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 Delays in achieving safety changes within self-set timeframes
Wider context from the report “3. I am concerned that the Health Board continue to fail to achieve changes in a timely manner , even in circumstances where they have set their own timeframe and that as a result of this lives are being put 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 adopt accelerated N-acetylcysteine administration into a standard operating protocol
Wider context from the report “1. Evidence given at the inquest by the ED Consultant indicated that it has been recognised that the accelerated administration of N-Acetylcysteine may be beneficial in the treatment of a ████████ but this has not yet been adopted into a Standard Operating Protocol despite this having been proposed in August 2021
” 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 procedures mitigating risks from failure to act on diagnostic results within the stated timeframe
Wider context from the report “2. Following the issue of a regulation 28 report on the 14th of July 2021 in connection with the inquest touching upon the death of Rhian Roberts in similar circumstances, the response from BCUHB indicated by way of a letter dated the 7th of September 2021 that procedures to mitigate risks due to failure to act on diagnostic results would be approved and active by the 1st of October 2021 , however at the time of concluding the inquest of Kyle Hurst on the 22nd of October, this had not been accomplished .
” 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 Track serious incident investigation actions in the Datix patient safety system and audit completion timeframes and supporting evidence.
Verbatim wording from the response “In April 2021 we changed our serious incident process and this included all investigation reports going for scrutiny and approval at an Incident Learning Panel. This new step in the process adds an organisational level of scrutiny on all investigations completed by our clinical divisions and we have seen an improvement in the quality of reports and action plans as a result. We are also now tracking actions from these investigation reports through our Datix patient safety system and auditing compliance with action completion timeframes and evidence.” Source location 2021-0359-Response-from-BCUHB_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review historic serious incident action plans and verify evidence for each action through an appointed clinician.
Verbatim wording from the response “This process covers incidents from April 2021 onwards, and so for incidents prior to this we have appointed a clinician to undertake a review of historic action plans to ensure evidence is available against each action. This person commenced in post in November, however they have been redeployed to front line services as a result of the current COVID wave, and we hope they will be available to return back to this important work during January 2022.” Source location 2021-0359-Response-from-BCUHB_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the ratified procedure defining staff roles and processes for communicating critical and unexpected pathology results.
Verbatim wording from the response “In relation to the procedures to mitigate the risk of not acting upon diagnostic results, we have developed a new Procedure for the Communication of Critical and Unexpected Pathology Results. This document sets out the roles and responsibilities of staff and the process to follow. This new procedure has been ratified.” Source location 2021-0359-Response-from-BCUHB_Published
Open published response
Concerns raised 5 Delays in sharing learning from adverse incidents View source Delays in investigating adverse incidents View source Delays in implementing actions following adverse incidents View source Failure to verify completion of requested toxicology screening or record why it was not undertaken View source Failure to approve the updated procedure for direct communication of life-threatening blood results View source See 2 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. 5
Action
Update, approve and activate the SOP for telephoning reports and life-threatening results, and discuss it in team briefings.
Stated completedThe respondent said that this action was complete when they made their response on 15 July 2021. View source
Action
Require timely completion and weekly governance tracking of investigations, with advance approval for extensions.
Stated completedThe respondent said that this action was complete when they made their response on 15 July 2021. View source
Action
Upload approved serious-incident actions to Datix, require completion evidence, measure timely closure and audit evidence quality.
Stated completedThe respondent said that this action was complete when they made their response on 15 July 2021. View source
Action
Develop and operate learning-sharing channels, including a portal, lessons-on-a-page, digital dissemination and monthly learning events.
Stated in progressThe respondent said that this action was in progress when they made their response on 15 July 2021. View source
Action
Operate a new serious-incident process with daily review, executive oversight, rapid learning escalation, appointed investigators and senior reviewers.
Stated in progressThe respondent said that this action was in progress when they made their response on 15 July 2021. View source See 2 more actions
×
AI-generated summary
Rhian Margaret 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
Rhian Margaret Roberts was admitted to hospital after being found unresponsive at home following a presumed overdose, with extremely high paracetamol levels identified on admission. ICU clinicians did not become aware of the results until the early hours of the following morning, and she died on 25 November 2020. Concerns included uncertainty about whether a requested toxicology screen was undertaken, delays in approving an updated procedure for communicating life-threatening blood results, and delays in investigating incidents, sharing learning and implementing actions.
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 sharing learning from adverse incidents
Wider context from the report “3. I am concerned that the continual delays in investigating adverse incidents, sharing learning and implementing actions following the same, create risks to patient safety.
” 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 investigating adverse incidents
Wider context from the report “3. I am concerned that the continual delays in investigating adverse incidents , sharing learning and implementing actions following the same, create risks to patient safety.
” 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 implementing actions following adverse incidents
Wider context from the report “3. I am concerned that the continual delays in investigating adverse incidents, sharing learning and implementing actions following the same , create risks to patient safety.
” 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 verify completion of requested toxicology screening or record why it was not undertaken
Wider context from the report “1. On arrival at ICU the clerking-in doctor requested a toxicology screen to include paracetamol and salicylate levels (notwithstanding that blood tests to include this were already in hand) and there was no evidence available at the inquest to establish whether or not the toxicology screen requested by the doctor was undertaken and if not why not .
” 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 approve the updated procedure for direct communication of life-threatening blood results
Wider context from the report “2. An internal investigation by the health board following Mrs Roberts’ death rightly established that action needed to be taken to update or modify the SOP for communicating of life-threatening blood results directly with clinical areas and an action plan indicated that this would be completed by the 30th of June 2021. At the time of the inquest on the 13th of July, the proposed update remained in draft form only and had not yet been approved .
” 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 Update, approve and activate the SOP for telephoning reports and life-threatening results, and discuss it in team briefings.
Verbatim wording from the response “The Standard Operating Procedure (SOP) for telephoning reports and results was updated, approved and active as of the 20th July 2021 and discussed in the team brief meeting.” Source location 2021-0242-Betsi-Cadwaladr-University-Health-Board_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require timely completion and weekly governance tracking of investigations, with advance approval for extensions.
Verbatim wording from the response “Depending on the complexity of the incident, investigations are required to be completed within 25 to 45 working days. Any extensions must be requested in advance from the Associate Director of Quality Assurance. The progress of the investigation is tracked via a weekly governance report that is scrutinised in directorate weekly governance meetings.” Source location 2021-0242-Betsi-Cadwaladr-University-Health-Board_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Upload approved serious-incident actions to Datix, require completion evidence, measure timely closure and audit evidence quality.
Verbatim wording from the response “All actions arising from a serious incident investigation will be uploaded to the Datix incident system on final approval of the investigation by the Corporate Patient Safety Team. Services will upload evidence of completion when closing actions. The timely closure of actions will become a performance measure and audits will take place of submitted evidence to ensure quality and learning.” Source location 2021-0242-Betsi-Cadwaladr-University-Health-Board_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and operate learning-sharing channels, including a portal, lessons-on-a-page, digital dissemination and monthly learning events.
Verbatim wording from the response “Finally, we are strengthening the sharing of learning by developing a learning portal, lessons on a page, digital sharing of learning and a monthly lessons learned event. To support the new processes, a comprehensive training passport is being finalised. This passport consists of modular courses to develop skills as an investigating officer or senior reviewer. A mentor scheme, drop in support sessions and an ongoing community of practice will also be launched. The application of human factors skills will be a key element of this training.” Source location 2021-0242-Betsi-Cadwaladr-University-Health-Board_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a new serious-incident process with daily review, executive oversight, rapid learning escalation, appointed investigators and senior reviewers.
Verbatim wording from the response “A new process to support the services to deliver timely investigations was commenced in April 2021. This process will improve performance and ensure investigations are robust, proportionate and timely.” Source location 2021-0242-Betsi-Cadwaladr-University-Health-Board_Published
Open published response
Concerns raised 2 Failure to make every possible effort to contact people under mental health care after credible indications of an immediate risk of harm View source Inadequate arrangements to protect people under mental health care after indications of an immediate risk of harm View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Develop a social work checklist guiding risk assessment, escalation, communication, recording and crisis planning for mental health and duty cases.
Stated completedThe respondent said that this action was complete when they made their response on 14 April 2021. View source
Action
Disseminate the checklist and safety-huddle procedures to Community Mental Health Team social work staff.
Stated completedThe respondent said that this action was complete when they made their response on 14 April 2021. View source
Action
Develop Local Authority mental health, escalation, risk-management, pathway, and reporting and recording policies and procedures, including crisis planning.
Stated plannedThe respondent said that this action was planned when they made their response on 14 April 2021. View source
Action
Implement an additional 4:30pm safety huddle to review heightened risks, minute actions, coordinate out-of-hours mitigation and escalate unresolved risks.
Stated completedThe respondent said that this action was complete when they made their response on 14 April 2021. View source See 1 more action
×
AI-generated summary
Hannah Elizabeth Browning · 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
Hannah Elizabeth Browning, who was receiving treatment for mental health issues and had a history of self-harm and suicidal thoughts, expressed an intention to end her life on 10 October 2018. She subsequently placed a ligature around her neck and sustained a hypoxic brain injury, dying at Wrexham Maelor Hospital on 12 October 2018. The principal concern was that inadequate arrangements and insufficient efforts were made by Mental Health Services to protect her and contact her after she indicated an immediate risk of harm.
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 make every possible effort to contact people under mental health care after credible indications of an immediate risk of harm
Wider context from the report “That despite giving an indication of an immediate and fixed plan to harm herself, which she then acted upon, the Mental Health Services made inadequate arrangements to protect her and made no attempt to contact her to either seek to ensure her safety or to advise her of the intention to review her case at an MDT five days later and to reinforce the interim options available to her in crisis .
Despite hearing evidence at the inquest of the steps taken by BCUHB and WCBC (who act in partnership for the provision of Mental Health Services) to improve the service, I was not provided with any assurances as to measures which had or could be taken to ensure that every possible effort is made to contact a person under their care, who has communicated a credible indication of an immediate risk of harm to themselves.
” 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 arrangements to protect people under mental health care after indications of an immediate risk of harm
Wider context from the report “That despite giving an indication of an immediate and fixed plan to harm herself, which she then acted upon, the Mental Health Services made inadequate arrangements to protect her and made no attempt to contact her to either seek to ensure her safety or to advise her of the intention to review her case at an MDT five days later and to reinforce the interim options available to her in crisis.
Despite hearing evidence at the inquest of the steps taken by BCUHB and WCBC (who act in partnership for the provision of Mental Health Services) to improve the service, I was not provided with any assurances as to measures which had or could be taken to ensure that every possible effort is made to contact a person under their care, who has communicated a credible indication of an immediate risk of harm to themselves.
” 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 a social work checklist guiding risk assessment, escalation, communication, recording and crisis planning for mental health and duty cases.
Verbatim wording from the response “Actions to Date – development of a checklist. (Please see Checklist attached as Appendix 1)” Source location 2021-0106-Response-from-Wrexham-County-Borough-Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the checklist and safety-huddle procedures to Community Mental Health Team social work staff.
Verbatim wording from the response “All of the above actions have been shared with the Community Mental Health Team Social work team manager who has disseminated these to all social work staff within the team. In addition to the above actions the below actions are planned over the time period identified below.” Source location 2021-0106-Response-from-Wrexham-County-Borough-Council
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 Local Authority mental health, escalation, risk-management, pathway, and reporting and recording policies and procedures, including crisis planning.
Verbatim wording from the response “Actions Planned for development over the next 6-9 months include:” Source location 2021-0106-Response-from-Wrexham-County-Borough-Council
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 an additional 4:30pm safety huddle to review heightened risks, minute actions, coordinate out-of-hours mitigation and escalate unresolved risks.
Verbatim wording from the response “4. BCUHB implementation of an additional Safety huddle. A morning safety huddle is already in place, BCUHB have developed a further safety huddle at the end of each day (4.30pm) which::” Source location 2021-0106-Response-from-Wrexham-County-Borough-Council
Open published response
Concerns raised 2 Reluctance to supplement locum references with telephone calls to referees View source Lack of a recognised protocol for observing and assessing locum staff in practice View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Implement the locum staff local-induction requirement, including role expectations, limitations and supervised-practice arrangements.
Stated completedThe respondent said that this action was complete when they made their response on 18 March 2020. View source
Action
Report compliance and remedial action for locum induction and assessment requirements through the monthly Medical Agency Locum Report.
Stated plannedThe respondent said that this action was planned when they made their response on 18 March 2020. View source
Action
Require Clinical Directors to provide interim verbal or email confirmation that supervised locum individuals are competent.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 March 2020. View source
Action
Audit compliance with locum induction and practice-assessment requirements across post-SOP appointments.
Stated completedThe respondent said that this action was complete when they made their response on 18 March 2020. View source
Action
Obtain completed practice-assessment forms for the remaining locum individuals.
Stated plannedThe respondent said that this action was planned when they made their response on 18 March 2020. View source
Action
Implement the locum staff assessment-of-practice and performance requirement covering clinical skills, knowledge, attitudes, relationships and integrity.
Stated completedThe respondent said that this action was complete when they made their response on 18 March 2020. View source
Action
Establish central collection and follow-up of locum induction and practice-assessment forms through the amended SOP.
Stated plannedThe respondent said that this action was planned when they made their response on 18 March 2020. View source
Action
Obtain capability and performance assurance for the 12 locum individuals remaining in the Health Board.
Stated completedThe respondent said that this action was complete when they made their response on 18 March 2020. View source
Action
Require locum practice-assessment forms by the tenth day of placement, signed by the Clinical Director and submitted to the Medical Bank Service.
Stated plannedThe respondent said that this action was planned when they made their response on 18 March 2020. View source
Action
Develop a revised reference-validation process covering referee screening, pre-interview checks, recorded clarifications and additional competence or performance validation.
Stated completedThe respondent said that this action was complete when they made their response on 18 March 2020. View source See 7 more actions
×
AI-generated summary
Arthur Price Hughes · 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
Arthur Price Hughes underwent emergency surgery on 20 October 2014, during which significant bleeding occurred; despite further surgical interventions, the injury sustained resulted in his subsequent death. The report raised concerns about the lack of a recognised protocol for observing, assessing and mentoring newly appointed locum staff, and about reluctance to supplement references with telephone calls to referees.
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 Reluctance to supplement locum references with telephone calls to referees
Wider context from the report “2. Whilst it would appear that the process by which the taking up of references has improved significantly for the appointment of locums since 2014, evidence provided at the inquest appears to indicate that there is a marked reluctance at a managerial level for references to be supplemented by telephone calls to the referees .
” 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 recognised protocol for observing and assessing locum staff in practice
Wider context from the report “1. The appointment of locum staff is a necessary requirement within the Health Board to provide continuity of service and the recruitment process in relation to locums ensures that they have the appropriate qualifications to undertake the roles for which they are appointed. However, there does not appear to a recognised protocol or policy by which their work is initially observed, assessed or evaluated in practice , with the result that locum staff could be required to undertake tasks or roles which are at the limit or beyond their capabilities thus creating a risk to patients which may include a risk to life. A more rigid or defined approach to observing and assessing (and where necessary mentoring) new recruits to ensure that their skills and working practices match their apparent qualifications could be beneficial in ensuring a quality of service.
” 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 Implement the locum staff local-induction requirement, including role expectations, limitations and supervised-practice arrangements.
Verbatim wording from the response “A Standard Operating Procedure (SOP) had been revised and implemented previously as reported during the inquest. The SOP required clinical departments to undertake the following for all locum appointments (both fixed term contracts and agency locums).” Source location 2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Report compliance and remedial action for locum induction and assessment requirements through the monthly Medical Agency Locum Report.
Verbatim wording from the response “vi. Compliance and action taken to remedy non-compliance with both requirements included in the monthly Medical Agency Locum Report to the Executive Director of Workforce and Organisational Development and Board Committee – original due date 28 April 2020.” Source location 2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require Clinical Directors to provide interim verbal or email confirmation that supervised locum individuals are competent.
Verbatim wording from the response “In the intervening period, Clinical Directors are required to provide verbal/email confirmation that individuals working under their supervision (accountability) are competent to do so.” Source location 2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with locum induction and practice-assessment requirements across post-SOP appointments.
Verbatim wording from the response “An audit of compliance had been undertaken in relation to the two requirements above against appointments (18 placements) made following revision of the SOP in 2019.” Source location 2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain completed practice-assessment forms for the remaining locum individuals.
Verbatim wording from the response “ii. In addition to the immediate assurance, Clinical Directors were asked to provide completed assessment forms for each of the individuals – original due date 31 March 2020;” Source location 2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the locum staff assessment-of-practice and performance requirement covering clinical skills, knowledge, attitudes, relationships and integrity.
Verbatim wording from the response “A Standard Operating Procedure (SOP) had been revised and implemented previously as reported during the inquest. The SOP required clinical departments to undertake the following for all locum appointments (both fixed term contracts and agency locums).” Source location 2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish central collection and follow-up of locum induction and practice-assessment forms through the amended SOP.
Verbatim wording from the response “iii. The Standard Operating Procedure (SOP) has been amended to ensure central collection and follow up of both Local Induction and Assessment of Practice and Performance pro forma – due to be implemented 01 April 2020;” Source location 2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain capability and performance assurance for the 12 locum individuals remaining in the Health Board.
Verbatim wording from the response “Action taken to date:” Source location 2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require locum practice-assessment forms by the tenth day of placement, signed by the Clinical Director and submitted to the Medical Bank Service.
Verbatim wording from the response “v. Assessment of Practice and Performance pro forma required by the tenth day of placement, signed by the Clinical Director and submitted to the Medical Bank Service – original due date 10 April 2020;” Source location 2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a revised reference-validation process covering referee screening, pre-interview checks, recorded clarifications and additional competence or performance validation.
Verbatim wording from the response “Action taken to date:” Source location 2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
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 COVID-19 major incident response delayed approval and implementation of the revised reference-validation process until June 2020.
Verbatim wording from the response “The additional elements of this process were due to be reviewed, approved and implemented from 01 April. However, this has been delayed due to the activation of the Major Incident Response to COVID-19.” Source location 2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
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 COVID-19 major incident response delayed implementation of central locum induction and assessment documentation requirements until revised dates.
Verbatim wording from the response “iii. The Standard Operating Procedure (SOP) has been amended to ensure central collection and follow up of both Local Induction and Assessment of Practice and Performance pro forma – due to be implemented 01 April 2020;” Source location 2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Open published response
Concerns raised 3 Failure to eliminate factors causing delays in hospital admission and treatment View source Failure to provide timely ambulance handover and admission View source Unavailability of ambulances for allocation to other calls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Peter Andrew Connelly · 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
Peter Andrew Connelly was transferred to hospital on 19 February 2018, waited several hours for admission and medical examination, was diagnosed with acute pancreatitis, and died on 20 February 2018. The principal concern was continuing extreme pressure and delays in emergency department admission and treatment, which the report stated could place patients’ lives at risk and lead to preventable deaths; the delay was accepted not to have caused or contributed to Mr Connelly’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 Failure to eliminate factors causing delays in hospital admission and treatment
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”.
In the intervening period from then until the present either I or my Assistant Coroners have issued at least twelve similar regulation 28 reports expressing concerns associated with unacceptable delays and yet despite being given assurances in the responses to the same by BCUHB and WAST (and other organisations) that action is being taken to reduce such delays, the situation continues to prevail.
As has been stated previously in my other reports, I recognise that the issues which cause these difficulties are multifactorial, however unless services and resources are made available or working practices altered to facilitate change then it is inevitable that future deaths will occur which might have otherwise been preventable. Patients’ lives are being placed at risk and this is wholly unacceptable.”
Notwithstanding the fact that Mr Connelly’s death preceded the said February 2019 report and that there has been a reduction in the number of hours which ambulances were kept waiting outside ED since his death, the evidence which I heard at his inquest informed me that the ED at the Maelor Hospital, Wrexham continues to operate under extreme pressures and at an average scale of escalation (namely 3.1) which I consider is a clear indication that the various factors which cause delays in admission to hospital, have not been eliminated . Consequently it remains the case that delays in treatment may occur along with deaths which should be preventable by timely medical intervention.
” 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 timely ambulance handover and admission
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”.
In the intervening period from then until the present either I or my Assistant Coroners have issued at least twelve similar regulation 28 reports expressing concerns associated with unacceptable delays and yet despite being given assurances in the responses to the same by BCUHB and WAST (and other organisations) that action is being taken to reduce such delays, the situation continues to prevail .
As has been stated previously in my other reports, I recognise that the issues which cause these difficulties are multifactorial, however unless services and resources are made available or working practices altered to facilitate change then it is inevitable that future deaths will occur which might have otherwise been preventable. Patients’ lives are being placed at risk and this is wholly unacceptable.”
Notwithstanding the fact that Mr Connelly’s death preceded the said February 2019 report and that there has been a reduction in the number of hours which ambulances were kept waiting outside ED since his death, the evidence which I heard at his inquest informed me that the ED at the Maelor Hospital, Wrexham continues to operate under extreme pressures and at an average scale of escalation (namely 3.1) which I consider is a clear indication that the various factors which cause delays in admission to hospital, have not been eliminated. Consequently it remains the case that delays in treatment may occur along with deaths which should be preventable by timely medical intervention.
” 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 ambulances for allocation to other calls
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls ”.
In the intervening period from then until the present either I or my Assistant Coroners have issued at least twelve similar regulation 28 reports expressing concerns associated with unacceptable delays and yet despite being given assurances in the responses to the same by BCUHB and WAST (and other organisations) that action is being taken to reduce such delays, the situation continues to prevail.
As has been stated previously in my other reports, I recognise that the issues which cause these difficulties are multifactorial, however unless services and resources are made available or working practices altered to facilitate change then it is inevitable that future deaths will occur which might have otherwise been preventable. Patients’ lives are being placed at risk and this is wholly unacceptable.”
Notwithstanding the fact that Mr Connelly’s death preceded the said February 2019 report and that there has been a reduction in the number of hours which ambulances were kept waiting outside ED since his death, the evidence which I heard at his inquest informed me that the ED at the Maelor Hospital, Wrexham continues to operate under extreme pressures and at an average scale of escalation (namely 3.1) which I consider is a clear indication that the various factors which cause delays in admission to hospital, have not been eliminated. Consequently it remains the case that delays in treatment may occur along with deaths which should be preventable by timely medical intervention.
” Open source report
Concerns raised 1 Delays in handover of patients at emergency departments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Madeline Constance Staples · 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
Madeline Constance Staples, an 86-year-old woman, suffered an unwitnessed fall at her care home on 6 April 2018, sustaining fractures to both legs. Delays in obtaining ambulance assistance and transporting her to hospital meant she remained in pain for several hours. The report raised concerns about repeated unacceptable delays linked to emergency department handovers and unavailable ambulance resources, placing patients’ lives at risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in handover of patients at emergency departments
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”.
In the intervening period from then until the present either I or my Assistant Coroners have issued at least a further twelve similar regulation 28 reports expressing concerns associated with unacceptable delays and yet despite being given assurances in the responses to the same by BCUHB and WAS T (and other organisations) that action is being taken to reduce such delays, the situation continues to prevail .
As has been stated previously in my other reports, I recognise that the issues which cause these difficulties is multifactorial, however unless services and resources are made available or working practices altered to facilitate change then it is inevitable that future deaths will occur which might have otherwise been preventable. Patients' lives are being placed at risk and this is wholly unacceptable.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations