Bryntirion Surgery

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First report 27 Jul 2015•Latest report 4 Sep 2015

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Bryntirion Surgery linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Mrs. Mary Patricia James · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs. Mary Patricia James had a prosthetic heart valve requiring anticoagulation, but INR monitoring was inadequate and there was uncertainty about whether she was taking Warfarin. Concerns included failures in communication between the INR Unit, care home and GP, and that she was not admitted to hospital on 15 May 2015 despite concern about a possible ischaemic leg. The inquest concluded: “Ischaemic leg contributed to by inadequate Warfarin monitoring and dosing”.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bryntirion Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate monitoring of INR levels

    Wider context from the report

    “(1) Inadequate monitoring of INR levels in a patient suffering from dementia; ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bryntirion Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate communication about anticoagulation monitoring and potential therapy adjustment

    Wider context from the report

    “(3) Inadequate communication between the INR Unit, the Care Home and the GP regarding this patient’s anticoagulation monitoring and the potential need for therapy adjustment; ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bryntirion Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of certainty whether Warfarin was being taken

    Wider context from the report

    “(2) Lack of certainty whether Warfarin was being taken by the patient; ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bryntirion Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment

    Wider context from the report

    “(4) That against this background and the Care Home’s concern about a possible ischaemic leg, Mrs. James was not admitted to hospital on the 15th May, 2015 when there may have been a window of opportunity to have adjusted the anticoagulation therapy. ”
    Open source report

  2. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Mr. Arthur Cook · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr. Arthur Cook had poor circulation and a chronic open wound that developed into an MRSA-infected category 4 pressure ulcer while he was resident at Four Seasons Healthcare Residential Home. He failed to respond to treatment and died. Concerns included insufficient tissue viability nursing capacity, inadequate pressure-ulcer documentation and repositioning charts, and a lack of integrated skin care across services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bryntirion Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient staffing of Tissue Viability Nurses

    Wider context from the report

    “(1) Staffing levels of Tissue Viability Nurses within the Aneurin Bevan Health Board are low and to the extent that at times this service cannot be provided according to need; ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bryntirion Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain adequate repositioning charts

    Wider context from the report

    “(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bryntirion Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain adequate pressure ulcer documentation

    Wider context from the report

    “(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bryntirion Surgery; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of integrated skin care across Health Boards and Primary healthcare services

    Wider context from the report

    “(3) An apparent lack of integrated skin care within and between Health Boards and Primary healthcare services. ”
    Open source report
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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