Recipient

Betsi Cadwaladr University LHB

First report 25 Sep 2013•Latest report 27 Feb 2026

Recipient record

Reports, concerns and published responses

Health and care · Local health board. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 83
Published responses: 78%
Concerns addressed: 164
Stated actions: 575

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

78%published responses found

575stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Betsi Cadwaladr University LHB linked to the concerns in each report. Select any concern, action or position to view the source wording.

7 Oct2014
North Wales (East and Central)
Concerns raised1
1. Lack of a documented regime for regular fetal-heart auscultation after maternal opiate administration
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

Elouise Winship · 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

Elouise Winship was delivered unresponsive on 11 March 2011, was resuscitated, and died 13 hours later. Concerns included the absence of a documented standard regime for fetal heart auscultation after maternal opiates and the need for further maternal examination and fresh observations following a recognisable change in condition during labour.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation
Lack of a documented regime for regular fetal-heart auscultation after maternal opiate administration
Wider context from the report
“1. That although a Local Serious Review was undertaken following Elouise’s death in which it was agreed that the fetal heart should have been auscultated on a regular basis following administration of opiates to the mother, there is no documented regime by which this has been adopted into standard practice. ”
Open source report
29 Sep2014
North Wales (East and Central)
Concerns raised2
1. Failure to communicate the effects of caffeine and smoking changes on clozapine levels
2. Failure to communicate the warning signs of clozapine toxicity
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

Christopher Paul Davies · 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 Paul Davies was found unresponsive at home on 5 February 2014 and was verified dead that day; the inquest recorded accidental death, with the cause stated as clozapine poisoning. Concerns were raised that information about possible interactions between clozapine, caffeine and changes in smoking, and about warning signs of toxicity, had not been communicated to the deceased or Community Mental Health Team staff.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate the effects of caffeine and smoking changes on clozapine levels
Wider context from the report
“He stated that although his son’s clozapine levels were being regularly monitored, at no point was he ever made aware of the possible interaction between caffeine or the cessation/reduction of smoking in relation to clozapine levels, nor was he made aware of the possible warning signs of toxicity. It was therefore felt that there should be greater emphasis placed on the sharing of this knowledge with users and with staff within the Community Mental Health Team. It was also felt that due to memory issues, patients should be regularly reminded of this information. ”
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 communicate the warning signs of clozapine toxicity
Wider context from the report
“He stated that although his son’s clozapine levels were being regularly monitored, at no point was he ever made aware of the possible interaction between caffeine or the cessation/reduction of smoking in relation to clozapine levels, nor was he made aware of the possible warning signs of toxicity. It was therefore felt that there should be greater emphasis placed on the sharing of this knowledge with users and with staff within the Community Mental Health Team. It was also felt that due to memory issues, patients should be regularly reminded of this information. ”
Open source report
12 Sep2014
North Wales (East and Central)
Concerns raised6
1. Delays in the provision of ambulance assistance
2. Failure of Emergency Department patient handover practices to prevent prolonged ambulance waits and resource unavailability
3. Failure to ensure emergency clinicians know what pain relief has already been provided
1. Unavailability of senior clinicians for overnight second opinions
2. Failure to rectify previously identified patient handover delays
3. Lack of emergency clinicians’ awareness of overnight patient-discharge policies
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 12
1. Action
  Develop and implement a process for escalating delayed ambulance assessments to NHS Direct Wales for additional telephone clinical assessment.
  Stated planned
2. Action
  Implement the revised ambulance handover safety audit across the Health Board and report its results monthly.
  Stated in progress
3. Action
  Consult on and ratify revised ambulance handover protocols before formal implementation across the Health Board and Trust.
  Stated planned
1. Action
  Investigate serious incidents involving both organisations jointly and share the resulting learning.
  Stated completed
2. Action
  Establish holding areas in each Emergency Department when required to enable safe, timely patient offloading.
  Stated in progress
3. Action
  Consult on and ratify a North Wales escalation protocol before implementing it across the area.
  Stated planned
4. Action
  Issue Medical Director advice supporting joint assessment of ambulance patients at Emergency Department front doors and safe transfer of suitable patients.
  Stated completed
5. Action
  Operate cross-organisational escalation arrangements and conference calls to agree joint action plans for ongoing handover delays.
  Stated in progress
6. Action
  Introduce a Wales-wide Clinical Desk staffed by paramedics and nurses to provide secondary triage and clinical support for delayed calls.
  Stated planned
7. Action
  Review and align Welsh Medical Priority Dispatch System codes with other UK ambulance services using the system.
  Stated completed
8. Action
  Enhance senior clinical, nursing and operational leadership to support Emergency Departments and patient flow.
  Stated completed
9. Action
  Use the Ysbyty Gwynedd handover protocol across the Health Board as an interim consistent approach pending formal policy approval.
  Stated completed
AI-generated summary

Clive Harold Turner · 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

Clive Harold Turner was taken to hospital after delays in the response to a call for medical assistance and was discharged after being incorrectly diagnosed as constipated. He was later found deceased at home from a gastrointestinal haemorrhage due to ischaemic bowel resulting from atherosclerosis. Concerns included uncertainty about pain relief provided by the ambulance service, lack of awareness of overnight discharge policies, and the absence of senior clinicians available for a second opinion.

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 the provision of ambulance assistance
Wider context from the report
“1. That there were significant delays in the provision of assistance to Mr Turner by the Welsh Ambulance Service ”
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 Emergency Department patient handover practices to prevent prolonged ambulance waits and resource unavailability
Wider context from the report
“2. That the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls. Whilst this is a multi-factorial problem, improvements must be made so as to reduce the risk of future deaths. ”
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 emergency clinicians know what pain relief has already been provided
Wider context from the report
“That ████████SHO in Emergency Medicine indicated in her evidence as follows :- 1. that she did not know what pain relief had been provided to Mr Turner by the Welsh Ambulance Service 2. that she was not aware of any policies within BCUHB relating to the discharge of patients overnight. 3. that there were no senior clinicians on duty from whom she could seek a second opinion due to the lateness of the hour when she was attending to Mr Turner. ”
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 senior clinicians for overnight second opinions
Wider context from the report
“That ████████SHO in Emergency Medicine indicated in her evidence as follows :- 1. that she did not know what pain relief had been provided to Mr Turner by the Welsh Ambulance Service 2. that she was not aware of any policies within BCUHB relating to the discharge of patients overnight. 3. that there were no senior clinicians on duty from whom she could seek a second opinion due to the lateness of the hour when she was attending to Mr Turner. ”
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 rectify previously identified patient handover delays
Wider context from the report
“3. It is of considerable concern to me that item 2 above is a direct repeat of a concern which I raised in a previous Regulation 28 report following the death of Mr Frederick Pring in March 2013, twelve months before that of Mr Turner, the joint response of WAST and BCUHB being received exactly one week before Mr Turner's death. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation
Lack of emergency clinicians’ awareness of overnight patient-discharge policies
Wider context from the report
“That ████████SHO in Emergency Medicine indicated in her evidence as follows :- 1. that she did not know what pain relief had been provided to Mr Turner by the Welsh Ambulance Service 2. that she was not aware of any policies within BCUHB relating to the discharge of patients overnight. 3. that there were no senior clinicians on duty from whom she could seek a second opinion due to the lateness of the hour when she was attending to Mr Turner. ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and implement a process for escalating delayed ambulance assessments to NHS Direct Wales for additional telephone clinical assessment.

Verbatim wording from the response
“To prevent this break down in communication in the future, the Trust has developed a clear process for escalating calls where a delayed face to face assessment (i.e. ambulance response) is offset by gaining additional clinical assistance from NHSDW, who can undertake a telephone assessment in the absence of an ambulance response. This will be in place from 1 December 2014.”

Source location
2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014
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 revised ambulance handover safety audit across the Health Board and report its results monthly.

Verbatim wording from the response
“The audit of ambulance handover to provide assurance in relation to patient safety during this period of care has been revised by the BCUHB Associate Medical Director for Unscheduled Care. The new process has been piloted at one of the Emergency Departments in North Wales and following some amendment will be implemented across BCUHB and reported monthly. This has already commenced in Ysbyty Glan Clwyd.”

Source location
2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014
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
Consult on and ratify revised ambulance handover protocols before formal implementation across the Health Board and Trust.

Verbatim wording from the response
“BCUHB has developed a protocol for their area to ensure a consistent approach to ambulance handover across North Wales. The Medical Director has mandated the protocol that is currently used at Ysbyty Gwynedd Hospital to be used across the Health Board for use in the interim period until a new Handover Policy for BCUHB can be formally agreed. The revised protocols are currently out for consultation and will require ratification by both BCUHB and the Trust prior to formal implementation.”

Source location
2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014
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
Investigate serious incidents involving both organisations jointly and share the resulting learning.

Verbatim wording from the response
“Holding areas are being established in each Emergency Department when required to enable patients to be offloaded in a safe and timely manner. Serious incidents where there are joint issues for BCUHB and the Trust are now investigated jointly and learning outcomes shared. Senior Clinical, Nurse and Operational Management Leadership have been enhanced by the Health Board to ensure robust support for the Emergency Departments and patient flow.”

Source location
2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014
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 holding areas in each Emergency Department when required to enable safe, timely patient offloading.

Verbatim wording from the response
“Holding areas are being established in each Emergency Department when required to enable patients to be offloaded in a safe and timely manner. Serious incidents where there are joint issues for BCUHB and the Trust are now investigated jointly and learning outcomes shared. Senior Clinical, Nurse and Operational Management Leadership have been enhanced by the Health Board to ensure robust support for the Emergency Departments and patient flow.”

Source location
2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014
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
Consult on and ratify a North Wales escalation protocol before implementing it across the area.

Verbatim wording from the response
“BCUHB has developed an escalation protocol for their area to ensure a consistent approach across North Wales. The protocol is currently out for consultation and will require ratification by the North Wales Unscheduled Care Programme Board prior to implementation. This has included advice issued by the Medical Director to support and encourage NHS Managers and Clinicians to work closely with the Trust staff at the Emergency Departments (ED) ‘front doors’ to jointly assess patients held in ambulances and identify patients that could either safely be transferred to the waiting room or be brought into the department without delay.”

Source location
2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Issue Medical Director advice supporting joint assessment of ambulance patients at Emergency Department front doors and safe transfer of suitable patients.

Verbatim wording from the response
“BCUHB has developed an escalation protocol for their area to ensure a consistent approach across North Wales. The protocol is currently out for consultation and will require ratification by the North Wales Unscheduled Care Programme Board prior to implementation. This has included advice issued by the Medical Director to support and encourage NHS Managers and Clinicians to work closely with the Trust staff at the Emergency Departments (ED) ‘front doors’ to jointly assess patients held in ambulances and identify patients that could either safely be transferred to the waiting room or be brought into the department without delay.”

Source location
2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014
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 cross-organisational escalation arrangements and conference calls to agree joint action plans for ongoing handover delays.

Verbatim wording from the response
“There is engagement at all levels between the Trust and BCUHB, with conference calls arranged to agree joint action plans to address ongoing delays. Duty Control Managers from the Trust will initially contact the Hospital Clinical Site Managers if ambulances are delayed. The escalation process will continue with the Trusts Locality Managers contacting the Senior Site Operational Managers in BCUHB and then the Trusts Head of Service engaging with the Chief Operating Officer within BCUHB out of hours as there is an ‘On Call’ system Bronze to Bronze, Silver to Silver and Gold to Gold engagement between both organisations to ensure that a seamless escalation process exists.”

Source location
2014-0404-Response-by-Welsh-Ambulance-Service
Page 3 · response
Published 12 September 2014
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 Wales-wide Clinical Desk staffed by paramedics and nurses to provide secondary triage and clinical support for delayed calls.

Verbatim wording from the response
“Clinical Desk The Trust is introducing a Clinical Desk into the Clinical Contact Centre in Vantage Point House, Cwmbran, which will be in operation for the whole of Wales. This will comprise of Paramedics and Nurses providing further early triage of calls using the Manchester Triage System to ensure the correct and most appropriate response is sent to meet the clinical needs of the patient. This will be implemented by the Trust in December 2014 and provides:”

Source location
2014-0404-Response-by-Welsh-Ambulance-Service
Page 4 · response
Published 12 September 2014
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 align Welsh Medical Priority Dispatch System codes with other UK ambulance services using the system.

Verbatim wording from the response
“Improvement to Call Prioritisation Like many other UK ambulance services, the Trust uses the international accredited Medical Priority Dispatch System (MPDS). This is a unified system for consistent call handling of”

Source location
2014-0404-Response-by-Welsh-Ambulance-Service
Page 3 · response
Published 12 September 2014
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
Enhance senior clinical, nursing and operational leadership to support Emergency Departments and patient flow.

Verbatim wording from the response
“Holding areas are being established in each Emergency Department when required to enable patients to be offloaded in a safe and timely manner. Serious incidents where there are joint issues for BCUHB and the Trust are now investigated jointly and learning outcomes shared. Senior Clinical, Nurse and Operational Management Leadership have been enhanced by the Health Board to ensure robust support for the Emergency Departments and patient flow.”

Source location
2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014
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 the Ysbyty Gwynedd handover protocol across the Health Board as an interim consistent approach pending formal policy approval.

Verbatim wording from the response
“BCUHB has developed a protocol for their area to ensure a consistent approach to ambulance handover across North Wales. The Medical Director has mandated the protocol that is currently used at Ysbyty Gwynedd Hospital to be used across the Health Board for use in the interim period until a new Handover Policy for BCUHB can be formally agreed. The revised protocols are currently out for consultation and will require ratification by both BCUHB and the Trust prior to formal implementation.”

Source location
2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014
Open published response
2 Jul2014
North Wales (East and Central)
Concerns raised2
1. Inconsistent criteria for requesting CT scans outside standard hours and at weekends
2. Inconsistent levels of care provided to patients across the 24-hour period
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Existing emergency on-call arrangements ensure life-threatening CT referrals receive urgent scanning at any time, regardless of whether it is within normal working hours.
  Existing arrangements considered sufficient
AI-generated summary

Ronald Perry · 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

Ronald Perry attended Glan Clwyd Hospital on 17 January 2014, was discharged after examination, then collapsed several hours later and could not be resuscitated after readmission. Evidence at the inquest indicated that a CT scan might probably have detected his aneurysm, and raised concern about inconsistent criteria for requesting CT scans outside normal hours and at weekends, creating continuing risks to 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
Inconsistent criteria for requesting CT scans outside standard hours and at weekends
Wider context from the report
“During the course of the inquest, evidence given by ████████ ████████ indicated that had the Deceased undergone a CT scan then it is probable that his aneurysm would have been detected and that he would have undergone surgery. However different criteria exist within BCUHB by which CT scans can be requested by clinicians dependent upon the time of day (before or after 5.00 pm) or whether such a request is made at a weekend. That unless steps are taken to provide consistency within the levels of care provided to patients on a 24 hour basis then there will be continuing risks to patients "out of hours" and may lead to future deaths. ”
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
Inconsistent levels of care provided to patients across the 24-hour period
Wider context from the report
“During the course of the inquest, evidence given by ████████ ████████ indicated that had the Deceased undergone a CT scan then it is probable that his aneurysm would have been detected and that he would have undergone surgery. However different criteria exist within BCUHB by which CT scans can be requested by clinicians dependent upon the time of day (before or after 5.00 pm) or whether such a request is made at a weekend. That unless steps are taken to provide consistency within the levels of care provided to patients on a 24 hour basis then there will be continuing risks to patients "out of hours" and may lead to future deaths. ”
Open source report
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 emergency on-call arrangements ensure life-threatening CT referrals receive urgent scanning at any time, regardless of whether it is within normal working hours.

Verbatim wording from the response
“The Radiology service at all three district general hospital’s in North Wales operates a full service Monday to Friday 8.30 am to 5.30pm with some scanning lists being extended into the evenings. This comprises of lists with booked outpatients, urgent suspected cancer patients, inpatients and clinical emergencies. At all other times a general X-ray service is offered alongside an emergency on call service for CT and ultrasound scanning. The emergency on call service is provided on a consultant to consultant basis for all cases where scanning is required to diagnose an emergency or life threatening condition.”

Source location
2014-0302-Response-by-University-Health-Board
Page 1 · response
Published 2 July 2014
Open published response
2 Jul2014
North Wales (East and Central)
Concerns raised1
1. Failure of the process for conducting and completing SIRs
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

Esther Jane 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

Esther Jane Jones died at Maelor Hospital, Wrexham, on 30 March 2013. Her death was recorded as due to natural causes, with concerns about missed medication and the process for conducting and completing Serious Incident Reviews, which was said to pose continuing risks to others and may lead to future deaths.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation
Failure of the process for conducting and completing SIRs
Wider context from the report
“That unless steps are taken to improve the process by which SIRs are conducted and completed, then this could pose continuing risks to others and may lead to future deaths. ”
Open source report
13 Jun2014
North Wales (East and Central)
Concerns raised1
1. Failure to balance patient confidentiality with familial support for recovery
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Existing confidentiality procedures and capacity-based decision-making are considered sufficient to balance confidentiality with appropriate familial involvement and support.
  Existing arrangements considered sufficient
AI-generated summary

Alun Sheppard · 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 21 December 2013, Alun Sheppard inflicted a number of stab wounds upon himself with a kitchen knife at The Fields, Holt, Wrexham. He initially survived and was treated, but his condition deteriorated and he died at Maelor Hospital Wrexham on 10 January 2014. The principal concern was whether the Health Board could balance the patient’s right to confidentiality with facilitating familial support to optimise the prospect of recovery.

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 balance patient confidentiality with familial support for recovery
Wider context from the report
“Effectively the concern in this case revolves around whether the Health Board are able to balance the patient's right to confidentiality whilst also seeking to optimize the prospect of recovery by facilitating familial support. ”
Open source report
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 confidentiality procedures and capacity-based decision-making are considered sufficient to balance confidentiality with appropriate familial involvement and support.

Verbatim wording from the response
“The policy of the Health Board is to use a confidentiality form, a copy of which is enclosed. If a patient has capacity to make decisions about whether or not families or carers are involved in a patient's care planning and care, services are obliged to respect that decision unless there is an overriding public interest that merits disclosure of information. If a patient makes a capacious decision not to involve their family or carers in their care, mental health practitioners still have a responsibility to listen to any concerns and act upon them accordingly. If a patient is deemed to lack capacity, a disclosure of information needs to be based on a Best Interest Decision.”

Source location
2014-0268-Response-by-NHS-Wales
Page 1 · response
Published 13 June 2014
Open published response
21 Jan2014
North Wales (East and Central)
Concerns raised1
1. Failure of Emergency Department patient handover practices to prevent unacceptable delays
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Amend Llandudno Minor Injuries Unit access criteria to treat more patients locally.
  Stated completed
2. Action
  Continue participating in the National Patient Flow Collaborative to improve unscheduled-care consistency and sustainability.
  Stated in progress
3. Action
  Commission joint senior-manager workstreams to improve unscheduled-care flow and signpost patients to alternative care pathways.
  Stated completed
1. Action
  Communicate handover-delay risks and patient-flow responsibilities to clinical, operational and senior medical staff.
  Stated completed
2. Action
  Perform monthly clinical audits of patients delayed in ambulances outside Emergency Departments and use findings to improve patient flow.
  Stated planned
3. Action
  Agree and implement a joint flow chart addressing clinical risks for patients waiting in ambulances.
  Stated in progress
4. Action
  Implement the Frailty Programme to support early discharge across the Health Board.
  Stated planned
5. Action
  Complete and agree an All-Wales Handover Policy for evidence-based patient handover between clinical teams.
  Stated in progress
AI-generated summary

Frederick Douglas Pring · 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

Frederick Douglas Pring experienced chest pains, but no ambulance was available after his first emergency call because of delays handing over patients at hospitals and ambulance crews being on rest breaks. He died at home on 21 March 2013 before an ambulance arrived; a post-mortem identified ischaemic heart disease and severe chronic obstructive pulmonary disease. The principal concern was that delays in patient handovers at Emergency Departments left patients waiting in ambulances and made ambulance resources unavailable for other calls.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Betsi Cadwaladr University LHB; that does not assign responsibility.
PFD Monitor interpretation
Failure of Emergency Department patient handover practices to prevent unacceptable delays
Wider context from the report
“That the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls. Whilst this is a multi-factorial problem, improvements must be made so as to reduce the risk of future deaths. ”
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
Amend Llandudno Minor Injuries Unit access criteria to treat more patients locally.

Verbatim wording from the response
“• Redefining ‘border’ areas to equate the volume of WAST attendances at the three DGHs;”

Source location
2014-0024-Response-by-Welsh-Ambulance-Service
Page 5 · response
Published 21 January 2014
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 participating in the National Patient Flow Collaborative to improve unscheduled-care consistency and sustainability.

Verbatim wording from the response
“There will be a focus on implementing the “Frailty Programme” to provide early supportive discharge across the Health Board. The Health Board has two teams taking part in the National Patient Flow Collaborative which has clear aims to make consistent and sustainable improvements to Unscheduled Care.”

Source location
2014-0024-Response-by-Welsh-Ambulance-Service
Page 6 · response
Published 21 January 2014
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
Commission joint senior-manager workstreams to improve unscheduled-care flow and signpost patients to alternative care pathways.

Verbatim wording from the response
“A ‘Delivery Group’ has been commissioned by the Local Health Board comprising of Senior Managers from the two organisations to oversee developments within Unscheduled Care in North Wales. The Group has various work streams to implement approaches which will improve flow and signpost patients to alternative pathways of care, as opposed to conveying to Emergency Departments by default. In line with the practice in the other Clinical Contact Centres, Advanced Paramedic Practitioners (APPs) are now working within the Clinical Contact Centres in order to enhance patient safety and to provide clinical advice to the Clinical Contact operational WAST outcalls, and also to patients and relatives who require our services.”

Source location
2014-0024-Response-by-Welsh-Ambulance-Service
Page 5 · response
Published 21 January 2014
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
Communicate handover-delay risks and patient-flow responsibilities to clinical, operational and senior medical staff.

Verbatim wording from the response
“The issues which you have raised are vitally important and the Health Board is committed to working with the Ambulance Trust and other partners to improve the current situation as a matter of urgency. The BCUHB Medical Director has communicated these issues to all Clinical Leaders, Consultant Medical Staff and NHS Professional Managers across the Health Board. (Please see Appendices 2 & 3)”

Source location
2014-0024-Response-by-Welsh-Ambulance-Service
Page 5 · response
Published 21 January 2014
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
Perform monthly clinical audits of patients delayed in ambulances outside Emergency Departments and use findings to improve patient flow.

Verbatim wording from the response
“(1) There will be monthly clinical audits performed to provide assurance regarding the safe management of patients who are delayed in Ambulances outside Emergency Departments prior to admission. The audits will facilitate the implementation of practice changes which improve patient flow. The results of the audit will be presented to the Medical Director, Director of Nursing, Interim Chief Operating Officer, local Hospital Management Teams, local Patient Safety Groups to ensure Health Board assurance. The audit tool is attached (Please see Appendix 4).”

Source location
2014-0024-Response-by-Welsh-Ambulance-Service
Page 6 · response
Published 21 January 2014
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
Agree and implement a joint flow chart addressing clinical risks for patients waiting in ambulances.

Verbatim wording from the response
“(2) WAST and the Health Board have accelerated the discussion which was taking place relating to agreement and implementation of a ‘flow chart’ (Please see Appendix 5 (in draft)) to address the clinical risks relating to patients waiting in Ambulances. This is being further discussed at a meeting on Thursday 27 March 2014.”

Source location
2014-0024-Response-by-Welsh-Ambulance-Service
Page 6 · response
Published 21 January 2014
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 Frailty Programme to support early discharge across the Health Board.

Verbatim wording from the response
“There will be a focus on implementing the “Frailty Programme” to provide early supportive discharge across the Health Board. The Health Board has two teams taking part in the National Patient Flow Collaborative which has clear aims to make consistent and sustainable improvements to Unscheduled Care.”

Source location
2014-0024-Response-by-Welsh-Ambulance-Service
Page 6 · response
Published 21 January 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Complete and agree an All-Wales Handover Policy for evidence-based patient handover between clinical teams.

Verbatim wording from the response
“(3) WAST and the Health Board are working together with colleagues across Wales regarding completion of an All Wales Handover Policy which describes evidence based processes for patient handover between clinical teams. We will forward this to you as soon as it is completed and agreed.”

Source location
2014-0024-Response-by-Welsh-Ambulance-Service
Page 6 · response
Published 21 January 2014
Open published response
25 Sep2013
North Wales (East and Central)
Concerns raised1
1. Failure to conduct tests required by a clinician
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Deliver Train the Trainer support and ward-level mandatory education on Clostridium difficile management and obtaining specimens.
  Stated in progress
2. Action
  Implement a ward improvement plan with staff training and monitoring of compliance with sample-obtaining responsibilities.
  Stated in progress
3. Action
  Implement a revised Infection Prevention Education Programme covering diarrhoea management and prompt submission of specimens.
  Stated completed
1. Action
  Run a staff-wide communications and awareness campaign reinforcing immediate actions for diarrhoea, including obtaining and sending specimens for analysis.
  Stated completed
2. Action
  Include the sample-obtaining issue in ward Safety Briefings for four weeks and circulate a related memo across PCSM East clinical areas.
  Stated completed
3. Action
  Disseminate written reminders to Bersham Ward staff about timely investigations and obtaining stool samples, with signed acknowledgement.
  Stated completed
4. Action
  Finalize a ward standards plan using key indicators and increased monitoring to check that specimens are sent promptly when diarrhoea occurs.
  Stated in progress
5. Action
  Recirculate the policy for managing suspected and confirmed Clostridium difficile infection to all PCSM clinical areas.
  Stated completed
6. Action
  Conduct an unannounced adult-ward spot check linking diarrhoea cases with laboratory receipt of stool samples and provide immediate staff education where samples were missing.
  Stated completed
Respondent positions 1
1. Position
  The Health Board considers the issues raised adequately addressed by the actions taken and does not identify further responsive work.
  No action considered necessary
AI-generated summary

Gwilym Pugh 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

Gwilym Pugh Jones was admitted to Wrexham Maelor Hospital after an apparent stroke and later developed symptoms suggestive of a Clostridium Difficile infection. A stool sample requested by a clinician was not obtained or tested, resulting in a missed opportunity for diagnosis and treatment; he subsequently died with sepsis, peritonitis and toxic megacolon associated with pseudomembranous colitis.

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 conduct tests required by a clinician
Wider context from the report
“(1) Tests were not conducted despite being required by a clinician and this resulted in a missed opportunity to provide a diagnosis and treatment. ”
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 Train the Trainer support and ward-level mandatory education on Clostridium difficile management and obtaining specimens.

Verbatim wording from the response
“Mandatory training is in place for all staff members on an annual basis. In recent months, the Governance Team in PCSM East have undertaken a “Train the Trainer” programme with the Infection Control Team and are assisting in the training of staff at ward level for times when staff cannot be released from the ward area to attend training sessions. The training which is delivered through the mandatory presentation covers the management of suspected and confirmed cases of Clostridium Difficile and the process of obtaining samples for testing.”

Source location
2013-0239-Response
Page 3 · response
Published 26 January 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement a ward improvement plan with staff training and monitoring of compliance with sample-obtaining responsibilities.

Verbatim wording from the response
“It therefore appears that the request for a stool sample was an omission on the part of nursing staff. This has been discussed with them, both individually and collectively, and their practice is being monitored by the Ward Sister who has implemented an improvement plan which includes a training programme for all staff. The Ward Sister has provided an assurance to the Matron that staff are now aware of their responsibilities with regards to the obtaining of samples.”

Source location
2013-0239-Response
Page 2 · response
Published 26 January 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement a revised Infection Prevention Education Programme covering diarrhoea management and prompt submission of specimens.

Verbatim wording from the response
“The Infection Prevention Education Programme within BCUHB was reviewed so as to ensure that education is provided to staff on all key issues. The revised programme includes education on management of patients who present with diarrhoea and the need to ensure specimens are sent to the laboratory. This came into being in January 2014.”

Source location
2013-0239-Response
Page 4 · response
Published 26 January 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Run a staff-wide communications and awareness campaign reinforcing immediate actions for diarrhoea, including obtaining and sending specimens for analysis.

Verbatim wording from the response
“As part of actions being introduced to reduce the number of cases of Clostridium Difficile infection, a communications and awareness campaign was introduced in December 2013 which is aimed at all staff. This reinforces key standard required to prevent Clostridium Difficile infection and all the actions that must be taken immediately a patient develops diarrhoea, including obtaining a specimen and sending it for analysis.”

Source location
2013-0239-Response
Page 4 · response
Published 26 January 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Include the sample-obtaining issue in ward Safety Briefings for four weeks and circulate a related memo across PCSM East clinical areas.

Verbatim wording from the response
“Matron ████████ has also directed that the issue was to be on every Safety Briefing for a period of four weeks therefore a memo was distributed to all Clinical areas within the PCSM CPG (East), outlining the matter (number 5 on the attached action plan).”

Source location
2013-0239-Response
Page 3 · response
Published 26 January 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Disseminate written reminders to Bersham Ward staff about timely investigations and obtaining stool samples, with signed acknowledgement.

Verbatim wording from the response
“The Matron for the relevant area ████████ has written to all staff on Bersham Ward individually outlining the concerns regarding the failure to obtain stool samples for this patient. The letter reminded staff of their duty of care to undertake investigations in a timely manner. A copy of this letter is attached, together with a copy of the signature sheet which staff were required to sign when they had read their letter (items 3 and 4 attached to the action plan).”

Source location
2013-0239-Response
Page 3 · response
Published 26 January 2014
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
Finalize a ward standards plan using key indicators and increased monitoring to check that specimens are sent promptly when diarrhoea occurs.

Verbatim wording from the response
“A plan to ensure that key standards for the prevention and management of Clostridium Difficile infection are highly visible and clearly understood is in the final stages of development. This work includes the use of key indicators in all wards when a case occurs. As a consequence of this, there will be an increase in the monitoring frequency of key standards and specifically includes a check to ensure that specimens are sent rapidly once diarrhoea occurs. The standards sheet is currently being finalised but a copy of the current version is attached (11) with RAG – red, amber, green status – ratings included as an example.”

Source location
2013-0239-Response
Page 4 · response
Published 26 January 2014
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
Recirculate the policy for managing suspected and confirmed Clostridium difficile infection to all PCSM clinical areas.

Verbatim wording from the response
“There are also a number of Policies which guide staff on the prevention and control of infection. In these Policies the standard procedures for obtaining samples and managing infectious conditions are clearly set out for staff to follow. As stated above, these are readily available in the ward area and online and staff are expected to adhere to these processes.”

Source location
2013-0239-Response
Page 3 · response
Published 26 January 2014
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 an unannounced adult-ward spot check linking diarrhoea cases with laboratory receipt of stool samples and provide immediate staff education where samples were missing.

Verbatim wording from the response
“An unannounced spot check was performed across all adult wards in Wrexham Maelor between 1st and 7th November 2013 to identify patients with diarrhoea and cross check this information with stool samples received in the laboratory. Of the 456 patients reviewed, a total of 17 had diarrhoea and samples from 14 of the 17 had been sent to the laboratory for analysis. The Infection Prevention Nurses provided on the spot education to staff, reinforcing the need for samples to be taken in the 3 cases where a sample had not been sent. A copy of the spot check summary is attached (12).”

Source location
2013-0239-Response
Page 4 · response
Published 26 January 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Health Board considers the issues raised adequately addressed by the actions taken and does not identify further responsive work.

Verbatim wording from the response
“This concludes the actions that have been taken to address the issues raised in your Regulation 28 report and I hope that you feel they have been addressed adequately. However, please do not hesitate to contact me if you require any additional information or if I can be of further assistance.”

Source location
2013-0239-Response
Page 4 · response
Published 26 January 2014
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised1

Lack of a documented regime for regular fetal-heart auscultation after maternal opiate administration

Concerns raised2

Failure to communicate the effects of caffeine and smoking changes on clozapine levels

Failure to communicate the warning signs of clozapine toxicity

Concerns raised6

Delays in the provision of ambulance assistance

Failure of Emergency Department patient handover practices to prevent prolonged ambulance waits and resource unavailability

Failure to ensure emergency clinicians know what pain relief has already been provided

Unavailability of senior clinicians for overnight second opinions

Failure to rectify previously identified patient handover delays

Lack of emergency clinicians’ awareness of overnight patient-discharge policies

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.12

Concerns raised2

Inconsistent criteria for requesting CT scans outside standard hours and at weekends

Inconsistent levels of care provided to patients across the 24-hour period

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Concerns raised1

Failure of the process for conducting and completing SIRs

Concerns raised1

Failure to balance patient confidentiality with familial support for recovery

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Concerns raised1

Failure of Emergency Department patient handover practices to prevent unacceptable delays

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.8

Actions described in response 12

Respondent positions 1

Respondent positions 1

Actions described in response 8