Concerns raised 4 Failure to provide timely admission to the emergency department View source Failure of patient flow processes View source Unavailability of required resources View source Delays in ambulance response or transfer 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
Gladys May Williams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Gladys May Williams fell at her care home on 6 March 2018, was discharged from hospital, deteriorated, and experienced delays in ambulance response and handover on 7 March. The report raises continuing concerns about ambulance delays, emergency department admission, resource availability and patient flow, stating that patients’ lives may be 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 provide timely admission to the emergency department
Wider context from the report “The issues of ambulance delays/admission to ED /availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems appear to be continuing notwithstanding the various measures which I am informed have been and are continuing to be put in place by WAST and BCUHB to mitigate such problems and I continue to believe and be extremely concerned that patients’ lives are being placed at risk as a result. Whilst it no longer appears to be the case that problems of this nature can be attributed to “winter pressures” it is nonetheless of grave concern that we are approaching another winter period without any clear indication that progress is being made to improve upon the previous position.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of patient flow processes
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems appear to be continuing notwithstanding the various measures which I am informed have been and are continuing to be put in place by WAST and BCUHB to mitigate such problems and I continue to believe and be extremely concerned that patients’ lives are being placed at risk as a result. Whilst it no longer appears to be the case that problems of this nature can be attributed to “winter pressures” it is nonetheless of grave concern that we are approaching another winter period without any clear indication that progress is being made to improve upon the previous position.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Unavailability of required resources
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources /patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems appear to be continuing notwithstanding the various measures which I am informed have been and are continuing to be put in place by WAST and BCUHB to mitigate such problems and I continue to believe and be extremely concerned that patients’ lives are being placed at risk as a result. Whilst it no longer appears to be the case that problems of this nature can be attributed to “winter pressures” it is nonetheless of grave concern that we are approaching another winter period without any clear indication that progress is being made to improve upon the previous position.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance response or transfer
Wider context from the report “The issues of ambulance delays /admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems appear to be continuing notwithstanding the various measures which I am informed have been and are continuing to be put in place by WAST and BCUHB to mitigate such problems and I continue to believe and be extremely concerned that patients’ lives are being placed at risk as a result. Whilst it no longer appears to be the case that problems of this nature can be attributed to “winter pressures” it is nonetheless of grave concern that we are approaching another winter period without any clear indication that progress is being made to improve upon the previous position.
” Open source report
Concerns raised 4 Delays in ambulance response View source Lack of availability of resources View source Failures in patient flow View source Failures in admission to the emergency department 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
Margaret Megan 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
Margaret Megan Evans fell outside her home on 22 January 2018 and sustained a fractured hip. Delays in ambulance attendance, admission to the emergency department and being seen by an ED doctor left her lying on a concrete path for more than three hours and delayed medical assessment; the report states that it cannot be said these delays contributed to her death, which was recorded as accidental with hospital-acquired pneumonia and a fractured neck of femur.
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
Wider context from the report “The issues of ambulance delays /admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of availability of resources
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources /patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failures in patient flow
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failures in admission to the emergency department
Wider context from the report “The issues of ambulance delays/admission to ED /availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result .
” Open source report
Concerns raised 3 Delays in formulating action plans after serious incident investigations and reviews View source Failure to implement action plans within agreed timescales View source Delays in concluding serious incident investigations and reviews View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Neville Welton · 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
Neville Welton attended Wrexham Maelor Hospital on the evening of 12 December 2017 after referral by his GP. Delays in assessment and treatment, associated with capacity and patient flow problems, staffing issues, and administrative and escalation failures, were followed by deterioration and his death in the early hours of the next morning. Concerns included the delay in completing the Health Board’s investigation and action plan, missed implementation timescales, and wider delays in completing serious incident reviews and action plans.
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 formulating action plans after serious incident investigations and reviews
Wider context from the report “The various factors referred to in paragraph 4 will be further considered at the inquest hearing, however I am concerned firstly by the length of time taken by the Health Board to conclude its Confidential Investigation and to formulate an Action Plan as this was not completed until the 27th of April 2018, some four and a half months after Mr Welton’s death.
I am further concerned that notwithstanding that an Action Plan had been established with agreed timescales for implementation of actions, these timescales have not been met and matters remain outstanding at the present time.
Whilst this investigation and report relates to the death of Mr Welton, I am concerned generally by the length of time which is taken by the Health Board to conclude its Serious Incident Reviews and thereafter to formulate and implement Action Plans .
” 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 action plans within agreed timescales
Wider context from the report “The various factors referred to in paragraph 4 will be further considered at the inquest hearing, however I am concerned firstly by the length of time taken by the Health Board to conclude its Confidential Investigation and to formulate an Action Plan as this was not completed until the 27th of April 2018, some four and a half months after Mr Welton’s death.
I am further concerned that notwithstanding that an Action Plan had been established with agreed timescales for implementation of actions, these timescales have not been met and matters remain outstanding at the present time .
Whilst this investigation and report relates to the death of Mr Welton, I am concerned generally by the length of time which is taken by the Health Board to conclude its Serious Incident Reviews and thereafter to formulate and implement Action Plans .
” 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 concluding serious incident investigations and reviews
Wider context from the report “The various factors referred to in paragraph 4 will be further considered at the inquest hearing, however I am concerned firstly by the length of time taken by the Health Board to conclude its Confidential Investigation and to formulate an Action Plan as this was not completed until the 27th of April 2018, some four and a half months after Mr Welton’s death.
I am further concerned that notwithstanding that an Action Plan had been established with agreed timescales for implementation of actions, these timescales have not been met and matters remain outstanding at the present time.
Whilst this investigation and report relates to the death of Mr Welton, I am concerned generally by the length of time which is taken by the Health Board to conclude its Serious Incident Reviews and thereafter to formulate and implement Action Plans.
” 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 a project-management approach for comprehensive investigations, including completion milestones agreed with the designated Chair.
Verbatim wording from the response “3. A project management approach to be used when conducting a comprehensive investigation with milestones for completion signed up to by the designated Chair (see appendix 2). This approach is not yet in place and will be implemented as part of the revised model described above.” Source location 2018-0150-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a weekly Incident Review Meeting to review recent incidents, monitor delayed investigations, and drive investigations and action plans to completion.
Verbatim wording from the response “2. The Health Board is to introduce a weekly Incident Review Meeting (Scoping document Appendix 1) to review on a regular basis all incidents reported on Datix in the previous 7 days. The meeting will be chaired by the Associate Director of Quality Assurance and attended by the senior staff with a specific responsibility for quality and patient safety from each division.” Source location 2018-0150-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the serious-incident investigation model, pairing Corporate Concerns Team staff with catastrophic-incident investigators and expanding staff training capacity.
Verbatim wording from the response “Moving forward
In terms of moving forward a number of actions are being implemented to improve the timeliness of our processes and the development of the action plans:” Source location 2018-0150-Response-by-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 Legal advice was required before the investigation report could be signed off, delaying completion.
Verbatim wording from the response “• Legal advice in relation to breach of duty, qualifying liability and causation was required and it was assessed that the report could not be signed off by the Chair until this was received.” Source location 2018-0150-Response-by-University-Health-Board
Open published response
Concerns raised 3 Lack of staff understanding and empathy regarding care and service delivery issues View source Inadequate CMHT staff training in risk assessment View source Inadequate CMHT staff training in escalation of concerns towards formal psychiatric assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel Watson · 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
Daniel Watson was found hanged at his home on 5 June 2017 and was verified dead from hanging. The report identified care and service delivery problems, missed opportunities to improve his mental health, and concerns about staff understanding of risk assessment and escalation towards formal psychiatric assessment.
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 staff understanding and empathy regarding care and service delivery issues
Wider context from the report “1. The Concerns Root Cause Analysis Investigation undertaken by BCUHB revealed a multitude of care and service delivery problems and contributory factors in relation to the care and treatment of the Deceased which cumulatively represented missed opportunities to improve his mental health and the evidence given at the inquest by the social worker and community psychiatric nurse demonstrated a complete lack of understanding and empathy in relation to these 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 Inadequate CMHT staff training in risk assessment
Wider context from the report “2. That there needs to be a significant improvement in the training of staff within the CMHT in relation to their understanding of risk assessment and potential escalation of concerns towards a formal psychiatric assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Inadequate CMHT staff training in escalation of concerns towards formal psychiatric assessment
Wider context from the report “2. That there needs to be a significant improvement in the training of staff within the CMHT in relation to their understanding of risk assessment and potential escalation of concerns towards a formal psychiatric assessment .
” 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 Deliver the confirmed 2018 WARRN training dates through specialised accredited trainers.
Verbatim wording from the response “In relation to your second area of concern relating to a significant improvement in the training of staff within the CMHT in relation to their understanding of risk assessment and potential escalation of concerns to a formal Psychiatric Assessment. The Wales Applied Risk Research Network (WARRN) Asking Difficult Questions and Formulating Risk (WARRN ADQ) is a National Programme of training, endorsed by Welsh Government, in the assessment, formulation and management of risk to self or others. One of the main aims of WARRN is to drive forward a standardised and consistent approach to risk assessment and formulation nationally, across services. The MHL Division will continue to make available the WARRN Accredited Programme for Care Coordinators and new training dates have been confirmed for 2018 to be delivered through our group of specialised trainers.” Source location 2017-0370-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and provide an action plan addressing identified service-delivery and care problems.
Verbatim wording from the response “In relation to your first matter of concern in that the Concerns Root Cause Analysis Investigation undertaken by BCUHB revealed a multitude of care and delivery problems which cumulatively represented missed opportunities to improve the Deceased’s mental health. As you are aware an action plan has been produced to improve on the service delivery and this has been provided to you. In relation to the evidence given at the Inquest by the Community Psychiatric Nurse (CPN), I can confirm that the CPN was provided with an initial debriefing session to reflect on the delivery of evidence provided at the Inquest. Further debriefing and on-going supervision will provide the opportunity for the CPN to optimise learning and provide a focus on their understanding and empathy for their continued professional development, which will be incorporated into their appraisal.” Source location 2017-0370-Response-by-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 initial debriefing and continue staff debriefing and supervision to support learning, empathy and professional development.
Verbatim wording from the response “In relation to your first matter of concern in that the Concerns Root Cause Analysis Investigation undertaken by BCUHB revealed a multitude of care and delivery problems which cumulatively represented missed opportunities to improve the Deceased’s mental health. As you are aware an action plan has been produced to improve on the service delivery and this has been provided to you. In relation to the evidence given at the Inquest by the Community Psychiatric Nurse (CPN), I can confirm that the CPN was provided with an initial debriefing session to reflect on the delivery of evidence provided at the Inquest. Further debriefing and on-going supervision will provide the opportunity for the CPN to optimise learning and provide a focus on their understanding and empathy for their continued professional development, which will be incorporated into their appraisal.” Source location 2017-0370-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue making the accredited WARRN risk-assessment programme available to care coordinators.
Verbatim wording from the response “In relation to your second area of concern relating to a significant improvement in the training of staff within the CMHT in relation to their understanding of risk assessment and potential escalation of concerns to a formal Psychiatric Assessment. The Wales Applied Risk Research Network (WARRN) Asking Difficult Questions and Formulating Risk (WARRN ADQ) is a National Programme of training, endorsed by Welsh Government, in the assessment, formulation and management of risk to self or others. One of the main aims of WARRN is to drive forward a standardised and consistent approach to risk assessment and formulation nationally, across services. The MHL Division will continue to make available the WARRN Accredited Programme for Care Coordinators and new training dates have been confirmed for 2018 to be delivered through our group of specialised trainers.” Source location 2017-0370-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a focused learning session for the wider team on empathy toward families and transparency at inquests.
Verbatim wording from the response “An initial focused session for the wider team’s learning will be held around awareness of empathy towards families and transparency to the Coroner at Inquest” Source location 2017-0370-Response-by-University-Health-Board
Open published response
Concerns raised 5 Failure to reliably identify matters requiring investigation View source Lack of defined and consistently applied criteria for identifying and acting on learning opportunities View source Lack of clarity about senior paediatric assessment requirements before discharge View source Failure to reliably select appropriate staff for investigations View source Failure to ensure timely learning and action from investigations 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
Kate Louise Pierce · 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
Kate Louise Pierce became unwell on 29 March 2006 and was discharged from hospital after being diagnosed with viral tonsillitis. She returned approximately 36 hours later in a deteriorated condition, was diagnosed with pneumococcal meningitis, and later died in Florida on 19 March 2013 after suffering brain damage and other health conditions. The principal concerns were uncertainty about when a sick child should receive senior paediatric assessment before discharge, and a lack of clearly defined and consistently applied processes for identifying and acting on learning opportunities after adverse events or re-presentation.
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 reliably identify matters requiring investigation
Wider context from the report “(2) I heard evidence at length from the Health Board’s current Clinical Lead for Paediatrics about (inter alia) the measures which are in place to ensure that lessons can be learnt (and acted upon) promptly when things do not go to plan. Specifically I heard about steps taken to learn lessons from situations in which a child might re-present in a worse condition following an earlier discharge – a situation which might result from a missed diagnosis. I did not emerge from this evidence with any confidence that there exist clearly defined and consistently applied criteria from ensuring that learning opportunities are being actively sought out and acted upon. For example, I was told that there is no defined list of triggers; with much left to judgement of individuals in the senior management team. This evidence, supplemented by the relevant contents of the letter of 4 October 2017, leaves me concerned that too much is left to chance in the identification of matters requiring investigation ; in the selection of staff and in the urgency of lessons being learnt and acted upon. The current system might therefore warrant a review (perhaps including consideration of best practice elsewhere, in other hospitals outside the Health Board) to see whether grounds for improvement exist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of defined and consistently applied criteria for identifying and acting on learning opportunities
Wider context from the report “(2) I heard evidence at length from the Health Board’s current Clinical Lead for Paediatrics about (inter alia) the measures which are in place to ensure that lessons can be learnt (and acted upon) promptly when things do not go to plan. Specifically I heard about steps taken to learn lessons from situations in which a child might re-present in a worse condition following an earlier discharge – a situation which might result from a missed diagnosis. I did not emerge from this evidence with any confidence that there exist clearly defined and consistently applied criteria from ensuring that learning opportunities are being actively sought out and acted upon . For example, I was told that there is no defined list of triggers ; with much left to judgement of individuals in the senior management team. This evidence, supplemented by the relevant contents of the letter of 4 October 2017, leaves me concerned that too much is left to chance in the identification of matters requiring investigation; in the selection of staff and in the urgency of lessons being learnt and acted upon. The current system might therefore warrant a review (perhaps including consideration of best practice elsewhere, in other hospitals outside the Health Board) to see whether grounds for improvement exist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about senior paediatric assessment requirements before discharge
Wider context from the report “(1) There remains uncertainty about the circumstances in which a sick child should be seen by a senior Paediatrician (Registrar or above) prior to discharge. During the hearing I was shown a document headed ‘Guidance to Paediatric Junior Doctors on Discharge [sic] Children From Assessment Unit’, which I was given to understand reflects current practice and represents an improvement on the position in 2006. The information in the letter of 4 October 2017 is broadly consistent with it. Both documents are silent as to whether a parental request for a second opinion should automatically lead to an examination of the child by the senior doctor , as was opined in court, where the importance and significance of parents’ views were noted. . I am concerned that a lack of clarity about the Health Board’s expectations in this respect may continue to allow for the possibility of a child being discharged without a sufficient (and sufficiently senior) assessment having been made .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably select appropriate staff for investigations
Wider context from the report “(2) I heard evidence at length from the Health Board’s current Clinical Lead for Paediatrics about (inter alia) the measures which are in place to ensure that lessons can be learnt (and acted upon) promptly when things do not go to plan. Specifically I heard about steps taken to learn lessons from situations in which a child might re-present in a worse condition following an earlier discharge – a situation which might result from a missed diagnosis. I did not emerge from this evidence with any confidence that there exist clearly defined and consistently applied criteria from ensuring that learning opportunities are being actively sought out and acted upon. For example, I was told that there is no defined list of triggers; with much left to judgement of individuals in the senior management team. This evidence, supplemented by the relevant contents of the letter of 4 October 2017, leaves me concerned that too much is left to chance in the identification of matters requiring investigation; in the selection of staff and in the urgency of lessons being learnt and acted upon. The current system might therefore warrant a review (perhaps including consideration of best practice elsewhere, in other hospitals outside the Health Board) to see whether grounds for improvement exist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely learning and action from investigations
Wider context from the report “(2) I heard evidence at length from the Health Board’s current Clinical Lead for Paediatrics about (inter alia) the measures which are in place to ensure that lessons can be learnt (and acted upon) promptly when things do not go to plan. Specifically I heard about steps taken to learn lessons from situations in which a child might re-present in a worse condition following an earlier discharge – a situation which might result from a missed diagnosis. I did not emerge from this evidence with any confidence that there exist clearly defined and consistently applied criteria from ensuring that learning opportunities are being actively sought out and acted upon. For example, I was told that there is no defined list of triggers; with much left to judgement of individuals in the senior management team. This evidence, supplemented by the relevant contents of the letter of 4 October 2017, leaves me concerned that too much is left to chance in the identification of matters requiring investigation; in the selection of staff and in the urgency of lessons being learnt and acted upon. The current system might therefore warrant a review (perhaps including consideration of best practice elsewhere, in other hospitals outside the Health Board) to see whether grounds for improvement exist.
” 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 Alter parent discharge information to state explicitly that parents may request escalation for a consultant review.
Verbatim wording from the response “Whilst we are confident that the culture of the department is such that a parental request or indeed concern from any member of staff would lead to a consultant review, we have taken the decision to alter the parent discharge information to explicitly state this.” Source location 2017-0312-Response-by-University-Health-Board
Open published response
5 Oct 2017 Simon Willans · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 8 Failure to commence heparin when DVT or PE is a differential diagnosis View source Discharge decisions made without involvement of a clinician responsible for the patient's care View source Failure to provide safety-netting instructions for worsening condition View source Addition of diagnoses to clinical correspondence without examining the patient View source Failure to effectively scrutinise the ambulatory care unit following a patient death View source Failure to elicit family history of pulmonary embolism View source Failure to record consultant assessment and review of clinical results View source Delay in sending discharge information to the GP 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
Simon Willans · 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
Simon Willans was admitted to Ysbyty Gwynedd with breathlessness, recent loss of consciousness and a swollen right calf, and was discharged with diagnoses of orthostatic hypotension and anxiety. He died from a pulmonary embolism the following day. Concerns included inadequate assessment and follow-up, failure to elicit a family history of pulmonary embolism, lack of safety-netting, and failure to commence heparin despite DVT/PE being a differential diagnosis.
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 commence heparin when DVT or PE is a differential diagnosis
Wider context from the report “(6) Heparin was not commenced even though a DVT /PE was one differential diagnosis
” 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 Discharge decisions made without involvement of a clinician responsible for the patient's care
Wider context from the report “(3) Mr Willans appears to have been discharged by a Nurse Practioner ████████ who had no involvement in the care of Mr Willans . ████████, or any other doctor does not appear to have been involved in the discharge of Mr Willans . Nurse Practitioner Jones adds another diagnosis to the GP letter over and above that of her colleague despite never seeing the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to provide safety-netting instructions for worsening condition
Wider context from the report “(4) There is insufficient safety netting for this patient . He was not told what to do in the event of a worsening of his condition . The letter to the GP was faxed the day after discharge by which time he had died
” 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 Addition of diagnoses to clinical correspondence without examining the patient
Wider context from the report “(3) Mr Willans appears to have been discharged by a Nurse Practioner ████████ who had no involvement in the care of Mr Willans. ████████, or any other doctor does not appear to have been involved in the discharge of Mr Willans. Nurse Practitioner Jones adds another diagnosis to the GP letter over and above that of her colleague despite never seeing the patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively scrutinise the ambulatory care unit following a patient death
Wider context from the report “(1) BCUHB have only just commenced an SIR on this matter and the ambulatory care unit, its structure, practices, systems, staff have not been effectively scrutinised following Mr Willans death in direct contravention of the policy of BCUHB on reporting and given this the following concerns do not appear to have been addressed potentially compromising patient safety until the conclusion of the SIR
” 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 elicit family history of pulmonary embolism
Wider context from the report “(5) The history recovered by Nurse Practitioner ████████ is inadequate in that it did not elicit family history of Pulmonary Embolism
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to record consultant assessment and review of clinical results
Wider context from the report “(2) ████████ the Consultant in charge of the unit did not make any entries in any of the notes for Mr Willans . There is no record of him examining the patient, the abnormal test results, the detail of the ultrasound scan .
” 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 Delay in sending discharge information to the GP
Wider context from the report “(4) There is insufficient safety netting for this patient. He was not told what to do in the event of a worsening of his condition. The letter to the GP was faxed the day after discharge by which time he had died
” Open source report
Concerns raised 4 Failure to maintain effective patient flow View source Absence of an agreed and effective system plan View source Failure to ensure effective admission to the Emergency Department View source Unavailability of necessary resources 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
Catherine Haf 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
Catherine Haf Roberts arrived at hospital by ambulance after becoming unwell with persistent diarrhoea and waited outside before remaining in the emergency department for 58 hours because of capacity and ward-space constraints. Her condition deteriorated after transfer to a medical ward, and she died in hospital on 11 February 2016. The principal concern was the continuing lack of an agreed and effective system plan addressing emergency department admission, resource availability and patient flow, which the report states was 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 Failure to maintain effective patient flow
Wider context from the report “The issues of admission to the Emergency Department/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by the Senior Coroner on several occasions following previous inquests.
Despite the above reports issued to the Health Board these problems continue to the present day and patients lives are being placed at risk as a result. Whilst I am aware that all necessary parties are working towards a system plan to address these issues and that elements of that plan have been agreed, there remains no agreed and effective system plan in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Absence of an agreed and effective system plan
Wider context from the report “The issues of admission to the Emergency Department/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by the Senior Coroner on several occasions following previous inquests.
Despite the above reports issued to the Health Board these problems continue to the present day and patients lives are being placed at risk as a result. Whilst I am aware that all necessary parties are working towards a system plan to address these issues and that elements of that plan have been agreed, there remains no agreed and effective system plan in place .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure effective admission to the Emergency Department
Wider context from the report “The issues of admission to the Emergency Department /availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by the Senior Coroner on several occasions following previous inquests.
Despite the above reports issued to the Health Board these problems continue to the present day and patients lives are being placed at risk as a result. Whilst I am aware that all necessary parties are working towards a system plan to address these issues and that elements of that plan have been agreed, there remains no agreed and effective system plan in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Unavailability of necessary resources
Wider context from the report “The issues of admission to the Emergency Department/availability of resources /patient flow and the multifactorial problems associated with cases of this nature have been reported upon by the Senior Coroner on several occasions following previous inquests.
Despite the above reports issued to the Health Board these problems continue to the present day and patients lives are being placed at risk as a result. Whilst I am aware that all necessary parties are working towards a system plan to address these issues and that elements of that plan have been agreed, there remains no agreed and effective system plan in place.
” Open source report
Concerns raised 4 Failure to ensure availability of resources View source Failure of patient flow processes View source Continuing problems with admission to the emergency department View source Continuing ambulance delays View source See 1 more concern
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. 27
Action
Align senior medical staffing hours with peak ED demand, including extended consultant cover.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 August 2017. View source
Action
Open additional surge inpatient bed capacity during peak demand when staffing permits safe operation.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source
Action
Review and amend medical and nursing rotas to reflect ED demand and increase senior cover.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source
Action
Introduce Treatment Escalation Plans for nursing and residential homes to support safe care without ambulance conveyance.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 August 2017. View source
Action
Develop guidance for ambulance resources supporting patient discharge, transfer, routine transport, and repatriation.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 August 2017. View source
Action
Staff additional holding areas away from ED during extreme pressure to support patient flow.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source
Action
Implement the SAFER patient-flow bundle across all three acute hospital sites, supported by senior clinical leadership and communications.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 August 2017. View source
Action
Operate the Local Escalation Action Plan to minimise ambulance handover delays, including hospital liaison support.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source
Action
Provide triage, medical review, harm review, and physiological monitoring for patients delayed in ambulances at Ysbyty Glan Clwyd.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source
Action
Apply paramedic guidance for identifying patients suitable for handover to the ED waiting room.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source
Action
Operate a rapid assessment unit at Ysbyty Maelor Wrexham to assess and admit ED and GP patients promptly.
Stated plannedThe respondent said that this action was planned when they made their response on 31 August 2017. View source
Action
Operate a Step Down Manager role coordinating transfers of patients with complex care needs to appropriate next-stage services.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source
Action
Increase Clinical Support Desk staffing by up to 30 whole-time equivalents using secured Welsh Government funding.
Stated plannedThe respondent said that this action was planned when they made their response on 31 August 2017. View source
Action
Conduct daily discharge-focused board rounds and weekly reviews of delayed transfers of care at both hospital sites.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source
Action
Open three additional ED rooms for minor injuries, emergency nurse practitioners, and GP out-of-hours services.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source
Action
Implement an escalation protocol for safely managing delayed ambulance handovers and releasing ambulances for urgent calls.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source
Action
Recruit permanent medical staff for Ysbyty Maelor Wrexham’s middle-grade, SHO, and consultant vacancies.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 August 2017. View source
Action
Introduce unified assessment documentation for patients awaiting admission from ED.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 August 2017. View source
Action
Increase specialty medical and surgical in-reach to assess ED patients before inpatient admission.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 August 2017. View source
Action
Expand Ysbyty Glan Clwyd ED capacity through additional assessment spaces, observation beds, and flexible use of available clinical areas.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source
Action
Operate the Clinical Support Desk to provide telephone clinical triage and direct patients to appropriate care pathways.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source
Action
Recruit additional ED nursing and medical staff and increase the funded staffing establishments.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 August 2017. View source
Action
Establish a Night Sister post to support clinical site management, patient flow, quality, and safety.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source
Action
Use demand-management communications and escalation between ambulance and hospital senior managers during handover delays.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source
Action
Explore establishing a Rapid Assessment and Treatment area at Ysbyty Glan Clwyd.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 August 2017. View source
Action
Provide overnight district nursing in Wrexham to support safe care at home instead of hospital stays.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source
Action
Operate the clinical response model that prioritises life-saving ambulance calls and provides bespoke responses for other patients.
Stated completedThe respondent said that this action was complete when they made their response on 31 August 2017. View source See 24 more actions
×
AI-generated summary
Daphne Edith Williams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daphne Edith Williams fell outside her home on 23 September 2016 and sustained a fractured hip. An ambulance response took more than six hours, during which she remained on a concrete path; the report raised concerns about ambulance delays, emergency department admission, resource availability and patient flow, while stating that the delay could not be said to have contributed to her death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure availability of resources
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources /patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of patient flow processes
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Continuing problems with admission to the emergency department
Wider context from the report “The issues of ambulance delays/admission to ED /availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Continuing ambulance delays
Wider context from the report “The issues of ambulance delays /admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result.
” 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 Align senior medical staffing hours with peak ED demand, including extended consultant cover.
Verbatim wording from the response “• The service is also working towards better matching senior medical staff working hours with times of peak patient demand. The aim is to have the Consultant late day shift extended from 18.00hrs to 22.00hrs and have a second Consultant working until 9pm Monday to Friday” Source location 2017-0167-Response-by-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 Open additional surge inpatient bed capacity during peak demand when staffing permits safe operation.
Verbatim wording from the response “• During times of peak demand, additional ‘surge’ inpatient bed capacity is opened in line with available staffing. This includes the use of medical and surgical assessment spaces as overnight inpatient beds and the escalation of additional beds on some wards where staffing levels enable this to be done safely.” Source location 2017-0167-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and amend medical and nursing rotas to reflect ED demand and increase senior cover.
Verbatim wording from the response “• Medical and nursing staffing rotas have been reviewed and amended to better reflect the peaks of patient demand in ED and changes have also been made to increase the senior level cover in the department.” Source location 2017-0167-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce Treatment Escalation Plans for nursing and residential homes to support safe care without ambulance conveyance.
Verbatim wording from the response “Complimenting this work by WAST are a range of BCUHB initiatives to reduce ambulance conveyance/ED attendance. These include:” Source location 2017-0167-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop guidance for ambulance resources supporting patient discharge, transfer, routine transport, and repatriation.
Verbatim wording from the response “Healthcare Inspectorate Wales is soon due to commence a patient discharge thematic review within BCUHB which may identify new actions for the Health Board and possibly its partners to complete to realise improvements to the discharge planning process. WAST is currently developing ‘Patient Transfer, Discharge, Routine and Repatriation Guidance’ to ensure that WAST and the wider NHS community fully understand the process of requesting an ambulance resource for particular groups of patients who need transport to enable their discharge/transfer to another facility. This will help ensure timely discharge using the most appropriate resource whilst also maintaining the availability of WAST resources to respond to 999 calls.” Source location 2017-0167-Response-by-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 Staff additional holding areas away from ED during extreme pressure to support patient flow.
Verbatim wording from the response “• In times of extreme pressure, additional holding areas are staffed away from ED to assist with the pull through of patients from ED to sustain flow of emergency patients.” Source location 2017-0167-Response-by-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 SAFER patient-flow bundle across all three acute hospital sites, supported by senior clinical leadership and communications.
Verbatim wording from the response “4.3. SAFER
BCUHB has committed to implement the SAFER bundle in all 3 acute hospital sites over the next 6 months. This is an evidence based bundle of actions shown to reduce length of stay and support safe patient discharge. The key elements of this are:” Source location 2017-0167-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Local Escalation Action Plan to minimise ambulance handover delays, including hospital liaison support.
Verbatim wording from the response “With WAST, BCUHB has also developed a Local Escalation Action Plan (LEAP) which clearly outlines the escalation processes for WAST and BCUHB staff to apply to enable ambulance crews to hand over patients to ED with minimum delay. As part of the ‘LEAP’ protocol, WAST provides a Hospital Ambulance Liaison Officer (HALO) or a Duty Operational Manager (DOM) at hospitals when ambulances are delayed. These are usually WAST Clinical Team Leaders whose role is to supervise crews experiencing handover delays and liaise directly with ED.” Source location 2017-0167-Response-by-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 triage, medical review, harm review, and physiological monitoring for patients delayed in ambulances at Ysbyty Glan Clwyd.
Verbatim wording from the response “For Ysbyty Glan Clwyd, patients who cannot be immediately accommodated into a clinically appropriate ED space will undergo a triage assessment by an ED nurse and a clinical medical review. Patients held in an ambulance for an hour or more will have a full ‘harm’ review to commence assessment/treatment and ensure their care outcome is not compromised. The recording of patients’ vital signs including the National Early Warning Score (NEWS) is routinely recorded as part of these assessments and is integrated into the paramedics’ patient record.” Source location 2017-0167-Response-by-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 Apply paramedic guidance for identifying patients suitable for handover to the ED waiting room.
Verbatim wording from the response “The WAST Clinical Contact Centre (CCC) uses a demand management plan to ensure good communications with hospital sites about WAST community activity and demand, particularly during times of handover delays. Delays are escalated to a WAST senior manager who liaises with senior BCUHB officers to agree how resources can be safely released to respond to WAST community activity.
WAST and BCUHB have together developed guidance for paramedics to identify patients well enough to be placed in the ED waiting room, rather than wait on an emergency ambulance.” Source location 2017-0167-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a rapid assessment unit at Ysbyty Maelor Wrexham to assess and admit ED and GP patients promptly.
Verbatim wording from the response “• From the 1st August 2017, a rapid assessment unit will be operational to assess and admit patients from ED (and GPs) without undue delay. From the autumn, this will be complimented with a Frailty Assessment Unit with a focus on admission avoidance to return individuals to their own homes with the support of community staff, including therapists. The unit will provide rapid assessment and treatment of patients who have the potential to return home the same day or within a maximum of 72 hours. Patients will be treated as ambulatory until proven otherwise and within the unit, individuals will receive rapid diagnosis and stabilisation before they are supported home.” Source location 2017-0167-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a Step Down Manager role coordinating transfers of patients with complex care needs to appropriate next-stage services.
Verbatim wording from the response “• A ‘Step Down’ Manager post has been created who works collaboratively with community health and social care colleagues to ensure that patients with complex care needs are moved to the next stage of their care pathway without undue delay (this may be: placement in a nursing/residential home, transfer to a community hospital or back to their own homes with packages of support). However local” Source location 2017-0167-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase Clinical Support Desk staffing by up to 30 whole-time equivalents using secured Welsh Government funding.
Verbatim wording from the response “1.2. Increase effectiveness of the Clinical Support Desk
As the result of a service improvement initiative, WAST has invested in a Clinical Support Desk within the Clinical Contact Centre (CCC). This means that a clinician (nurse / paramedic) is available to clinically assess, through telephone triage, the needs of patients and advise on appropriate alternative care pathways or conveyance. This initiative has proved highly successful, resulting in an average of 2,500 calls per month having a non-ambulance outcome, thereby substantially reducing ambulance conveyances to hospital. Following the success of this initiative, WAST has successfully presented a business case to the Ambulance Services Commissioner and Welsh Government and has received funding from Welsh Government to increase the clinicians employed in the clinical support desk for up to 30 whole time equivalents.” Source location 2017-0167-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct daily discharge-focused board rounds and weekly reviews of delayed transfers of care at both hospital sites.
Verbatim wording from the response “5. Improvement in the discharge/transfer of care of patients at the end of their acute hospital stay.
As well as the actions outlined above, BCUHB works collaboratively with WAST and Local Authorities to support the safe discharge/transfer of care of patients following their acute hospital stay to ensure patients don’t remain in hospital longer than they require. At both Ysbyty Maelor Wrecsam and Ysbyty Glan Clwyd, there is a strong focus on early identification of patients who are medically fit for discharge to ensure timely discharge. Daily ‘board rounds’ are held across acute adult wards to ensure daily discussion of each patient and their care needs, including discharge planning as appropriate with local authority colleagues. There is a weekly review at both hospital sites of patients experiencing a ‘Delayed Transfers of Care’ (DTOC).” Source location 2017-0167-Response-by-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 Open three additional ED rooms for minor injuries, emergency nurse practitioners, and GP out-of-hours services.
Verbatim wording from the response “• 3 additional rooms in ED have been opened for Minors patients, the ENP service and GP Out of Hours services.” Source location 2017-0167-Response-by-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 an escalation protocol for safely managing delayed ambulance handovers and releasing ambulances for urgent calls.
Verbatim wording from the response “BCUHB has developed an escalation protocol to ensure a consistent approach to the safe management of patients whose handover is delayed. This is to support the procedure to enable the immediate release of delayed ambulances to enable WAST to respond to life threatening or clinically urgent 999 calls in the community (the immediate release system).” Source location 2017-0167-Response-by-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 Recruit permanent medical staff for Ysbyty Maelor Wrexham’s middle-grade, SHO, and consultant vacancies.
Verbatim wording from the response “• The recruitment of medical staff is ongoing to improve cover of the medical rota from August 2017 at middle grade and SHO level. There are 2 wte Consultant vacancies currently covered with locum Consultants. There is a focused campaign of work ongoing to recruit to these key posts on a permanent basis.” Source location 2017-0167-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce unified assessment documentation for patients awaiting admission from ED.
Verbatim wording from the response “• A modified form of unified assessment documentation for patients awaiting admission from ED has been under development. This supports the provision of inpatient level type care to ED patients, ensuring their clinical outcomes and treatment is not compromised. It is intended to fully introduce this process in early August, following a period of trial to ensure all documentation and processes are fully fit for purpose.” Source location 2017-0167-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase specialty medical and surgical in-reach to assess ED patients before inpatient admission.
Verbatim wording from the response “• Work is also on-going to increase specialty ‘in reach’ into ED by medical and surgical specialties who attend ED to review patients rather than wait for them to be admitted to an inpatient ward. This does result in some patients being discharged home from ED.” Source location 2017-0167-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand Ysbyty Glan Clwyd ED capacity through additional assessment spaces, observation beds, and flexible use of available clinical areas.
Verbatim wording from the response “• A review of the use of the physical space within ED has created an open ambulatory chair centric area with 4 additional assessment/treatment spaces; the commissioning of 2 additional beds in the observation bedded area of the ED; the use of the co-located GP Out of Hours area during the day (Monday to Friday, 9am - 5pm) to provide 4 rooms for assessment / treatment; and the adoption of a flexible approach, in extenuating circumstances, to the use of all space within the ED during times of peak pressure.” Source location 2017-0167-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Clinical Support Desk to provide telephone clinical triage and direct patients to appropriate care pathways.
Verbatim wording from the response “1.2. Increase effectiveness of the Clinical Support Desk
As the result of a service improvement initiative, WAST has invested in a Clinical Support Desk within the Clinical Contact Centre (CCC). This means that a clinician (nurse / paramedic) is available to clinically assess, through telephone triage, the needs of patients and advise on appropriate alternative care pathways or conveyance. This initiative has proved highly successful, resulting in an average of 2,500 calls per month having a non-ambulance outcome, thereby substantially reducing ambulance conveyances to hospital. Following the success of this initiative, WAST has successfully presented a business case to the Ambulance Services Commissioner and Welsh Government and has received funding from Welsh Government to increase the clinicians employed in the clinical support desk for up to 30 whole time equivalents.” Source location 2017-0167-Response-by-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 Recruit additional ED nursing and medical staff and increase the funded staffing establishments.
Verbatim wording from the response “• On-going recruitment of nursing and medical staff is a key focus. This has resulted in an increase in the funded nursing establishment in ED from 56 WTE to 94 WTE, and an increase in funded medical staff posts to double the posts from 4 to 8 full time Consultants and from 5 to 8 middle grade senior doctors. It will take time to attract and recruit substantive staff to all posts although recent recruitment campaigns for senior medical staff have met with success. It is anticipated that the Consultant and senior middle grade doctor posts will all be filled with substantive appointments by the end of 2017. Until this time, the service is employing locum medical staff to provide as much service cover and continuity of care as possible.” Source location 2017-0167-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a Night Sister post to support clinical site management, patient flow, quality, and safety.
Verbatim wording from the response “• A Night Sister post has been put in place to assist the Clinical Site Manager with patient flow and associated quality and safety issues” Source location 2017-0167-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use demand-management communications and escalation between ambulance and hospital senior managers during handover delays.
Verbatim wording from the response “The WAST Clinical Contact Centre (CCC) uses a demand management plan to ensure good communications with hospital sites about WAST community activity and demand, particularly during times of handover delays. Delays are escalated to a WAST senior manager who liaises with senior BCUHB officers to agree how resources can be safely released to respond to WAST community activity.
WAST and BCUHB have together developed guidance for paramedics to identify patients well enough to be placed in the ED waiting room, rather than wait on an emergency ambulance.” Source location 2017-0167-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore establishing a Rapid Assessment and Treatment area at Ysbyty Glan Clwyd.
Verbatim wording from the response “At Ysbyty Maelor Wrecsam, a holding area in ED is created whenever possible during the day to enable patients of low risk to be handed over without delay by WAST and brought into ED. At Ysbyty Glan Clwyd, options are being explored to establish a physical ‘RATS’ (Rapid Assessment & Treatment Service) area in ED to enable the rapid handover and assessment of patients.” Source location 2017-0167-Response-by-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 overnight district nursing in Wrexham to support safe care at home instead of hospital stays.
Verbatim wording from the response “• During times of peak demand, additional ‘surge’ inpatient bed capacity is opened in line with available staffing. This includes the escalation of additional beds on some wards where staffing levels enable this to be done safely. The District Nursing Service in Wrexham is now available overnight, enabling more patients to be safely cared for at home rather than remain in hospital.” Source location 2017-0167-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the clinical response model that prioritises life-saving ambulance calls and provides bespoke responses for other patients.
Verbatim wording from the response “In October 2015 WAST introduced a new clinical response model to implement new ways in which callers to 999 are assessed. This sought to ensure that patients and users of the service received the most appropriate care and a response to suit their individual needs. The changes made clearly identify those patients who require an immediate life-saving response and these patients receive the highest priority response in the fastest possible time.
All other patients receive a bespoke clinical response based on their condition, rather than a response based solely on a time standard. These changes sought to improve the patient’s care, outcome and experience, as well as improve patient flow into hospitals.” Source location 2017-0167-Response-by-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 Establishing a North Wales Bed Bureau was not considered feasible for improving acute hospital access because of geography and local-admission priorities.
Verbatim wording from the response “In reviewing the action plans already submitted in response to previous Regulation 28 reports relating to patient flow, BCUHB notes that all previous actions have been implemented or are work in progress, with the exception of the establishment of a North Wales Bed Bureau. After consideration of this, it was not deemed a feasible way of improving access for acute hospital admissions across North Wales due to geography and enabling the admission of emergency patients to as local a hospital as possible, as often as possible.” Source location 2017-0167-Response-by-University-Health-Board
Open published response
Concerns raised 4 Delays in emergency department patient handover View source Failure to maintain adequate emergency department staffing View source Insufficient hospital bed capacity for admissions View source Failure of hospital patient flow and delayed transfer of care processes 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
Lilly Baxandall · 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
Lilly Baxandall was found collapsed at home after an unwitnessed fall and was taken to hospital by ambulance. Her ambulance handover was delayed for almost four hours amid capacity issues, and a CT scan later showed a large acute subdural haematoma that could not be treated; she died on 5 September 2014. The report raised concerns about continuing ambulance and handover delays, bed shortages, patient flow and delayed transfers of care, 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 emergency department patient handover
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 September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients".
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care.
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays /bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” 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 adequate emergency department staffing
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 September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients" .
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care.
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” 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 hospital bed capacity for admissions
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 September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients".
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care.
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions ”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” 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 hospital patient flow and delayed transfer of care processes
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 September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients".
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care .
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment ”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” 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 Invest in integrated generic health and social-care support staff to assist hospital discharges in Wrexham.
Verbatim wording from the response “Provision of dedicated hospital social workers and Assistant Team Manager to facilitate discharge as soon as an individual is medically fit to leave the acute hospital. The social workers are based at the Maelor Hospital and Chirk community hospital and are integrated with the Discharge Liaison team.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a Night Sister post to support patient flow and safety at Ysbyty Maelor Wrexham.
Verbatim wording from the response “• A Night Sister post has been put in place to assist the Clinical Site Manager with patient flow and associated quality and safety issues” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop the IV suite to provide emergency and elective IV therapy without overnight admission.
Verbatim wording from the response “• The provision of an IV suite continues to develop as an important service to enable individuals to receive IV therapy as a day attender (both emergency and elective) without the need for an overnight hospital stay.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement escalation protocols and joint action plans for delayed ambulance handovers.
Verbatim wording from the response “BCUHB has developed an escalation protocol to ensure a consistent approach to the safe management of patients whose handover is delayed. This is to support the procedure to enable the immediate release of delayed ambulances to enable WAST to respond to life threatening or clinically urgent 999 calls in the community (the immediate release system).” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit and increase funded nursing and medical staffing at Ysbyty Glan Clwyd ED.
Verbatim wording from the response “• On-going recruitment of nursing and medical staff is a key focus. This has resulted in an increase in the funded nursing establishment in ED from 56 WTE to 94 WTE, and an increase in funded medical staff posts to double the posts from 4 to 8 full time Consultants and from 5 to 8 middle grade senior doctors. It will take time to attract and recruit substantive staff to all posts although recent recruitment campaigns for senior medical staff have met with success. It is anticipated that the Consultant and senior middle grade doctor posts will all be filled with substantive appointments by the end of 2017. Until this time, the service is employing locum medical staff to provide as much service cover and continuity of care as possible.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop patient-transfer, discharge, routine and repatriation guidance for ambulance-resource requests.
Verbatim wording from the response “Healthcare Inspectorate Wales is soon due to commence a patient discharge thematic review within BCUHB which may identify new actions for the Health Board and possibly its partners to complete to realise improvements to the discharge planning process.
WAST is currently developing ‘Patient Transfer, Discharge, Routine and Repatriation Guidance’ to ensure that WAST and the wider NHS community fully understand the process of requesting an ambulance resource for particular groups of patients who need transport to enable their discharge/transfer to another facility. This will help ensure timely discharge using the most appropriate resource whilst also maintaining the availability of WAST resources to respond to 999 calls.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand Ysbyty Glan Clwyd ED assessment capacity through additional spaces, observation beds and daytime GP facilities.
Verbatim wording from the response “• A review of the use of the physical space within ED has created an open ambulatory chair centric area with 4 additional assessment/treatment spaces; the commissioning of 2 additional beds in the observation bedded area of the ED; the use of the co-located GP Out of Hours area during the day (Monday to Friday, 9am - 5pm) to provide 4 rooms for assessment / treatment; and the adoption of a flexible approach, in extenuating circumstances, to the use of all space within the ED during times of peak pressure.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide hospital liaison officers or duty operational managers when ambulance handovers are delayed.
Verbatim wording from the response “With WAST, BCUHB has also developed a Local Escalation Action Plan (LEAP) which clearly outlines the escalation processes for WAST and BCUHB staff to apply to enable ambulance crews to hand over patients to ED with minimum delay. As part of the ‘LEAP’ protocol, WAST provides a Hospital Ambulance Liaison Officer (HALO) or a Duty Operational Manager (DOM) at hospitals when ambulances are delayed. These are usually WAST Clinical Team Leaders whose role is to supervise crews experiencing handover delays and liaise directly with ED.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trial Frailty Assessment Units to support front-door assessment and admission avoidance.
Verbatim wording from the response “• In early autumn, a Frailty Assessment Unit will be trialled, providing a more comprehensive assessment of frail patients at the ‘front door’ with the aim of avoiding admission for some of these by providing additional community support to enable patients to be safely managed in their own homes. This needs further discussion with the local authorities.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish five short-term extra-care apartments to support admission avoidance and timely discharge in Conwy.
Verbatim wording from the response “Conwy have established 5 successful short term apartments at our Extra Care Housing Schemes. These apartments provide individuals with their own flat and an on-site support teams focused on Reablement and retaining independence. This supports individuals to either avoid a hospital admission or facilitate discharge to an intermediate facility before (primarily) returning home. These beds have further strengthened our ability to offer appropriate and timely discharge for people who are medically fit to leave inpatient beds but are not yet ready to go home.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide dedicated hospital social-work staffing and rapid reablement support for discharge in Flintshire.
Verbatim wording from the response “Flintshire has community based, responsive Community Care services which work effectively to prevent people being admitted to hospital when it is feasible and safe for these people to be supported at home. We have a leading Reablement Service which intervenes effectively, often on the same day and certainly with due urgency to ensure people maintain their independence, do not deteriorate and are supported at home. We also have a fully functioning Single Point of Access with involvement of the Voluntary Sector and co-located with Health. Finally, Flintshire leads on behalf of Wrexham, BCUHB and our County with a Community Equipment Service which provides rapid and responsive equipment again if needed, on the same day.
There are 10 dedicated hospital social workers to facilitate discharge as soon as an individual is medically fit to leave the acute hospital.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit medical staff and revise staffing rotas at Ysbyty Maelor Wrexham ED.
Verbatim wording from the response “• The recruitment of medical staff is ongoing to improve cover of the medical rota from August 2017 at middle grade and SHO level. There are 2 wte Consultant vacancies currently covered with locum Consultants. There is a focused campaign of work ongoing to recruit to these key posts on a permanent basis.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase specialty medical and surgical in-reach into ED to support earlier assessment and discharge.
Verbatim wording from the response “• Work is also on-going to increase speciality ‘in reach’ into ED by medical and surgical specialties who attend ED to review patients rather than wait for them to be admitted to an inpatient ward. This does result in some patients being discharged home from ED.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a Step Down Manager post to coordinate movement of complex-care patients through discharge pathways.
Verbatim wording from the response “• A ‘Step Down’ Manager post has been created who works collaboratively with community health and social care colleagues to ensure that patients with complex care needs are moved to the next stage of their care pathway without undue delay” Source location 2017-0160-Response-by-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 Align senior medical staffing hours with peak ED demand.
Verbatim wording from the response “• The service is also working towards better matching senior medical staff working hours with times of peak patient demand. The aim is to have the Consultant late day shift extended from 18.00hrs to 22.00hrs and have a second Consultant working until 9pm Monday to Friday” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a rapid assessment unit at Ysbyty Maelor Wrexham to assess and admit patients from ED and primary care without undue delay.
Verbatim wording from the response “• From the 1st August 2017, a rapid assessment unit will be operational to assess and admit patients from ED (and GPs) without undue delay. From the autumn, this will be complimented with a Frailty Assessment Unit with a focus on admission avoidance to return individuals to their own homes with the support of community staff, including therapists. The unit will provide rapid assessment and treatment of patients who have the potential to return home the same day or within a maximum of 72 hours. Patients will be treated as ambulatory until proven otherwise and within the unit, individuals will receive rapid diagnosis and stabilisation before they are supported home.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop enhanced multidisciplinary community resource teams to provide care at home.
Verbatim wording from the response “• Developing enhanced multi-disciplinary community resource teams (CRT) to provide more care for individuals in their own homes. The CRTs are in varying degrees of development across North Wales and whilst have the potential to better manage care closer at home need to build on the range of successful intermediate care provision already delivered in the 6 local authorities.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore a Rapid Assessment and Treatment area at Ysbyty Glan Clwyd for rapid handover and assessment.
Verbatim wording from the response “At Ysbyty Maelor Wrexham, a holding area in ED is created whenever possible during the day to enable patients of low risk to be handed over without delay by WAST and brought into ED. At Ysbyty Glan Clwyd, options are being explored to establish a physical ‘RATS’ (Rapid Assessment & Treatment Service) area in ED to enable the rapid handover and assessment of patients.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use paramedic guidance to identify suitable patients for transfer to ED waiting rooms rather than remaining in ambulances.
Verbatim wording from the response “The WAST Clinical Contact Centre (CCC) uses a demand management plan to ensure good communications with hospital sites about WAST community activity and demand, particularly during times of handover delays. Delays are escalated to a WAST senior manager who liaises with senior BCUHB officers to agree how resources can be safely released to respond to WAST community activity.
WAST and BCUHB have together developed guidance for paramedics to identify patients well enough to be placed in the ED waiting room, rather than wait on an emergency ambulance.” Source location 2017-0160-Response-by-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 SAFER patient-flow bundle across all three acute hospital sites.
Verbatim wording from the response “4.3. SAFER
BCUHB has committed to implement the SAFER bundle in all 3 acute hospital sites over the next 6 months. This is an evidence based bundle of actions shown to reduce length of stay and support safe patient discharge. The key elements of this are:” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a joint Single Point of Access and step-down cluster to support hospital discharge in Denbighshire.
Verbatim wording from the response “This has resulted in a number of changes to how services have been provided in the past and include a joint Single Point of Access with agreed pathways for discharge from hospital and a co-located Community Team of health and social care professionals able to work together more effectively. The latter will be rolled out across the County when its effectiveness has been reviewed.” Source location 2017-0160-Response-by-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 overnight district nursing in Wrexham to support safe care at home.
Verbatim wording from the response “• During times of peak demand, additional ‘surge’ inpatient bed capacity is opened in line with available staffing. This includes the escalation of additional beds on some wards where staffing levels enable this to be done safely. The District Nursing Service in Wrexham is now available overnight, enabling more patients to be safely cared for at home rather than remain in hospital.” Source location 2017-0160-Response-by-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 Open additional surge inpatient capacity during peak demand where staffing permits safe operation.
Verbatim wording from the response “• During times of peak demand, additional ‘surge’ inpatient bed capacity is opened in line with available staffing. This includes the use of medical and surgical assessment spaces as overnight inpatient beds and the escalation of additional beds on some wards where staffing levels enable this to be done safely.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establishing a North Wales Bed Bureau was not feasible because geography and local emergency admissions require access to the nearest appropriate hospital.
Verbatim wording from the response “In reviewing the action plans already submitted in response to the 7 previous Regulation 28 reports that are referenced in the Regulation 28 for Lilly Baxandall, BCUHB notes that all previous actions have been implemented or are work in progress, with the exception of the establishment of a North Wales Bed Bureau. After consideration of this, it was not deemed a feasible way of improving access for acute hospital admissions across North Wales due to geography and enabling the admission of emergency patients to as local a hospital as possible, as often as possible.” Source location 2017-0160-Response-by-University-Health-Board
Open published response
Concerns raised 2 Delays in developing and implementing a safe discharge procedure View source Lack of a procedure to ensure that referrals are received and actioned 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
Carol Ann Harvey · 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
Carol Ann Harvey, aged seventy, was discharged from hospital with care planned at home, but no carers attended after a referral message was left without confirmation that it had been received. She was found the following morning drowsy, vomiting and having suffered significant blood loss, and died in hospital on 9 April 2016 following a paracetamol overdose and a pre-existing cardiac condition. The principal concerns were the lack of a procedure to confirm that referrals had been received and actioned, and delay in implementing a safe hospital discharge procedure.
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 developing and implementing a safe discharge procedure
Wider context from the report “(b) The Action Plan which has been produced by the Health Board following an investigation into this death indicates that a Standard Operating Procedure for the safe discharge of patients from the Acute Hospital environment is being developed , however it was not possible to provide a completion and implementation date for this , notwithstanding that the death was eleven months ago. I am concerned that delays in undertaking work of this kind could place existing patients at risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure to ensure that referrals are received and actioned
Wider context from the report “(a) That although a referral had been made to the District Nurse Team, there is no procedure in place to ensure that such a referral has been both received and actioned .
” Open source report
Concerns raised 1 Lack of a reliable system for delivering histology results to named consultants View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Raymond Edwards · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Raymond Edwards underwent surgery for ischaemic bowel and later developed an anastomotic leak, sepsis and multi-organ failure; he died on 2 December 2015. The principal concern was the absence of a reliable system for ensuring that histology results reached the named consultant, in this case delaying awareness of amyloidosis.
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 reliable system for delivering histology results to named consultants
Wider context from the report “During the Inquest it became clear that there is no reliable system or protocol for the dissemination of histology results to the named consultant for a patient . In this case the consultant for Mr Edwards informed the inquest that the histology result had gone to the file of Mr Edwards as he had been discharged . He did not chase the result as the operation passed without incident. The Consultant informed the court that had he had the result of histology showing amyloidosis that he would immediately have referred the patient on for urgent investigation of this serious condition. Having had these results at an early stage would have informed the treatment for Mr Edwards subsequently. The fact that this information was not passed in a timely fashion did not cause or contribute to the death of Mr Edwards. However, it is clear that unless there is a clear system for bringing histology results to the attention of a named Consultant that there could be a death in future . The consultant himself identified a need for a more robust system of delivering histology reports to consultants .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement Procedure MD23 to mitigate risks from failure to act on diagnostic results.
Verbatim wording from the response “As a result of cases where failure to act on findings caused delays in patient treatment a series of meetings were arranged to review current practice and establish consistent and robust systems for disseminating results following examinations and tests. Work was undertaken to develop BCUHB Procedure MD23 ‘Procedure to mitigate the risks due to failure to act on diagnostic results’ based on NPSA 16 guidance. This procedure was approved at the end of 2016 and a copy is in the action plan.” Source location 2017-0029-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop the CHAI Ping electronic reporting solution to alert requesting clinicians, record action taken, and reduce printing of WCP results.
Verbatim wording from the response “To strengthen this process an electronic reporting system with a function to alert the requesting clinician when histology reports are authorised for viewing needs to be made available. Work has begun to develop the CHAI Ping app to provide the solution to the current gap in the WCP of ‘notification’ that a result is available and ‘authorise and recording of action taken’. This would work with the WCP to enable the organisation to improve assurance and stop printing reports for the results in scope i.e. those available to view in the WCP.” Source location 2017-0029-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Following up and acting on histology results remains the ultimate responsibility of the health professional who ordered the investigation.
Verbatim wording from the response “It is the ultimate responsibility of the health professional ordering the investigation to follow up the results and to act on them. This has been facilitated by the histology reports being sent to the requesting clinician and not the clinical location of the procedure. However paper histology reports may not reach their intended destination and for this reason all histology reports are also made available to the named Consultant on the Welsh Clinical Portal (WCP).” Source location 2017-0029-Response-by-University-Health-Board
Open published response
Concerns raised 2 Insufficient hospital bed capacity causing delays in admissions View source Insufficient weekend hospital discharges contributing to bed blocking View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sarah Ann Tyler · 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
Sarah Ann Tyler was admitted to the Emergency Department on 8 February 2015 following an overdose of co-codamol and, while awaiting admission, used ECG leads as a ligature, resulting in a hypoxic brain injury. The substantive concerns were delays in hospital admissions due to insufficient beds and more acute bed blocking at weekends because of reduced discharges.
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 hospital bed capacity causing delays in admissions
Wider context from the report “1. That there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions .
2. That the issue of “bed blocking” is more acute at weekends due to reduced numbers of patients being discharged from hospital.
” 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 weekend hospital discharges contributing to bed blocking
Wider context from the report “1. That there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions.
2. That the issue of “bed blocking” is more acute at weekends due to reduced numbers of patients being discharged from hospital .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Unscheduled Care Plan to reduce admissions, shorten hospital stays and improve timely access to inpatient beds.
Verbatim wording from the response “Whilst the majority of patients are treated or admitted within the acceptable time, a significant minority took longer to be treated or admitted and a proportion of these will have waited significantly longer. The Health Board is required by Welsh Government to have a plan in place so that performance against the 4 hour target is improved, and that more patients are treated or admitted within 4 hours. The plan to achieve this improvement is set out in the Health Board’s plan for Unscheduled Care Plan, which is a chapter within the overall Health Board Operational Plan for 2017/8. The Unscheduled Care Plan is attached in appendix 1. (The plan is a draft at this stage pending feedback on the draft from Welsh Government).” Source location 2017-0002-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete joint assessment of delayed-transfer and length-of-stay causes with local authorities and independent care providers.
Verbatim wording from the response “Reducing Length of Stay
In addition to the work to reduce admissions, there is also a significant focus on reducing the time spent in hospital for patients that are admitted. Patients who experience a Delayed Transfer of Care (DTOC) wait for transfer to be arranged to a care home or for a support package to be provided in their own home. The Health Board carried out a detailed joint assessment of the issues that cause delay in December 2016 jointly with Local Authorities and the Independent Sector providers of care services (care home and home care). The plans to reduce DTOCs and length of stay are set out in the plan.” Source location 2017-0002-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide joint community and hospital services to avoid admissions where patients can safely be cared for at home.
Verbatim wording from the response “Admission Avoidance
Patients attend ED as a method of gaining access to health services. The Unscheduled Care plan sets out the overall approach to ensuring that wherever possible, patients can be treated without requiring admission to a hospital bed. The plan describes how community services and hospital services will be provided jointly so that patients will be provided with the same community services, irrespective of whether they present to our services through the GP or via the Emergency Department. For example, if a patient who is already known to community services attends ED, the District Nursing team are automatically informed and will attend to review if the patient can be cared for at home.” Source location 2017-0002-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Without wholesale changes to working practices, differences in hospital operations between Sundays and other days will continue.
Verbatim wording from the response “Bed availability at weekends
The Health Board does also ensure that doctors and discharge teams are available to support at weekends but, in the absence of a whole scale change in working practices, there will continue to be differences in the way that the hospital operates on a Sunday compared to other days in the week.” Source location 2017-0002-Response-by-University-Health-Board
Open published response
Concerns raised 3 Infrequent consultant psychiatrist review of recently sectioned and treated inpatients View source Delays in completion of Care Treatment Plans after inpatient discharge View source Insufficient staffing cover during sickness and holidays View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christopher Glyn 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
Christopher Glyn Jones died after placing himself into collision with a train while under the care of the Community Mental Health Team. The inquest identified delays in treatment plans and risk assessments, failures in providing intended treatments, and inadequate escalation of concerns during a significant decline in his mental health; it also identified possible service deficiencies in staffing cover.
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 Infrequent consultant psychiatrist review of recently sectioned and treated inpatients
Wider context from the report “1. Evidence at the inquest indicated that the deceased was discharged from inpatient treatment on the 6th of January 2015 but his Care Treatment Plan was not completed until the end of April 2015 and that this would then only require review within a period of twelve months from that date , as a result it could have been the case that a patient who had recently been sectioned and treated as an inpatient may not then be seen by a consultant psychiatrist for a period in the region of sixteen months .
” 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 completion of Care Treatment Plans after inpatient discharge
Wider context from the report “1. Evidence at the inquest indicated that the deceased was discharged from inpatient treatment on the 6th of January 2015 but his Care Treatment Plan was not completed until the end of April 2015 and that this would then only require review within a period of twelve months from that date, as a result it could have been the case that a patient who had recently been sectioned and treated as an inpatient may not then be seen by a consultant psychiatrist for a period in the region of sixteen months.
” 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 staffing cover during sickness and holidays
Wider context from the report “2. Furthermore evidence indicated that although additional resources were currently being made available and deployed for Mental Health within BCUHB, there was also an increasing demand on the service and as a result there may still be deficiencies of service , for example in providing acceptable levels of cover for staff at times of sickness/holidays etc.
” Open source report
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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 Existing local arrangements are relied upon to provide CTP review cover during staff absence, with capacity difficulties escalated to senior management.
Verbatim wording from the response “In relation to your second area of concern relating to the need to provide acceptable levels of cover for staff at times of sickness/holidays etc. the Division has produced a multi-agency document “The Role of County Wide Mental Health Teams in Delivering Community Mental Health Services”, which is a supporting document to the MHM Code of Practice, and sets out the local requirements. This first became operational in August 2013 and has been reviewed regularly. A recent addendum to this protocol reminds staff that “Care and Treatment plans are the responsibility of the CTP coordinator or their associate. In the absence of a CTP coordinator, or associate, it is the Deputy County Manager’s responsibility to ensure that any CTPs which are due for review are appropriately updated.” Source location 2016-0319-Response-by-University-Health-Board
Open published response
Concerns raised 4 Lack of a finalised care pathway for patients presenting with an infected prosthesis View source Failure of patient flow within the Maelor Hospital causing delays in the Emergency Department View source Delays in transferring patients from ambulances and releasing ambulance resources for other calls View source Delays in administering antibiotics after knee aspiration 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
Pamela June Conway · 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
Pamela June Conway developed an infected knee and experienced cumulative delays, including around 21 hours before receiving antibiotics, during which she went into irrevocable septic shock. The concerns included the absence of a finalised care pathway for patients with an infected prosthesis and an almost two-hour delay between knee aspiration and antibiotic administration. The inquest recorded that her death was due to natural causes exacerbated by delayed medical treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of a finalised care pathway for patients presenting with an infected prosthesis
Wider context from the report “1. Evidence at the inquest indicated that discussions were taking place between different departments within BCUHB with a view to agreeing a protocol to establish an appropriate care pathway for patients presenting to the hospital with an infected prosthesis, however nothing had been finalised regarding the same .
” 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 patient flow within the Maelor Hospital causing delays in the Emergency Department
Wider context from the report “2. Evidence at the inquest indicated that the problem of “patient flow” within the Maelor Hospital continues to result in delays within the Emergency Department and it is of considerable concern to me that such problems have been the subject of previous regulation 28 reports and are also within the scope of a number of ongoing inquests.
” 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 transferring patients from ambulances and releasing ambulance resources for other calls
Wider context from the report “1. That notwithstanding changes which have been made by both BCUHB and WAST, there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls as a result of which the risk of future deaths continues.
” 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 administering antibiotics after knee aspiration
Wider context from the report “2. Furthermore evidence indicated that although it was always intended that antibiotics would be administered once the patient's knee had been aspirated, there was a delay of almost two hours between this procedure and the administration of antibiotics (a delay which was explained by being due to “normal hospital procedures” ).
” Open source report
Concerns raised 2 Failure to follow the Therapeutic Engagement and Observation Policy and escalate observation levels when required View source Lack of automatic escalation of observation levels after serious events placing patients at risk of immediate or imminent harm View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Danielle Rhian Robinson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Danielle Rhian Robinson, a 21-year-old detained under section 3 of the Mental Health Act, was found unresponsive with a ligature around her neck at the Heddfan Unit on 13 November 2014 and died on 16 November 2014 despite resuscitation attempts and subsequent treatment. The concerns identified were that observation policies were not being rigorously followed, resulting in missed opportunities to increase observation levels, and that the policy should provide an automatic safety-net response after serious events placing a patient at immediate or imminent 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 follow the Therapeutic Engagement and Observation Policy and escalate observation levels when required
Wider context from the report “(1) That the Therapeutic Engagement and Observation Policy presently adopted by BCUHB is not being rigorously followed by staff with the result that opportunities to escalate the level of observations when required are being missed .
” 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 automatic escalation of observation levels after serious events placing patients at risk of immediate or imminent harm
Wider context from the report “(2) That the current Therapeutic Engagement and Observation Policy there should be reviewed with consideration being given to implementing a system for situations where there is a serious event which places a patient at risk of immediate or imminent harm , that there should be an automatic escalation of observation levels to level 3 or 4 (within eyesight or arm’s length respectively) for a designated period and/or one to one engagement with the patient so as to provide an instant “safety net”.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold a learning event and formally relaunch the updated policy at the event.
Verbatim wording from the response “The division has its first learning event planned for September 2016 and the policy will be formally re-launched at this event.” Source location 2016-0205-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integrate compliance auditing into the divisional audit cycle and report outcomes and improvement suggestions through divisional governance to QSE.
Verbatim wording from the response “Roles and responsibilities of all staff are clearly detailed within the policy. In relation to the ongoing monitoring of compliance, an audit process is included which will now form part of the divisional audit cycle with outcomes and suggestions for improvements formally reported through our divisional governance structure to QSE.” Source location 2016-0205-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Therapeutic Engagement and Observation Policy to require automatic escalation of observations after serious self-harm pending full MDT review.
Verbatim wording from the response “In response to the Regulation 28, issued on May 28th 2016 as a result of the inquest into the death of Miss Danielle Rhian Robinson. I can confirm that the BCUHB Therapeutic Engagement and Observation Policy has been reviewed and updated to include the automatic escalation of observations following serious attempt of self-harm until a full multi-disciplinary team (MDT) review can take place, a copy is enclosed for your information.” Source location 2016-0205-Response-by-University-Health-Board
Open published response
Concerns raised 2 Failure to ensure that staff training and qualifications remain up to date View source Failure to ensure that staff are appropriately qualified for their required work View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John William Rogers · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John William Rogers was admitted to Glan Clwyd Hospital and later found collapsed near his bed following a cardiac arrest. During resuscitation, the defibrillator was set to 2 joules instead of 150 joules, and the error was not reported to the crash team for around 30 to 40 minutes; the report raised concerns that staff qualifications and training were not being kept sufficiently up to date.
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 ensure that staff training and qualifications remain up to date
Wider context from the report “That the current systems in place within BCUHB are not sufficiently robust to ensure that their staff are appropriately qualified to undertake the work required of them and that their training and qualifications remain up to date .
” 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 that staff are appropriately qualified for their required work
Wider context from the report “That the current systems in place within BCUHB are not sufficiently robust to ensure that their staff are appropriately qualified to undertake the work required of them and that their training and qualifications remain up to date.
” 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 Introduce a supportive and flexible approach to help staff complete mandatory training and keep their qualifications up to date.
Verbatim wording from the response “In reviewing the training framework and policies with colleagues, there are a range of actions which have been proposed and agreed within the Senior Managers and Executive Team, which will strengthen the current systems and processes to ensure training and qualifications status remain up to date (current) for the clinical area within which they work. To ensure that there are no lapses to training and qualifications, the Health Board has introduced a more rigorous approach to monitoring as well as a supportive and flexible approach for staff to complete their mandatory training.” Source location 2016-0097-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a more rigorous system for monitoring mandatory training and qualification compliance, with monthly reporting and oversight through Clinical Accountability meetings.
Verbatim wording from the response “In reviewing the training framework and policies with colleagues, there are a range of actions which have been proposed and agreed within the Senior Managers and Executive Team, which will strengthen the current systems and processes to ensure training and qualifications status remain up to date (current) for the clinical area within which they work. To ensure that there are no lapses to training and qualifications, the Health Board has introduced a more rigorous approach to monitoring as well as a supportive and flexible approach for staff to complete their mandatory training.” Source location 2016-0097-Response-by-University-Health-Board
Open published response
Concerns raised 1 Failure to set pulse oximeter alarm levels to reflect individual patients’ baseline oxygen saturations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kay Michelle Sheard · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kay Michelle Sheard underwent an outpatient procedure under sedation for removal of gall stones from the bile duct and subsequently suffered cardiorespiratory failure. The report raised concern that pulse oximeter alarm settings were routinely fixed at 85% without taking account of the individual patient’s normal oxygen saturation or the extent of a drop from that baseline.
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 pulse oximeter alarm levels to reflect individual patients’ baseline oxygen saturations
Wider context from the report “During the procedure the Deceased’s oxygen saturations were being monitored by a pulse oximeter for which I was advised that the alarm settings are routinely set at 85% . However all evidence indicated that it was the actual level of reading which would be significant for a patient but rather the amount by which saturations had dropped from the patient’s normal base level . Notwithstanding this, the evidence indicated that this would not be taken into account when fixing an alarm setting level and I am therefore concerned that there exists a potential risk to patients which could be reduced or eliminated by ensuring that the alarm level correctly reflects the individual patient’s condition.
” 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 Raise pulse oximeter alarm-setting issues at Welsh and UK level through the MHRA.
Verbatim wording from the response “A number of national and international bodies have produced guidelines on pulse oximetry. The Health Board has a significant amount of work to do on this issue, noting that pulse oximetry is used so widely, by so many different staff, in different clinical situations. However, our inquiries indicate that this issue also extends beyond the Health Board to the manufacturers, who install default alarm levels in their products, and the extent to which they support and facilitate user adjustment of alarm levels. Accordingly there are likely to be issues to be considered beyond BCU Health Board, and we will raise these both at Wales level, and at UK level through the MHRA (Medicines and Healthcare products Regulatory Agency).” Source location Kay-Sheard-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Check pulse oximeter alarm settings across approximately 1,200 devices.
Verbatim wording from the response “Since receiving the report BCU has done a significant amount of work in reviewing device holdings, checking device settings, and scoping the Action Plan for an inventory of approximately 1200 devices of varying complexity across the Health Board.” Source location Kay-Sheard-Response
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 Scope an action plan addressing pulse oximeter alarm-level safety.
Verbatim wording from the response “Since receiving the report BCU has done a significant amount of work in reviewing device holdings, checking device settings, and scoping the Action Plan for an inventory of approximately 1200 devices of varying complexity across the Health Board.” Source location Kay-Sheard-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Some pulse oximetry alarm-setting issues concern manufacturers and should be addressed through Wales- and UK-level channels, including the MHRA.
Verbatim wording from the response “A number of national and international bodies have produced guidelines on pulse oximetry. The Health Board has a significant amount of work to do on this issue, noting that pulse oximetry is used so widely, by so many different staff, in different clinical situations. However, our inquiries indicate that this issue also extends beyond the Health Board to the manufacturers, who install default alarm levels in their products, and the extent to which they support and facilitate user adjustment of alarm levels. Accordingly there are likely to be issues to be considered beyond BCU Health Board, and we will raise these both at Wales level, and at UK level through the MHRA (Medicines and Healthcare products Regulatory Agency).” Source location Kay-Sheard-Response
Open published response
Concerns raised 2 Lack of a coding system to make injury-identifying radiologist reports easily identifiable for prioritisation View source Failure to reliably deliver and make radiologist reports available in patient context to the Emergency Department View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Mary Myfanwy Hollands · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Mary Myfanwy Hollands, aged 98, sustained an unwitnessed fall at her nursing home and was later found to have a left hip bony injury that had not been identified on the initial X-ray. She deteriorated and died on 27 July 2015. The principal concern was that the system for conveying radiologists’ reports to the Emergency Department was not sufficiently reliable or safe, including failures in paper-report delivery and the lack of a prioritisation or coding system for reports identifying injuries.
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 coding system to make injury-identifying radiologist reports easily identifiable for prioritisation
Wider context from the report “(1) The system currently in place for radiologist’s reports being passed to the Emergency Department is not sufficiently reliable or safe so as to provide effective safety netting for patients.
(2) Under the current system the x ray will be put on the PACS system and any obvious bony injury will have the words “red dot” typed on the area of the injury. The Emergency Department doctor must analyse all X-rays to check for an injury, whether or not marked with “red dot”. This is then followed with a radiologists report within 48 hours. The report is put on the PACS system and a paper copy is despatched to the Emergency Department and attached to the notes. The radiologist will in his report note any injuries which he has seen. This provides a safety net where an Emergency Department doctor may have missed a more subtle injury so that a patient, whom has been discharged can be recalled for future advice and/or treatment.
(3) There is currently no coding system for radiologists to make those reports which identify injuries easily identifiable so that the busy Emergency Department can prioritise the reading of those reports with a view to recalling patients whose injuries have gone undetected. This is in the context of some 50000 patients passing through each Emergency Department each year, an average of one third of whom are x rayed . Time is currently being wasted in an already busy department ploughing through reports which do not need to be considered as no injury is disclosed.
(4) Also the method of passing the paper information to the Emergency Department is flawed. There are regular occasions when the paper report does not arrive, as happened in the case of Mrs Hollands, meaning that some patients are not recalled for necessary advice and treatment, as in the case of Mrs Hollands. Once the paper report arrives in the Emergency Department the paper notes have to be located and the paper report attached before it can be considered in context. On occasion a radiologist will come down and discuss a report. There appears to be a lack of consistency
(5) There needs to be a reliable system for the report of the radiologist to be delivered to the Emergency Department, prioritising patient’s with injuries. An optimum system could be devised between senior Consultant Radiologists and Senior Consultant Emergency doctors. This needs to be considered for use prior to digitalisation of Emergency Department notes and incorporated into the anticipated digitalised system.
” 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 reliably deliver and make radiologist reports available in patient context to the Emergency Department
Wider context from the report “(1) The system currently in place for radiologist’s reports being passed to the Emergency Department is not sufficiently reliable or safe so as to provide effective safety netting for patients.
(2) Under the current system the x ray will be put on the PACS system and any obvious bony injury will have the words “red dot” typed on the area of the injury. The Emergency Department doctor must analyse all X-rays to check for an injury, whether or not marked with “red dot”. This is then followed with a radiologists report within 48 hours. The report is put on the PACS system and a paper copy is despatched to the Emergency Department and attached to the notes. The radiologist will in his report note any injuries which he has seen. This provides a safety net where an Emergency Department doctor may have missed a more subtle injury so that a patient, whom has been discharged can be recalled for future advice and/or treatment.
(3) There is currently no coding system for radiologists to make those reports which identify injuries easily identifiable so that the busy Emergency Department can prioritise the reading of those reports with a view to recalling patients whose injuries have gone undetected. This is in the context of some 50000 patients passing through each Emergency Department each year, an average of one third of whom are x rayed . Time is currently being wasted in an already busy department ploughing through reports which do not need to be considered as no injury is disclosed.
(4) Also the method of passing the paper information to the Emergency Department is flawed. There are regular occasions when the paper report does not arrive , as happened in the case of Mrs Hollands, meaning that some patients are not recalled for necessary advice and treatment, as in the case of Mrs Hollands. Once the paper report arrives in the Emergency Department the paper notes have to be located and the paper report attached before it can be considered in context. On occasion a radiologist will come down and discuss a report. There appears to be a lack of consistency
(5) There needs to be a reliable system for the report of the radiologist to be delivered to the Emergency Department , prioritising patient’s with injuries. An optimum system could be devised between senior Consultant Radiologists and Senior Consultant Emergency doctors. This needs to be considered for use prior to digitalisation of Emergency Department notes and incorporated into the anticipated digitalised system.
” 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 Consider integrating Radiology and Emergency Department IT systems to support communication of results.
Verbatim wording from the response “Matters of concern paragraph 5. The health board will consider what integration of the Radiology and Emergency Department IT systems can be undertaken to support the communication process.” Source location Mary-Hollands-Response
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 an interim solution for Radiology and Emergency departments to communicate results and confirm receipt by referring departments.
Verbatim wording from the response “There is currently no electronic system available to highlight results and confirm that they have been received by the referrer. However the Radiology and Emergency departments are working together to develop an interim solution to ensure the results are communicated and received by the referring department.” Source location Mary-Hollands-Response
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 A coding system for radiology findings would be difficult to develop because radiologists lack the patient’s full clinical care context.
Verbatim wording from the response “Matters of concern paragraph 3. The suggestion is for a coding system to be in place. However, as the radiologists do not have the full clinical picture of the care given to the patient following their imaging it would be difficult to develop such a system.” Source location Mary-Hollands-Response
Open published response
Concerns raised 2 Lack of recording the type of issue in the notes View source Failure to conduct handovers by reference to nursing notes 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
Alan Walker · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alan Walker died after a nasogastric feeding set was connected to an intravenous line, resulting in the infusion of liquid feed. The report raised concern that equipment connectivity issues were not recorded in nursing notes and might not be relayed during staff handovers.
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 recording the type of issue in the notes
Wider context from the report “That by not recording within the notes the type of issue referred to in paragraph 4 (b) above and then by not conducting handovers by reference to the nursing notes there is a risk that potentially significant information is not relayed to staff who come on duty at a later 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 conduct handovers by reference to nursing notes
Wider context from the report “That by not recording within the notes the type of issue referred to in paragraph 4 (b) above and then by not conducting handovers by reference to the nursing notes there is a risk that potentially significant information is not relayed to staff who come on duty at a later time.
” Open source report
Concerns raised 1 Lack of an accessible, accurate central Emergency Department patient record 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
Vera Hilda Williams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Vera Hilda Williams attended the Emergency Department on several occasions with different symptoms and was later found by CT scan to have a ruptured aorta associated with an oesophageal rupture. She died at Glan Clwyd Hospital on 28 October 2015. The report raised concerns that Emergency Department staff did not have a digital central record of patients’ previous attendances, symptoms and treatment, requiring reliance on patient accounts and retrieval of paper notes, which could delay access to accurate information.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of an accessible, accurate central Emergency Department patient record
Wider context from the report “(1) Doctors and staff in the Emergency Department do not have a DIGITAL CENTRAL RECORD ( ie on a computer database) of who has passed through the Emergency Department , their symptoms and what treatment they have received.
(2 )Doctors must rely upon the patient telling them what has happened and then there is a delay whilst previous paper notes are located and retrieved. This lack of easy and swift access to accurate information is fraught with risks for patients and clinicians in the arena of Emergency medicine where time is of the essence in coming to a diagnosis. An accurate history is an essential tool in coming to that diagnosis. Any delay can have potentially fatal consequences for a patient.
” Open source report
Concerns raised 4 Inaccurate information in the Transfer of Care Form View source Failure to provide the Transfer of Care Form to escorting police for immediate availability to the custody nurse View source Failure to ensure completion of the Transfer of Care Form by the examining doctor View source Delays in completing the Transfer of Care Form at the time of examination 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
Andrew Selwyn 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
Andrew Selwyn Roberts was arrested on 24 December 2011, after being tasered and having taken an overdose, and was taken to hospital before being assessed as fit to return to custody. The transfer of care form inaccurately stated that he had been assessed by psychiatric liaison, although he had not been seen by that team. The substantive concerns were that the form was completed by a nurse rather than the examining doctor, contained inaccurate information, and was not completed and provided to police at the time of examination.
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 Inaccurate information in the Transfer of Care Form
Wider context from the report “1. That the Transfer of Care Form was not completed by the Doctor who had carried out the examination of the patient and the information contained therein was subsequently found to be inaccurate .
” 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 the Transfer of Care Form to escorting police for immediate availability to the custody nurse
Wider context from the report “2. That the Transfer of Care Form was not completed at the time of examination and provided to the Police Officers escorting the detained person to hospital so that it could be returned with them to custody and made immediately available to the custody nurse .
” 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 completion of the Transfer of Care Form by the examining doctor
Wider context from the report “1. That the Transfer of Care Form was not completed by the Doctor who had carried out the examination of the patient and the information contained therein was subsequently found to be inaccurate.
” 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 completing the Transfer of Care Form at the time of examination
Wider context from the report “2. That the Transfer of Care Form was not completed at the time of examination and provided to the Police Officers escorting the detained person to hospital so that it could be returned with them to custody and made immediately available to the custody nurse.
” Open source report
Concerns raised 4 Failure to provide access to mental health information during medical treatment View source Failure to review medication in accordance with accepted medical practice View source Lack of a system to ensure medication review View source Failure to consider care for vulnerable patients requiring additional 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
Nancy 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
Nancy Hughes, who had Alzheimer’s disease and was receiving Risperidone, fell at a care home and later suffered a further unwitnessed fall in hospital before dying on 3 January 2014. The concerns were that her medication was not reviewed as required and that there was insufficient cohesion between mental health and medical treatment, potentially affecting care for vulnerable patients.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to provide access to mental health information during medical treatment
Wider context from the report “2. That the evidence given by ████████ Consultant Orthopaedic Surgeon suggested that there was no cohesion between mental health treatment and medical treatment such that whilst receiving medical treatment he would not have access to mental health information relating to a patient and as a result there may be no consideration given to the care given to vulnerable patients requiring additional support.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to review medication in accordance with accepted medical practice
Wider context from the report “1. That there was no review of her medication in accordance with accepted medical practice and no system in place to ensure that this was undertaken.
” 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 system to ensure medication review
Wider context from the report “1. That there was no review of her medication in accordance with accepted medical practice and no system in place to ensure that this was undertaken .
” 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 consider care for vulnerable patients requiring additional support
Wider context from the report “2. That the evidence given by ████████ Consultant Orthopaedic Surgeon suggested that there was no cohesion between mental health treatment and medical treatment such that whilst receiving medical treatment he would not have access to mental health information relating to a patient and as a result there may be no consideration given to the care given to vulnerable patients requiring additional support .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and embed prescribing guidance for behavioural and psychological symptoms of dementia, including scheduled monitoring and medication review or discontinuation.
Verbatim wording from the response “For patients known to community teams their care coordinator will be a member of staff from that team, this could be a Consultant, a nurse, a social work or other professional. For patients not previously known to community team prior to their admission, a named nurse (care coordinator) must be allocated to that patient within the first 24 hours of the admission – this is part of the patient’s 7 day admission pathway.
The care coordinator, or named nurse has a responsibility for maintaining contact with the patient and the care team looking after the patient, if they are transferred for medical treatment into an acute hospital setting. This would include review of medication.
BCUHB Mental Health Medicines Management Group has developed a Prescribing Guideline for the Management of Behavioural and Psychological Symptoms of Dementia.” Source location 2015-0221-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Allocate a named care coordinator or nurse within 24 hours and require medication review and continuity of contact during transfers.
Verbatim wording from the response “This is a requirement under the Mental Health (Wales) Measure; there is a requirement for patients to have a named individual who coordinates their care, ie their Care Coordinator.” Source location 2015-0221-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve communication between transferring mental health wards and receiving acute hospitals, including transfer of mental health medical records.
Verbatim wording from the response “The role of the Care coordinator or named nurse incorporates key responsibilities for ensuring effective communication between the transferring ward and receiving ward. When patients are transferred from mental health facilities to an acute secondary care setting, mental health medical records should follow the patient. The Mental Health Improvement Group is also working to improve this.” Source location 2015-0221-Response-by-University-Health-Board
Open published response
Concerns raised 3 Unavailability of a rapid testing and reporting service for legionella View source Failure to expedite urgent blood test samples for laboratory analysis View source Failure to undertake timely urine testing for legionella View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sally Ellison · 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
Sally Ellison contracted legionella while on holiday in Tunisia in mid-May 2012 and died on 1 June 2012 from cardiac arrest, multi-organ failure and legionella pneumonia. Concerns were raised that testing for legionella was not undertaken until 31 May, with confirmation on 1 June, and that this may have delayed optimal treatment; the report also identified the need for earlier testing and a rapid testing and reporting service.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a rapid testing and reporting service for legionella
Wider context from the report “2. Not only should consideration therefore be given to undertaking tests at an earlier stage but there should also be available to the hospital a rapid testing and reporting service , either preferably a service within North Wales or utilising options within organisations geographically closer and more accessible than those in Cardiff.
” 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 expedite urgent blood test samples for laboratory analysis
Wider context from the report “1. That urgent blood tests were requested By ████████ (GP) at lunchtime on the 28th of April 2012, yet, despite these being noted as urgent, the samples were not conveyed to the laboratory for analysis after collection by the district nurse, until a routine collection of samples was undertaken from Colwyn Bay Community Hospital later that afternoon . As a result the delay in an analysis meant that results were not provided to surgery until the following morning. Whilst the evidence indicates that changes have been made within the laboratory at Glan Clwyd to enable the immediate reporting of all cases where the CRP is greater than 300, there was no evidence available to confirm that all urgent tests could be expedited by district nurses thus alleviating potentially life threatening delays in 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 Failure to undertake timely urine testing for legionella
Wider context from the report “1. That although it was clear upon her admission to Glan Clwyd on the 29th of May 2012 at around 16.00 hours, that she was suffering from a severe form of Community Acquired Pneumonia, and that this was recognised as being an atypical pneumonia that same evening, no urine sample was sent for analysis until overnight on the 31st of May with the confirmation of it being positive for legionella coming on the morning of the 1st of June. It is the case that treatment was already being given for the possibility of legionella from the 30th of May, but this was not against a confirmed diagnosis and therefore optimal treatment may have been delayed .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review primary-care urgent-sample requesting processes and prepare a memorandum covering sample labelling, transport and laboratory notification.
Verbatim wording from the response “From this, you have requested that actions should be taken to prevent future deaths. Because of this, the Pathology Clinical Programme Group (CPG), and in particular the Governance section of the CPG, has reviewed the process for the requesting of urgent samples from primary care across BCUHB. This process has been explained in a memorandum ████████ that will be distributed electronically to all GPs and Practice Managers supported by BCUHB. The memorandum includes the correct process for the labeling of samples and its transportation to minimise delay. It also includes the relevant departmental telephone numbers for the laboratories across North Wales to ensure that the sample requester can warn the relevant department of the samples imminent arrival.” Source location 2015-0163-Response-by-NHS-Wales
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 Distribute the urgent-sample process memorandum electronically to all BCUHB-supported GPs and practice managers.
Verbatim wording from the response “From this, you have requested that actions should be taken to prevent future deaths. Because of this, the Pathology Clinical Programme Group (CPG), and in particular the Governance section of the CPG, has reviewed the process for the requesting of urgent samples from primary care across BCUHB. This process has been explained in a memorandum ████████ that will be distributed electronically to all GPs and Practice Managers supported by BCUHB. The memorandum includes the correct process for the labeling of samples and its transportation to minimise delay. It also includes the relevant departmental telephone numbers for the laboratories across North Wales to ensure that the sample requester can warn the relevant department of the samples imminent arrival.” Source location 2015-0163-Response-by-NHS-Wales
Open published response
Concerns raised 3 Lack of clear training or guidance on exceptional deviations from the recognised psychiatric assessment pathway View source Insufficient engagement with family and carers about patients' Care and Treatment Plans View source Failure to ensure continuous access to existing patients' medical records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony Gwyn Williams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 9 February 2014, Anthony Gwyn Williams, whose mental health was declining, went to Pentwmpath Woods and took his own life with a ligature while his balance of mind was disturbed. Concerns included insufficient guidance on when staff could deviate from the recognised psychiatric assessment pathway, lack of continuous access to patients’ medical records, and the need for greater engagement with families and carers about care and treatment plans.
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 clear training or guidance on exceptional deviations from the recognised psychiatric assessment pathway
Wider context from the report “1. Although a memorandum has been issued to staff advising that there may be times when it is appropriate to deviate from the recognised pathway of psychiatric assessment within the Emergency Department, no clear training or guidance has been given to staff as to what may constitute such “exceptional cases” .
” 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 engagement with family and carers about patients' Care and Treatment Plans
Wider context from the report “3. There should be greater engagement with family and carers of patients (with patient consent) to ensure that they are aware of the contents of patient's Care and Treatment Plan especially with regard to the options which may exist in times of crisis .
” 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 continuous access to existing patients' medical records
Wider context from the report “2. There needs to be access to the medical records of existing patients at all times including evenings and weekends especially regarding a patient's Care and Treatment Plan .
” 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 Maintain increased out-of-hours psychiatric nursing presence on the Heddfan Adult Unit.
Verbatim wording from the response “1. Although a memorandum from the Chief of Staff was circulated to all Medical, Inpatient and Psychiatric Liaison staff on 8 September 2014, it did not provide these staff groups with any guidance as to what constitutes ‘exceptional cases’ in terms of where out of hours psychiatric assessments should take place. I am pleased to report that since this incident, we now have a larger number of psychiatric nurses present on the Heddfan Adult Unit out of hours and in similar situations in the future, socially anxious patients such as Mr Williams could be assessed at the Unit and would not need to await psychiatric assessment at the Emergency Department. Notwithstanding this, our Business Manager for Safety & Regulation will fully discuss this matter at the next Operational Management meeting to ensure full understanding and compliance across the Mental Health & Learning Disabilities Division.” Source location 2014-0523-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore electronic case records through the national procurement process and determine the preferred approach to developing them.
Verbatim wording from the response “2. In respect of medical and nursing staff having access to patients’ records, such as Care and Treatment Plans at all times, I can advise you that the adoption of an electronic case record is currently being explored as part of the Community Care Information System national procurement. The Health Board will determine its preferred approach to developing electronic records by March 2015.” Source location 2014-0523-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Family and carer involvement in care planning is legally limited where patients with capacity do not consent, unless overriding public interest justifies disclosure.
Verbatim wording from the response “general principal if a patient has capacity to make decisions about whether family members or carers are involved in a patient’s care planning and care, then services are obliged to respect that decision unless there is an overriding public interest, which merits disclosure of information. Where the involvement of family and carer’s is accepted by the patient, the sharing of the Care and Treatment Plan would be appropriate. I am assured that all patients are provided with a copy of their Care and Treatment Plans. If a patient lacks capacity to make decisions about the involvement of family or carers there should follow a best interest decision. I would suspect in the majority of cases the involvement of family and carers would be in a person’s best interest.” Source location 2014-0523-Response-by-University-Health-Board
Open published response
Concerns raised 3 Failure to provide Acute Liaison Nurse cover during staff absence View source Failure to mandate training on new procedures and protocols for all staff requiring awareness View source Insufficient Acute Liaison Nurse staffing capacity 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
Timothy Peter Cowen · 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
Timothy Peter Cowen underwent surgery on 23 April 2013 and subsequently developed bilateral extensive pneumonia with features of aspiration. He died on 2 May 2013 after deterioration and readmission to hospital. Concerns included non-mandatory training on new procedures and insufficient cover for Acute Liaison Nurses during absence.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Acute Liaison Nurse cover during staff absence
Wider context from the report “2. That whilst there has been established a new role of Acute Liaison Nurse to provide cohesion to the care given to patients requiring additional support, there are only three such ALNs and there is no cover in place when they are absent through illness or holidays .
” 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 mandate training on new procedures and protocols for all staff requiring awareness
Wider context from the report “1. That although a Root Cause Analysis undertaken by the health board has resulted in new training bundles being produced, training is not mandatory for all staff who would require to be made aware of the new procedures and protocols .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient Acute Liaison Nurse staffing capacity
Wider context from the report “2. That whilst there has been established a new role of Acute Liaison Nurse to provide cohesion to the care given to patients requiring additional support, there are only three such ALNs and there is no cover in place when they are absent through illness or holidays.
” 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