6 May 2026 Lisa Jayne Townsend · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Lack of an established protocol for escalation and referral of HPB-related matters to a tertiary centre View source Delays in seeking specialist advice and transferring patients to a tertiary centre 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
Lisa Jayne Townsend · 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
Lisa Jayne Townsend had abdominal pain and was diagnosed with cholecystitis and pancreatitis in late September 2024. Her gallbladder surgery was delayed and, during the operation on 1 October 2024, an injury was sustained to the bile duct; subsequent attempts to rectify it were unsuccessful. She later developed chronic sepsis and died on 20 March 2025. The report identified multiple delays and issues in her care, including the bile duct injury, as contributing 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of an established protocol for escalation and referral of HPB-related matters to a tertiary centre
Wider context from the report “During the inquest touching the death of Lisa Jayne Townsend, the Coroner heard evidence in respect of the absence of clear guidance and protocol for when a referral should be made by the local hospital (Princess of Wales, Bridgend) to the tertiary centre (University Hospital of Wales) in respect of Hepato-Pancreato-Biliary (HPB) related matters . There was a delay in advice being sought from and transfer to the tertiary centre taking place. There remains no established protocol to assist Clinicians with when they should escalate and seek further specialist advice from their tertiary centre to ensure timely consideration of the patient’s issue.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in seeking specialist advice and transferring patients to a tertiary centre
Wider context from the report “During the inquest touching the death of Lisa Jayne Townsend, the Coroner heard evidence in respect of the absence of clear guidance and protocol for when a referral should be made by the local hospital (Princess of Wales, Bridgend) to the tertiary centre (University Hospital of Wales) in respect of Hepato-Pancreato-Biliary (HPB) related matters. There was a delay in advice being sought from and transfer to the tertiary centre taking place. There remains no established protocol to assist Clinicians with when they should escalate and seek further specialist advice from their tertiary centre to ensure timely consideration of the patient’s issue.
” Open source report
6 Mar 2026 Alan Bevis TOMLINSON · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 6 Inconsistent gathering of clinical information during clinic visits View source Inadequate documentation of clinical findings View source Inadequate communication of clinical findings to the Cardiology team View source Lack of guidance on when pacemaker data should trigger cardiology review View source Limited physiologist knowledge of infective endocarditis View source Inconsistent implant site checks during clinic visits View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 12
Action
Implement the Fysicon electronic patient record to incorporate clinical notes and provide trend data for clinical decision-making.
Stated in progressThe respondent said that this action was in progress when they made their response on 10 March 2026. View source
Action
Circulate guidance on when and how physiologists should escalate patients to a cardiologist.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2026. View source
Action
Implement revised device escalation and referral criteria, including a mandatory referral trigger for loss of a twofold safety margin.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2026. View source
Action
Require clinic entries to document clinical findings, implant-site observations, red flags, patient symptoms, device data, and associated tests.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2026. View source
Action
Introduce a clinical history sheet requiring red-flag assessment and documented inspection of device implantation sites during device-check appointments.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2026. View source
Action
Present the device escalation SOP at the departmental Quality and Safety meeting.
Stated plannedThe respondent said that this action was planned when they made their response on 10 March 2026. View source
Action
Share the device escalation SOP with all physiologists.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2026. View source
Action
Develop broader red-flag questions and an associated training package for device clinics.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2026. View source
Action
Develop specific Cardiac Physiology inboxes within the existing e-Advice system.
Status unclearThe respondent did not make the status of this action clear when they made their response on 10 March 2026. View source
Action
Deliver physiologist training on infective endocarditis, unwell-patient red flags, and cardiology escalation.
Stated plannedThe respondent said that this action was planned when they made their response on 10 March 2026. View source
Action
Establish audits of notes-standard compliance and e-Advice usage and response times.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2026. View source
Action
Conduct monthly notes audits during the quarter following SOP presentation.
Stated plannedThe respondent said that this action was planned when they made their response on 10 March 2026. View source See 9 more actions
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AI-generated summary
Alan Bevis TOMLINSON · 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 Bevis TOMLINSON attended hospital on 16 April 2024 with illness, significant weight loss, anaemia and swelling around his pacemaker site, but was advised to return home because no cardiac bed was available. He died at home on 18 April 2024 from the effects of untreated infective endocarditis, likely associated with a longstanding infection at the pacemaker implant site. Concerns included missed referral to cardiology despite increasing pacemaker thresholds and visible illness, and failures to identify infective endocarditis, gather and document clinical information, and communicate findings effectively.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Inconsistent gathering of clinical information during clinic visits
Wider context from the report “Evidence from the Chief Physiologist identified wider concerns within the service, including:
1. Lack of guidance on when pacemaker data should trigger cardiology review;
2. Limited physiologist knowledge of infective endocarditis;
3. Inconsistent gathering of clinical information and implant site checks during clinic visits;
4. How clinical findings were documented and communicated, particularly to the Cardiology team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Inadequate documentation of clinical findings
Wider context from the report “Evidence from the Chief Physiologist identified wider concerns within the service, including:
1. Lack of guidance on when pacemaker data should trigger cardiology review;
2. Limited physiologist knowledge of infective endocarditis;
3. Inconsistent gathering of clinical information and implant site checks during clinic visits;
4. How clinical findings were documented and communicated, particularly to the Cardiology team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication of clinical findings to the Cardiology team
Wider context from the report “Evidence from the Chief Physiologist identified wider concerns within the service, including:
1. Lack of guidance on when pacemaker data should trigger cardiology review;
2. Limited physiologist knowledge of infective endocarditis;
3. Inconsistent gathering of clinical information and implant site checks during clinic visits;
4. How clinical findings were documented and communicated, particularly to the Cardiology team .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on when pacemaker data should trigger cardiology review
Wider context from the report “Evidence from the Chief Physiologist identified wider concerns within the service, including:
1. Lack of guidance on when pacemaker data should trigger cardiology review ;
2. Limited physiologist knowledge of infective endocarditis;
3. Inconsistent gathering of clinical information and implant site checks during clinic visits;
4. How clinical findings were documented and communicated, particularly to the Cardiology team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Limited physiologist knowledge of infective endocarditis
Wider context from the report “Evidence from the Chief Physiologist identified wider concerns within the service, including:
1. Lack of guidance on when pacemaker data should trigger cardiology review;
2. Limited physiologist knowledge of infective endocarditis ;
3. Inconsistent gathering of clinical information and implant site checks during clinic visits;
4. How clinical findings were documented and communicated, particularly to the Cardiology team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Inconsistent implant site checks during clinic visits
Wider context from the report “Evidence from the Chief Physiologist identified wider concerns within the service, including:
1. Lack of guidance on when pacemaker data should trigger cardiology review;
2. Limited physiologist knowledge of infective endocarditis;
3. Inconsistent gathering of clinical information and implant site checks during clinic visits ;
4. How clinical findings were documented and communicated, particularly to the Cardiology team.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Fysicon electronic patient record to incorporate clinical notes and provide trend data for clinical decision-making.
Verbatim wording from the response “Digital Support
We are implementing the Fysicon system, which is an electronic patient record. This will incorporate all clinical notes and will provide trend data to further enhance the clinical decision making and improve patient outcomes.” Source location Response from Cardiff and Vale 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 Circulate guidance on when and how physiologists should escalate patients to a cardiologist.
Verbatim wording from the response “• Training sessions have been arranged for delivery covering:
○ Recognition of infective endocarditis, including atypical presentations, will be delivered by a Consultant Cardiologist.
○ Recognising the generally unwell patient and Red Flags which will be delivered by the Nursing Practice Educators.
○ When and how to escalate to a cardiologist has been circulated via e-mail and will be delivered on the 13th of May Quality and Safety afternoon.” Source location Response from Cardiff and Vale 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 revised device escalation and referral criteria, including a mandatory referral trigger for loss of a twofold safety margin.
Verbatim wording from the response “Actions
The Health Board takes these findings extremely seriously. In response, the following actions have already been implemented:” Source location Response from Cardiff and Vale 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 Require clinic entries to document clinical findings, implant-site observations, red flags, patient symptoms, device data, and associated tests.
Verbatim wording from the response “Strengthened Documentation and Communication Pathways” Source location Response from Cardiff and Vale 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 clinical history sheet requiring red-flag assessment and documented inspection of device implantation sites during device-check appointments.
Verbatim wording from the response “Enhanced Clinical Assessment Standards” Source location Response from Cardiff and Vale 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 Present the device escalation SOP at the departmental Quality and Safety meeting.
Verbatim wording from the response “• A mandatory referral trigger is now in place if a device has lost a twofold safety margin. This has been clearly documented in the “Managing the Unwell Patient Standard Operating Procedure” (attached) which is stored on the departmental SharePoint.” Source location Response from Cardiff and Vale University Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the device escalation SOP with all physiologists.
Verbatim wording from the response “• A mandatory referral trigger is now in place if a device has lost a twofold safety margin. This has been clearly documented in the “Managing the Unwell Patient Standard Operating Procedure” (attached) which is stored on the departmental SharePoint.” Source location Response from Cardiff and Vale 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 broader red-flag questions and an associated training package for device clinics.
Verbatim wording from the response “To develop these service improvements benchmarking exercises were conducted. The development of the Red Flag questions is a change to practice in Wales. On discussion with our colleagues in neighbouring health boards, it appears the undergraduate Cardiac Physiology teaching on recognition of systemic illness in patients is limited. The questions in device clinics remain focused on cardiology specific conditions, such as heart failure. As a Health Board, we recognise that this would be too limited for our patient cohort. We have, therefore, developed broader Red Flag questions and an associated training package.” Source location Response from Cardiff and Vale 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 specific Cardiac Physiology inboxes within the existing e-Advice system.
Verbatim wording from the response “Strengthened Documentation and Communication Pathways” Source location Response from Cardiff and Vale 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 physiologist training on infective endocarditis, unwell-patient red flags, and cardiology escalation.
Verbatim wording from the response “Training and Education for Physiologists” Source location Response from Cardiff and Vale 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 audits of notes-standard compliance and e-Advice usage and response times.
Verbatim wording from the response “Audit and Quality Assurance” Source location Response from Cardiff and Vale 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 monthly notes audits during the quarter following SOP presentation.
Verbatim wording from the response “• Monthly notes audits will be conducted for the quarter following presentation of the SOP on the 13th of May.” Source location Response from Cardiff and Vale University Health Board
Open published response
27 Feb 2026 SUMMER RAE MANT · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Lack of standardised crash trolleys across hospital settings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
SUMMER RAE MANT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Summer Rae Mant, a four-year-old child with MIRAGE syndrome, developed severe infection and virus while an inpatient and suffered hypoxia and cardiac arrest during events on 17 and 18 March 2024. She later developed sudden multi-organ failure of uncertain cause and died at Ty Hafan on 21 September 2024. A substantive concern was a delay in obtaining adrenaline during resuscitation, associated with non-standardised crash trolleys and staff unfamiliarity with different hospital configurations.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised crash trolleys across hospital settings
Wider context from the report “During the resuscitation of Summer at Prince Charles Hospital in the theatre following intubation, there was a delay in obtaining adrenaline. The incident occurred at night and it involved a skeleton staff including some junior doctors, fairly new to the hospital.
The delay in finding adrenaline, was likely due to the fact that there is no standardised crash trolley , and junior doctors frequently rotate between hospitals and health boards and encounter different set-ups .
Paediatric crash trolleys are necessarily different to adult crash trolleys, but there was consensus in evidence that it would be safer if there was a single standardised version of each type across every hospital setting in which junior doctors rotate , to minimise confusion at a time critical moment.
” Open source report
4 Feb 2026 Joan Marilyn READ · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Lack of cross-cover for geriatric perioperative care during consultant absence View source Failure to establish year-round cross-cover within a doctor’s job plan View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joan Marilyn READ · 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
Joan Marilyn Read, aged 91, died at the University Hospital of Wales on 18 March 2025 after a period of deterioration and decline. A severely deranged B12 result was not communicated or treated following her 2023 admission, and the report states that failure to address the deficiency more than minimally contributed to her death. The principal concern was the absence of year-round cross-cover for the single consultant responsible for geriatric perioperative care, creating a risk that urgent results could be missed during absences.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-cover for geriatric perioperative care during consultant absence
Wider context from the report “(1) Evidence revealed that a single medical consultant is responsible for geriatric perioperative care (POPS). There is no cross-cover during periods of expected and unexpected absence. There is a risk that deranged test results or other urgent results will be missed when that doctor is absent ;
(2) Without a robust system for cross-cover 52 weeks per year recognised within another doctor’s job plan, this risk will likely continue, despite huge positive strides in communicating test results within the Trust.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to establish year-round cross-cover within a doctor’s job plan
Wider context from the report “(1) Evidence revealed that a single medical consultant is responsible for geriatric perioperative care (POPS). There is no cross-cover during periods of expected and unexpected absence. There is a risk that deranged test results or other urgent results will be missed when that doctor is absent;
(2) Without a robust system for cross-cover 52 weeks per year recognised within another doctor’s job plan , this risk will likely continue , despite huge positive strides in communicating test results within the Trust.
” 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 Embed senior decision-making resilience within emergency and surgical pathways.
Verbatim wording from the response “Expansion of the POPS Service – Sustainable Long-Term Plan (In Progress)” Source location 2026-0055 - Response from Cardiff and Vale University Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a POPS cross-cover rota.
Verbatim wording from the response “Expansion of the POPS Service – Sustainable Long-Term Plan (In Progress)” Source location 2026-0055 - Response from Cardiff and Vale 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 Prioritise consultant workforce expansion to support 52-week POPS service continuity.
Verbatim wording from the response “Expansion of the POPS Service – Sustainable Long-Term Plan (In Progress)” Source location 2026-0055 - Response from Cardiff and Vale 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 interim escalation, specialty review and structured documentation arrangements to provide POPS result cross-cover.
Verbatim wording from the response “We acknowledge the coroner’s concerns regarding the absence of POPS consultant cross-cover and the associated risk of delays in reviewing results or acting on abnormal findings. If further consultant support is needed out of hours, then the on-call service for hospital cover would be contacted POPS Consultant Cross-Cover – Interim Mitigation (Implemented).” Source location 2026-0055 - Response from Cardiff and Vale 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 Reinforce senior-clinician WCP result review and conduct twice-weekly POPS checks for abnormalities.
Verbatim wording from the response “Routine Electronic Communication via Welsh Clinical Portal (WCP) – Reinforced Use” Source location 2026-0055 - Response from Cardiff and Vale University Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a strengthened SOP requiring telephone communication, escalation and documentation for critically low Vitamin B12 results.
Verbatim wording from the response “Strengthened Laboratory SOP for Critically Low B12 Results (Implemented)” Source location 2026-0055 - Response from Cardiff and Vale 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 Organisational financial constraints prevent immediate completion of POPS service expansion and additional consultant workforce, although expansion remains an ongoing strategic objective.
Verbatim wording from the response “Expansion of the POPS service remains a recognised clinical need. Given organisational financial constraints, this is an ongoing strategic objective, but the Health Board is committed to:” Source location 2026-0055 - Response from Cardiff and Vale University Health Board
Open published response
12 Sep 2025 Gareth Idris Johnson · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Failure of safeguards for moving patients requiring critical care during times of pressure View source Lack of adequate hospital building maintenance View source Insufficient Critical Care capacity for patient volumes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 7
Action
Deliver scheduled infrastructure upgrades, including UPS installations and electrical-supply improvements, through the Estates programme.
Stated plannedThe respondent said that this action was planned when they made their response on 19 September 2025. View source
Action
Regularly review and simulate critical-care escalation and major-incident plans.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 September 2025. View source
Action
Implemented a Critical Care Escalation Plan governing staffed bed capacity, patient prioritisation, delayed-transfer escalation, clinically led transfers and diversion arrangements.
Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Developed a Major Incident Plan framework defining emergency command, reporting, escalation, evacuation, triage, patient transfer, communications and critical-care staff responsibilities.
Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Conduct annual stress testing and live major-incident exercises at least every three years, maintaining training records.
Stated plannedThe respondent said that this action was planned when they made their response on 19 September 2025. View source
Action
Developed an Electrical Failure Emergency Action Card covering power-failure response, vulnerable-patient evacuation, emergency decanting and business-continuity arrangements.
Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Provide ongoing staff training in major-incident response and escalation procedures.
Stated in progressThe respondent said that this action was in progress when they made their response on 19 September 2025. View source See 4 more actions
×
AI-generated summary
Gareth Idris Johnson · 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
Gareth Idris Johnson attended hospital with a bilateral pulmonary embolism and underwent catheter-directed thrombolysis. He later died at University Hospital of Wales from complications following the procedure. The report identified suboptimal post-operative anticoagulation management, including a lack of clarity about the appropriate heparin level, and raised concerns about transferring critical-care patients to PACU because of building maintenance, capacity pressures and infrastructure risks.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of safeguards for moving patients requiring critical care during times of pressure
Wider context from the report “Due to the age of the hospital building, maintenance is a constant battle. There are also capacity issues in Critical Care due to patient volumes.
Building infrastructure had been a constant feature on the corporate risk register and was now scored at its highest level.
Whilst measures have been put in place to safeguard against moving patients who require critical care from the Critical Care Unit, there remained fears that these systems would fail during times of pressure.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate hospital building maintenance
Wider context from the report “Due to the age of the hospital building, maintenance is a constant battle. There are also capacity issues in Critical Care due to patient volumes.
Building infrastructure had been a constant feature on the corporate risk register and was now scored at its highest level.
Whilst measures have been put in place to safeguard against moving patients who require critical care from the Critical Care Unit, there remained fears that these systems would fail during times of pressure.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient Critical Care capacity for patient volumes
Wider context from the report “Due to the age of the hospital building, maintenance is a constant battle. There are also capacity issues in Critical Care due to patient volumes.
Building infrastructure had been a constant feature on the corporate risk register and was now scored at its highest level.
Whilst measures have been put in place to safeguard against moving patients who require critical care from the Critical Care Unit, there remained fears that these systems would fail during times of pressure.
” 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 scheduled infrastructure upgrades, including UPS installations and electrical-supply improvements, through the Estates programme.
Verbatim wording from the response “• Infrastructure upgrades, including UPS installations and electrical supply improvements, scheduled as per the Estates programme.” Source location Response from Cardiff & Vale 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 Regularly review and simulate critical-care escalation and major-incident plans.
Verbatim wording from the response “• Regular review and simulation of escalation and major incident plans.” Source location Response from Cardiff & Vale 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 Implemented a Critical Care Escalation Plan governing staffed bed capacity, patient prioritisation, delayed-transfer escalation, clinically led transfers and diversion arrangements.
Verbatim wording from the response “The Health Board recognises the challenges posed by patient volumes and infrastructure. To address these, we have implemented the Critical Care Escalation Plan (October 2024), which details:” Source location Response from Cardiff & Vale 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 Developed a Major Incident Plan framework defining emergency command, reporting, escalation, evacuation, triage, patient transfer, communications and critical-care staff responsibilities.
Verbatim wording from the response “The Major Incident Plan v1.04 (DRAFT) provides a comprehensive framework for emergency preparedness, in line with the Civil Contingencies Act 2004. Key elements include.” Source location Response from Cardiff & Vale 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 annual stress testing and live major-incident exercises at least every three years, maintaining training records.
Verbatim wording from the response “• Annual stress testing and live exercises at least every three years, with training records maintained by the Critical Care Directorate.” Source location Response from Cardiff & Vale 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 Developed an Electrical Failure Emergency Action Card covering power-failure response, vulnerable-patient evacuation, emergency decanting and business-continuity arrangements.
Verbatim wording from the response “In response, we have developed the Electrical Failure Emergency Action Card (E1, draft October 2025), which outlines: Immediate actions to confirm and respond to power failures, including switching to unaffected supplies and declaring an ICU emergency if required.” Source location Response from Cardiff & Vale 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 ongoing staff training in major-incident response and escalation procedures.
Verbatim wording from the response “• Ongoing staff training in major incident response and escalation procedures.” Source location Response from Cardiff & Vale University Health Board
Open published response
21 May 2025 Robert Maxwell SMITH · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Lack of clear guidance on when and how information sharing and information gathering with family members should be undertaken View source Lack of clear requirements for recording information sharing and information gathering decisions on standard forms View source Insufficient detail in patient information leaflets about information sharing and information gathering View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Robert Maxwell SMITH · 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
Robert Maxwell Smith died by hanging on 26 October 2023, and the inquest concluded that his death was suicide. Concerns were raised that mental health services’ guidance and patient information about sharing and gathering information from family members lacked clarity and sufficient detail.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on when and how information sharing and information gathering with family members should be undertaken
Wider context from the report “1. The guidance provided to clinicians and nursing staff within the mental health services as to when information and sharing and information gathering was to be undertaken with, and from, family members and how such decisions are to be recorded on the standard forms lacked clarity, particularly as regards the distinction between information sharing and information gathering . Such guidance being of relevance when a patient has given consent for information sharing and gathering to take place and when, and in what circumstances, such steps would be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of clear requirements for recording information sharing and information gathering decisions on standard forms
Wider context from the report “1. The guidance provided to clinicians and nursing staff within the mental health services as to when information and sharing and information gathering was to be undertaken with, and from, family members and how such decisions are to be recorded on the standard forms lacked clarity , particularly as regards the distinction between information sharing and information gathering. Such guidance being of relevance when a patient has given consent for information sharing and gathering to take place and when, and in what circumstances, such steps would be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail in patient information leaflets about information sharing and information gathering
Wider context from the report “2. The information leaflet provided to patients lacked sufficient detail of the approach taken by mental health services on the issue of information sharing and information gathering so that patients could readily understand the difference between the two and understand when the need for information sharing and/or gathering could arise and what steps would be taken by mental health services .
” Open source report
13 Mar 2025 Colin Colley · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Lack of confidence among nursing staff and healthcare support workers in the use and importance of enhanced supervision and the Enhanced Supervision Document View source Lack of confidence among nursing staff and healthcare support workers in the use and implications of falls risk assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Colin Colley · 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
Colin Colley, who had dementia, frailty and a high assessed risk of falls, suffered an unwitnessed fall from a hospital bed after being left unsupervised with bed rails in place. He sustained a fatal brain bleed and died after transfer to the University Hospital of Wales. The principal concern was insufficient staff confidence and training in falls risk assessments, enhanced supervision and use of the Enhanced Supervision Document.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of confidence among nursing staff and healthcare support workers in the use and importance of enhanced supervision and the Enhanced Supervision Document
Wider context from the report “(1) Evidence was taken from nurses at St David’s that there remains a lack of confidence in both qualified nursing staff, healthcare assistants and healthcare support workers in the use of and implication of risk assessments around falls, and the use of and importance of enhanced supervision and the Enhanced Supervision Document . I am concerned that unless more training is provided and refreshed frequently, there is a risk of future deaths occurring, particularly given the cohort being nursed at that hospital and the turnover of staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of confidence among nursing staff and healthcare support workers in the use and implications of falls risk assessments
Wider context from the report “(1) Evidence was taken from nurses at St David’s that there remains a lack of confidence in both qualified nursing staff, healthcare assistants and healthcare support workers in the use of and implication of risk assessments around falls , and the use of and importance of enhanced supervision and the Enhanced Supervision Document. I am concerned that unless more training is provided and refreshed frequently, there is a risk of future deaths occurring, particularly given the cohort being nursed at that hospital and the turnover of staff.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the Falls Strategy Lead role to coordinate falls training and related improvement work.
Verbatim wording from the response “The falls training delivered within the Health Board was developed from a successful programme within Mental Health Services for Older People (MHSOP), which demonstrated a reduction in falls following the training sessions. This training was adapted to ensure suitability for physical health areas by a multidisciplinary team as part of the Dragon’s Heart Institute’s Spread and Scale Academy. A Falls Strategy Lead was recruited in July 2023 to support the coordination of training and other falls-related work.” Source location Response from Cardiff and Vale University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue rolling out falls prevention and management training, including preceptorship and healthcare support worker induction, while monitoring compliance.
Verbatim wording from the response “Expanding falls prevention and management training has been a particular focus for the Health Board, with St David’s Hospital serving as an early pilot site. Training sessions were provided to St David’s staff in September, October, and December 2024, with additional dates offered in May and June 2025. To date, 59% of qualified nurses have completed the training. We aim to reach compliance figures of a minimum of 85%. Study days have been booked, and the target compliance figure of 70 should be achievable by July 2025, provided there are no cancellations due to other pressures. The trajectory will be monitored to achieve and maintain in excess of 85% compliance by year end.” Source location Response from Cardiff and Vale 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 the digital multifactorial falls risk assessment within the Welsh Nursing Care Record at St David’s Hospital.
Verbatim wording from the response “A digital version of the MFRA is part of the suite of risk assessments within the Welsh Nursing Care Record (WNCR), which is live across St David’s Hospital. This provides additional data on the completion of the MFRA, which can be used to inform specific areas of focus for falls training. The Health Board has also led a proposal to update the digital MFRA, making it easier for staff to complete and placing a greater focus on actions taken to reduce patients’ falls risks. Compliance with falls guidance and documentation of falls risks is audited via the Tendable platform and feeds into the Health Board’s nursing dashboard.” Source location Response from Cardiff and Vale University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver enhanced-supervision education through pilots and the newly registered nurse preceptorship programme.
Verbatim wording from the response “Since autumn 2023, pilots of education programmes have been delivered to over ninety staff across the Health Board, and educational resources have been developed and are currently being delivered as part of the newly registered nurse preceptorship programme.” Source location Response from Cardiff and Vale 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 enhanced-supervision framework and develop a new governance policy through the task and finish and steering groups.
Verbatim wording from the response “Alongside this, a task and finish group is updating the existing enhanced supervision framework and developing a new policy to provide more robust governance around its use. From May 2025, a steering group has been convened, chaired by the Deputy Executive Nurse Director, to take forward this work.” Source location Response from Cardiff and Vale University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lead a proposal to update the digital multifactorial falls risk assessment to simplify completion and strengthen risk-reduction actions.
Verbatim wording from the response “A digital version of the MFRA is part of the suite of risk assessments within the Welsh Nursing Care Record (WNCR), which is live across St David’s Hospital. This provides additional data on the completion of the MFRA, which can be used to inform specific areas of focus for falls training. The Health Board has also led a proposal to update the digital MFRA, making it easier for staff to complete and placing a greater focus on actions taken to reduce patients’ falls risks. Compliance with falls guidance and documentation of falls risks is audited via the Tendable platform and feeds into the Health Board’s nursing dashboard.” Source location Response from Cardiff and Vale University Health Board
Open published response
14 Oct 2024 John Austin FOLLON · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Permission to silence patient monitoring alarms before checking the patient during night shifts View source Insufficient frequency of patient monitoring monitor checks View source Failure of the alarm system to prevent silencing without patient checking and to automatically reactivate View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
John Austin FOLLON · 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 Follon was admitted to hospital after an inferior myocardial infarction and underwent coronary stenting. While being monitored after the procedure, a telemetry lead became disconnected; the alarm was silenced without a patient check, and he was later found in cardiac arrest and died despite resuscitation. The report identifies an ongoing risk that patients may remain unmonitored for a significant period, particularly during night shifts, because alarms can be silenced without checking the patient and monitoring is not continuous.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Permission to silence patient monitoring alarms before checking the patient during night shifts
Wider context from the report “(1) Changes to the alarm system have been made following Mr Follon’s death such as making the alarm louder and ensuring a yellow ribbon appears and remains at the top of the monitoring screen until the alarm is reactivated. However, it is still possible for a member of staff to silence the alarm without checking on the patient and the alarm will remain silent until it is physically reactivated by a member of staff.
(2) Currently when the alarm is triggered, during the day shift, staff are required to check on the patient prior to the alarm being silenced, during a night shift staff are permitted to silence the alarm prior to checking the patient to reduce noise to a minimum while patients are sleeping. The latter was the position in the instant case when Mr Follon’s lead became detached.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient frequency of patient monitoring monitor checks
Wider context from the report “(3) The monitors are not checked constantly or even every hour but are checked twice during each shift . During a busy night shift or during handover, if the person silencing the alarm does not attend to the patient at the time the alarm sounds and if the amber ribbon, which now appears on the monitor alerting staff to a “lead off” scenario, goes unnoticed, the risk that a patient will not be monitored for a significant period of time remains .
(4) During a night shift, the circumstances in which Mr Follon died remain the same notwithstanding changes to nursing practice and the alarm system have been made. The risk of a patient not being monitored for a significant period of time remains and could give rise to a death in similar circumstances in the future .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of the alarm system to prevent silencing without patient checking and to automatically reactivate
Wider context from the report “(1) Changes to the alarm system have been made following Mr Follon’s death such as making the alarm louder and ensuring a yellow ribbon appears and remains at the top of the monitoring screen until the alarm is reactivated. However, it is still possible for a member of staff to silence the alarm without checking on the patient and the alarm will remain silent until it is physically reactivated by a member of staff .
(2) Currently when the alarm is triggered, during the day shift, staff are required to check on the patient prior to the alarm being silenced, during a night shift staff are permitted to silence the alarm prior to checking the patient to reduce noise to a minimum while patients are sleeping. The latter was the position in the instant case when Mr Follon’s lead became detached.
” 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 Complete revised alarm configurations for telemetry units in the Cardiothoracic areas.
Verbatim wording from the response “On review it was acknowledged that these circumstances could equally apply to a day shift and we fully acknowledge the above. However, following a number of meetings with our CVUHB clinical engineering department and the monitor manufacturer Phillips following receipt of the regulation 28 further amendments have been made to the system to mitigate the risk of this incident happening again.” Source location Response from Cardiff and Vale 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 Install matching configurations on monitors across Cardiothoracic clinical wards using a phased approach by 8 December 2024.
Verbatim wording from the response “Now that this work is complete, the next stage is to adjust the monitor configurations to match the central station and telemetry configuration; Clinical Engineering will visit the clinical areas to install these configurations onto the monitors. This will require a phased approach to maintain patient safety. All clinical wards in the Cardiothoracic Directorate will be complete by the assigned deadline of 8 December 2024.” Source location Response from Cardiff and Vale University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess and evaluate monitoring configurations across the Health Board and consider whether Cardiothoracic alarm changes should apply more widely.
Verbatim wording from the response “The subsequent steps after resolving the immediate Regulation 28 actions is to assess and evaluate the configurations across all patient monitoring in CVUHB. In the first instance this will provide us with a more robust understanding of the current configurations. Secondly, we can decide if the changes implemented in the Cardiothoracic areas (yellow priority of leads off/unplugged, and re-alarm for the same) are applicable across the Health Board. The Directors of Nursing have been asked by the Executive Nurse Director to scope and consider this regulation 28 in light of their own clinical areas and this work will be monitored via the Directors of Nursing forum.” Source location Response from Cardiff and Vale 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 louder alarms, persistent visual alerts, lead-off alarm prioritisation and renewed staff reminders to address unresolved alarms.
Verbatim wording from the response “(1) Changes to the alarm system have been made following Mr Follon’s death such as making the alarm louder and ensuring a yellow ribbon appears and remains at the top of the monitoring screen until the alarm is reactivated. However, it is still possible for a member of staff to silence the alarm without checking on the patient and the alarm will remain silent until it is physically reactivated by a member of staff.” Source location Response from Cardiff and Vale 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 Monitors are observed regularly throughout shifts and checked through established alarm-setting checklists and additional checks.
Verbatim wording from the response “(3) The monitors are not checked constantly or even every hour but are checked twice during each shift. During a busy night shift or during handover, if the person silencing the alarm does not attend to the patient at the time the alarm sounds and if the amber ribbon, which now appears on the monitor alerting staff to a “lead off” scenario, goes unnoticed, the risk that a patient will not be monitored for a significant period of time remains.” Source location Response from Cardiff and Vale 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 Staff are not formally permitted to silence alarms before reviewing patients at any time of day or night.
Verbatim wording from the response “(2) Currently when the alarm is triggered, during the day shift, staff are required to check on the patient prior to the alarm being silenced, during a night shift staff are permitted to silence the alarm prior to checking the patient to reduce noise to a minimum while patients are sleeping. The latter was the position in the instant case when Mr Follon’s lead became detached.” Source location Response from Cardiff and Vale University Health Board
Open published response
21 Mar 2024 Alan Richard Miles Davies · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 13 Failure to provide staff with clear information about food and fluid refusal duration and warning signs View source Insufficient consideration of alternative specialist placement View source Failure to provide rest breaks during prolonged night shifts View source Failure to communicate relevant clinical information before transfer View source Insufficient GP capacity to meet demand at HMP Cardiff View source Failure to provide agency staff with sufficient information for informed reception support View source Failure to accompany transfers with Caswell Clinic staff View source Failure to provide clear and understandable discharge information and assessment View source Insufficient assessment of whether needs are too complex for HMP Cardiff View source Failure of healthcare staff to challenge senior staff withdrawal from healthcare assistance View source Failure to devise and implement a clear plan for assessing capacity to refuse food or fluid View source Failure to devise and implement a clear plan for engagement with medical services and assessment of condition View source Lack of a food and fluid refusal policy View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Alan Richard Miles 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
Alan Richard Miles Davies was transferred to HMP Cardiff after 16 days of refusing food and was found collapsed in his cell 10 days later; he later died in hospital. The reported concerns included inadequate communication and handover of information, insufficient care planning and observation, the absence of a food and fluid refusal policy, inadequate staffing, and missed opportunities to escalate his care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to provide staff with clear information about food and fluid refusal duration and warning signs
Wider context from the report “(11) The Nurse, Health care assistant and Custodial manager responsible for Mr Davies on the night of his collapse were not provided with clear information regarding the duration of his fluid and food refusal or the warning signs to consider in the context of the known risk of sudden collapse
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient consideration of alternative specialist placement
Wider context from the report “(5) Mr Davies was transferred to HMP Cardiff with the intention that he be transferred again within a short time to HMP Parc. Insufficient consideration was given as to whether Mr Davies’ needs were better met at an alternative specialist institution .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to provide rest breaks during prolonged night shifts
Wider context from the report “(10) The Nurse and Health care assistant responsible for Mr Davies on the night of his collapse were working an 11.5 hour night shift without rest breaks , which they identified as being overly fatiguing
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant clinical information before transfer
Wider context from the report “(1) There was limited communication between the Caswell clinic and HMP Cardiff following the s 117 meeting until Mr Davies’ discharge . In particular, information that Mr Davies had commenced food refusal following the s 117 meeting and that it had not been possible to assess him physically prior to transfer was not clearly communicated to HMP Cardiff before the transfer occurred
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient GP capacity to meet demand at HMP Cardiff
Wider context from the report “(9) The number of GPs working in HMP Cardiff was insufficient to meet the demands upon them .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to provide agency staff with sufficient information for informed reception support
Wider context from the report “(3) Mr Davies was transferred to prison without being accompanied by a member of Caswell Clinic staff. Agency staff did not have sufficient information to be able to assist prison reception staff in an informed manner
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to accompany transfers with Caswell Clinic staff
Wider context from the report “(3) Mr Davies was transferred to prison without being accompanied by a member of Caswell Clinic staff . Agency staff did not have sufficient information to be able to assist prison reception staff in an informed manner
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear and understandable discharge information and assessment
Wider context from the report “(2) Discharge information and assessment was not provided to HMP Cardiff in a clear and easily understandable format to manage the known risks associated with the transfer of Mr Davies to prison
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient assessment of whether needs are too complex for HMP Cardiff
Wider context from the report “(4) Insufficient consideration was given to whether Mr Davies’ needs were too complex to be met by HMP 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare staff to challenge senior staff withdrawal from healthcare assistance
Wider context from the report “(12) The Health care assistant caring for Mr Davies overnight overheard more senior prison staff stating that they would not return to assist Mr Davies in healthcare , and felt unable to challenge this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to devise and implement a clear plan for assessing capacity to refuse food or fluid
Wider context from the report “(7) No clear plan for the assessment of Mr Davies’ capacity to refuse food or fluid was devised or implemented at HMP 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to devise and implement a clear plan for engagement with medical services and assessment of condition
Wider context from the report “(6) No clear plan to promote Mr Davies’ engagement with prison medical services, or the assessment of his mental or physical condition was devised or implemented at HMP 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of a food and fluid refusal policy
Wider context from the report “(8) No food and fluid refusal policy was in place to guide healthcare staff .
” 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 establish a standard operating procedure for communicating health information and determining appropriate placement before transfers to HMP Cardiff.
Verbatim wording from the response “Regarding communication pathways, collaborative efforts with relevant parties have led to the development of a Standard Operating Procedure (SOP) for transferring individuals with mental/physical health needs into our care. This SOP delineates the necessary information required by HMP Cardiff to assess the individual's health needs and outlines a reliable route for sharing information across organisations to mitigate information-related risks. The protocol also identifies” Source location Response from Cardiff and Vale 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 electronic templates to support application of the food and fluid refusal policy.
Verbatim wording from the response “A Joint Food and Fluid Refusal Policy is in place at HMP Cardiff, with training provided to healthcare and prison staff. Efforts are underway to develop electronic templates supporting the policy’s application. Training on Mental” Source location Response from Cardiff and Vale 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 mental capacity assessment training to medical staff and plan annual refresher updates.
Verbatim wording from the response “Capacity Assessment has been imparted to medical staff, with plans for annual updates.” Source location Response from Cardiff and Vale 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 GP capacity through increased core-establishment funding, a local-practice service-level agreement and recruitment of additional GPs.
Verbatim wording from the response “Efforts to address GP recruitment challenges include increased funding to expand the core GP establishment and the initiation of a Service Level Agreement with a local GP Practice. Additional GPs have been recruited to support current Vacancies” Source location Response from Cardiff and Vale University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind all staff to escalate patient-care or operational concerns to the nurse in charge or Head of Healthcare at any time.
Verbatim wording from the response “Management of Escalating Concerns” Source location Response from Cardiff and Vale 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 basic life support, mental capacity and bespoke prison-nursing training, with the bespoke programme underway from May 2024.
Verbatim wording from the response “Since September 2021, there has been a shift in the Healthcare Team's skill mix, with the appointment of more nurses possessing general medical skills. These nurses are better equipped to identify and respond to patients at risk of deterioration. Training initiatives, including basic life support and mental capacity assessment, have been implemented, supported by a Practice Development Nurse. Additionally, a bespoke training program for Prison Nurses in Wales has commenced. in May 2024.” Source location Response from Cardiff and Vale 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 and train staff on a joint food and fluid refusal policy at HMP Cardiff.
Verbatim wording from the response “A Joint Food and Fluid Refusal Policy is in place at HMP Cardiff, with training provided to healthcare and prison staff. Efforts are underway to develop electronic templates supporting the policy’s application. Training on Mental” Source location Response from Cardiff and Vale 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 revised night-shift working patterns, including a four-night/three-day rota for new staff, to reduce consecutive night working and workload.
Verbatim wording from the response “Despite national ongoing nursing shortages, strategies such as employing agency nurses with prison experience and introducing new roles like Pharmacy Technicians have been undertaken. Plans to employ a second Registered Nurse for night shifts are hindered by recruitment challenges but remain a priority. Changes to the night shift pattern are being implemented to alleviate staff workload. All new staff are employed on the basis on a 4 night/3-day rota, to reduce the need for staff to work 7 nights in a row. As explained at the inquest, the historical shift pattern inherited when the Healthcare Team transferred to the UHB (University Health Board) responsibility in 2013, has been difficult to change because staff wanted to retain this shift pattern and had some employment rights as part of the TUPE Transfer of Undertakings (Protection of Employment).” Source location Response from Cardiff and Vale 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 Employ a second registered nurse for night shifts.
Verbatim wording from the response “Despite national ongoing nursing shortages, strategies such as employing agency nurses with prison experience and introducing new roles like Pharmacy Technicians have been undertaken. Plans to employ a second Registered Nurse for night shifts are hindered by recruitment challenges but remain a priority. Changes to the night shift pattern are being implemented to alleviate staff workload. All new staff are employed on the basis on a 4 night/3-day rota, to reduce the need for staff to work 7 nights in a row. As explained at the inquest, the historical shift pattern inherited when the Healthcare Team transferred to the UHB (University Health Board) responsibility in 2013, has been difficult to change because staff wanted to retain this shift pattern and had some employment rights as part of the TUPE Transfer of Undertakings (Protection of Employment).” Source location Response from Cardiff and Vale 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 Recruitment challenges hinder employing a second registered nurse for night shifts, although this remains a priority.
Verbatim wording from the response “Despite national ongoing nursing shortages, strategies such as employing agency nurses with prison experience and introducing new roles like Pharmacy Technicians have been undertaken. Plans to employ a second Registered Nurse for night shifts are hindered by recruitment challenges but remain a priority. Changes to the night shift pattern are being implemented to alleviate staff workload. All new staff are employed on the basis on a 4 night/3-day rota, to reduce the need for staff to work 7 nights in a row. As explained at the inquest, the historical shift pattern inherited when the Healthcare Team transferred to the UHB (University Health Board) responsibility in 2013, has been difficult to change because staff wanted to retain this shift pattern and had some employment rights as part of the TUPE Transfer of Undertakings (Protection of Employment).” Source location Response from Cardiff and Vale 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 Existing night-shift patterns were difficult to change because staff preferences and TUPE employment rights constrained alterations.
Verbatim wording from the response “Despite national ongoing nursing shortages, strategies such as employing agency nurses with prison experience and introducing new roles like Pharmacy Technicians have been undertaken. Plans to employ a second Registered Nurse for night shifts are hindered by recruitment challenges but remain a priority. Changes to the night shift pattern are being implemented to alleviate staff workload. All new staff are employed on the basis on a 4 night/3-day rota, to reduce the need for staff to work 7 nights in a row. As explained at the inquest, the historical shift pattern inherited when the Healthcare Team transferred to the UHB (University Health Board) responsibility in 2013, has been difficult to change because staff wanted to retain this shift pattern and had some employment rights as part of the TUPE Transfer of Undertakings (Protection of Employment).” Source location Response from Cardiff and Vale University Health Board
Open published response
15 Nov 2023 Ocean-Leigh Pauline Jean Hayes · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Failure to advise parents on risks associated with their baby's sleeping arrangements View source Failure to physically risk assess infants' sleeping arrangements before 6 weeks of age 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
Ocean-Leigh Pauline Jean Hayes · 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
Ocean-Leigh Pauline Jean Hayes was aged 4 months when she died at home on 22 December 2021 after co-sleeping with her mother. Concerns included health visitors not always physically reviewing infant sleeping arrangements and potential missed opportunities to risk assess bedding, positioning and other co-sleeping arrangements, and to advise parents about risks.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to advise parents on risks associated with their baby's sleeping arrangements
Wider context from the report “(1) Guidance requires health visitors to physically review sleeping arrangements before the baby is 6 weeks old.
(2) I heard evidence that this was not always being done.
(3) There may be missed opportunities to physically risk assess sleeping arrangements including inter alia bedding, blankets, pillows, mattress and positioning, particularly where co-sleeping is a factor, and missed opportunities to advise parents on risks they may be taking .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to physically risk assess infants' sleeping arrangements before 6 weeks of age
Wider context from the report “(1) Guidance requires health visitors to physically review sleeping arrangements before the baby is 6 weeks old.
(2) I heard evidence that this was not always being done .
(3) There may be missed opportunities to physically risk assess sleeping arrangements including inter alia bedding, blankets, pillows, mattress and positioning, particularly where co-sleeping is a factor , and missed opportunities to advise parents on risks they may be taking.
” Open source report
13 Dec 2022 Yvonne Rankin · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Failure to ensure that patients and carers understand the specific signs of sepsis View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Yvonne Rankin · 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
Yvonne Rankin, aged 68, died at the University Hospital of Wales on 14 January 2021 after an infection at her PEG site returned and she quickly developed sepsis, despite extensive medical treatment. The concerns were that Yvonne and her family did not understand the specific signs of sepsis, which may have delayed calling 999, and whether sepsis information cards could be provided to patients and carers with PEGs or those at known risk of infection in the community.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that patients and carers understand the specific signs of sepsis
Wider context from the report “(1) although family and Yvonne were told that they could refer any concerns to various professionals including the Abbott nurse, they did not understand the specific signs of sepsis to watch out for ;
(2) had family understood the signs of sepsis, it is likely that they would have rung 999 much sooner; and
(3) It may be that patient/carer information cards setting out the common signs of sepsis already exists. Would it be possible to give out such information cards to patients/carers with PEGs and/or those who are at known risk of infection who are in the community?
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide sepsis symptom cards to children and their parents to promote awareness of childhood sepsis signs and symptoms.
Verbatim wording from the response “We will in addition ensure a sepsis card is also given to children and their parents. We will use the Paediatric Symptom Cards | The UK Sepsis Trust to promote awareness of the signs and symptoms of children who are developing sepsis. We will commence use of the cards as soon as possible.” Source location Response from Cardiff and Vale University Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update PEG patient and family information to include sepsis signs and symptoms, and provide it to new patients.
Verbatim wording from the response “The eCORFLO booklet (Information for patients, relatives and carers, Gastrostomy feeding tube, Percutaneous Endoscopic Gastrostomy) the patient is given at time of the procedure has been updated to reference to sepsis (attached as Appendix One).” Source location Response from Cardiff and Vale University Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider suitable generic sepsis information for use at the procedure and later in the community, including a credit-card-sized symptom card.
Verbatim wording from the response “In addition, we are considering suitable generic information to be given both at time of procedure and later in the community we are considering the SEPSIS awareness credit card size information. This will then be able to be used across wider areas, it gives simple clear information and is a highly visible card. We care for approximately 450 enterally fed patients within the UHB (not all with gastrostomies) so dietetics would purchase these so they could be issued at initial discharge as well as in the community when needed.” Source location Response from Cardiff and Vale University Health Board
Open published response
9 Nov 2022 Maria Immocalata Whale · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Failure of the 999 emergency triage questionnaire to adequately measure clinical gravity 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
Maria Immocalata Whale · 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
Maria Immocalata Whale, aged 67, suffered a fatal pelvic haemorrhage and abdominal wall haematoma at home on 29 June 2021 after experiencing increasing abdominal pain. The report identifies concerns about the inability of the Out of Hours GP service to provide assistance, the delayed ambulance response, and emergency triage that did not adequately assess the gravity of her condition.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of the 999 emergency triage questionnaire to adequately measure clinical gravity
Wider context from the report “(2) During the repeated calls to the 999 Emergency Services, ████████ was advised the following:
i) there were no resources available;
ii) Mrs. Whale did not meet the criteria to have an elevated priority status; and
iii) when asked to define the degree of pain suffered on a scale of 1-10 Mrs. Whale (who was screaming in agony) responded “11”. ████████ stated in Court that the call responder concluded that if Mrs. Whale could scream then she was not a priority. Within an hour of this conversation Mrs. Whale had died without any emergency support and in agony.
████████ Clinical Director of Cardiff and Vale UHB Urgent Care Service confirmed in Court that the Out of Hours (OoH) GP service had two GPs on duty that night – one of whom was attending a patient while the other was assisting the triage nurses. It was also confirmed that for the period during which ████████ had called the OoH service, the numbers of calls were comparatively low.
Under oath, Dr. ████████ stated that the advice given to ████████ by the triage nurse was correct – either to take Mrs. Whale to hospital by taxi or call 999. He confirmed that the triage nurse had recognised Mrs. Whale was gravely ill. He disagreed that the second GP should have attended Mrs. Whale saying that the GP could neither have assisted with the diagnosis nor with accessing emergency transport to hospital by advising the 999 service of the urgency of the need for hospital admission. Pain relief provision by the OoH GP service was not mentioned.
Dr. ████████ was adamant that an OoH GP would have been unable to expedite Mrs. Whale’s access to hospital even though the gravity of her condition was accepted. He was similarly adamant that a GP attending Mrs. Whale would not have been able to communicate the gravity of her condition to the emergency services any better than a lay person - in this case the distressed husband. Again, provision of pain relief was not mentioned.
The 999 Emergency Service triage patients for priority depending on the response provided by a person close at hand to the patient, to a series of scripted questions. The Welsh Ambulance Service Trust has advised the following:
• Red calls are the highest clinical priority and are deemed immediately life threatening e.g. cardiac arrest;
• Amber 1 calls have a high clinical priority and are still considered a life threatening emergency e.g. chest pain;
• Amber 2 calls have urgent clinical priority, are serious but not considered immediately life threatening, for example diabetic problems; and
• Green calls are not considered to have urgent clinical priority and are not considered serious or life threatening.
████████ in responding to these questions advised his wife was not a priority. Clearly, the triage questionnaire did not adequately measure the gravity of Mrs. Whale’s condition , as within two hours of being graded a ‘non-priority’ she was declared life extinct.
” Open source report
Concerns raised 2 Failure to review System 1 and medical records on prison admission View source Failure to identify and continue prescribed antidepressant treatment on admission View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
IAN JAMES WEEKS · 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
Ian Weeks was remanded into custody at HMP Cardiff and was later found to have hung himself from the shower rail in his cell, sometime between 20 and 21 October 2017. The concerns included that healthcare staff did not check records showing a recent suicide attempt or notice that he had been prescribed antidepressants, and that there was no effective process for reviewing System 1 records or a suicide and self-harm warning flag.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to review System 1 and medical records on prison admission
Wider context from the report “(1) Although it was recorded on System 1 that Mr Weeks had recently attempted suicide in another prison shortly before his admission to HMP Cardiff no member of Healthcare staff checked the medical records and further that although the GP records which were sent to the prison confirmed that Mr Weeks was prescribed anti-depressants in the community no member of Healthcare staff noticed this and as a consequence Mr Weeks was not given anti-depressants in HMP Cardiff.
The Healthcare witnesses, including the Head of Healthcare, indicated that a red flag for suicide or self-harm would be of great value for staff who because of insufficient staff and a heavy workload did not have time to review the System 1 record in any or any sufficient detail .
Further it was considered that all System 1 records should be reviewed when an individual is admitted into the prison and that there should be in place a process for doing so .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and continue prescribed antidepressant treatment on admission
Wider context from the report “(1) Although it was recorded on System 1 that Mr Weeks had recently attempted suicide in another prison shortly before his admission to HMP Cardiff no member of Healthcare staff checked the medical records and further that although the GP records which were sent to the prison confirmed that Mr Weeks was prescribed anti-depressants in the community no member of Healthcare staff noticed this and as a consequence Mr Weeks was not given anti-depressants in HMP Cardiff .
The Healthcare witnesses, including the Head of Healthcare, indicated that a red flag for suicide or self-harm would be of great value for staff who because of insufficient staff and a heavy workload did not have time to review the System 1 record in any or any sufficient detail.
Further it was considered that all System 1 records should be reviewed when an individual is admitted into the prison and that there should be in place a process for doing so.
” 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 Implementing a red-flag system requires partnership with the technology provider, health authorities and other prisons because it would affect all prisons.
Verbatim wording from the response “In order to pursue a red flag system, a partnership with TPP (SystmOne technology provider), NHS England, NHS Wales Informatics Service (NWIS) and other prisons will be required as this would be a change that would affect all prisons. The clinical team from HMP Cardiff intend to raise this issue at their next All Wales Prison Healthcare Meeting which Public Health Wales and Welsh Government also attend.” Source location 2020-0064-Response-from-Cardiff-and-Vale-NHS-Trust-1
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing dual screening reviews, supported by prison staff reviewing records and sharing important information, are considered sufficient for new admissions.
Verbatim wording from the response “As indicated, a large volume of information is contained within SystmOne. Existing process is for healthcare staff in the prison to undertake two screening reviews of new individuals in order to assess and plan their care. This is done in conjunction with prison staff who also review the SystmOne records and share important information.” Source location 2020-0064-Response-from-Cardiff-and-Vale-NHS-Trust-1
Open published response
28 Feb 2020 Lewys Ryan Aidan CRAWFORD · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Gaps in agency nurse training and understanding of septic screening procedures View source Lack of competent A&E consultant knowledge and understanding for identifying and diagnosing sepsis in babies and very young children View source Failure to use and record clear, continuing sepsis terminology in suspected sepsis patients View source Insufficient clinician and nurse use of the NICE Sepsis risk stratification tool for children aged under 5 years View source Failure to consider alternative antibiotic administration routes when cannulation is unsuitable View source Failure to complete a full septic screen and stabilise potentially septic babies and children before ward transfer View source See 3 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
Lewys Ryan Aidan CRAWFORD · 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
Lewys Ryan Aidan CRAWFORD was admitted to A&E on 21 March 2019 while likely in the early stages of meningococcal disease and died on 22 March 2019 after transfer to the Paediatric Critical Care Unit. The report identified missed opportunities to recognise sepsis, failure to administer antibiotics before 11:30pm, and concerns about staff training, use of sepsis guidance, terminology, and alternative antibiotic administration methods.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Gaps in agency nurse training and understanding of septic screening procedures
Wider context from the report “(2) There needs to be a greater understanding of, and reference to the NICE Sepsis risk stratification tool: children aged under 5 years in hospital by Clinicians and Nurses in both the A & E & Paediatric depts. Whilst it is appreciated that the finalisation of a bespoke sepsis tool, based upon the UK Sepsis Trust’s Tools and Pathways is awaited, until such time as its adopted, the Health Board needs to address apparent lapses in the understanding of what is required upon diagnosis of a potentially septic baby/child, particularly in the period between triage and admission to the ward. Specifically, the importance of stabilising the patient prior to transfer by completing a full septic screen. Furthermore, the Inquest highlighted gaps in the understanding and knowledge of agency nurses as to the septic screen and the steps to be followed . The Health Board needs a clear policy (and to ensure this is implemented & followed) to ensure that agency nurses are up to date with their training and understanding in this area of practice .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of competent A&E consultant knowledge and understanding for identifying and diagnosing sepsis in babies and very young children
Wider context from the report “(1) A potential deficiency in the knowledge and understanding of A & E Consultants coving in the paediatric A & E Department (whilst there is no on site consultant in paediatric emergency medicine) in the identification/diagnosis of sepsis in babies and very young children . Whilst it is appreciated that the quest to recruit further consultants in paediatric emergency medicine to provide more comprehensive cover in the Department continues, until such time as a sufficient complement is in place, and A & E Consultants provide some of the cover, the Health Board must ensure that those that do, are urgently and adequately trained to a competent standard to deliver the care required . It cannot be simply left to the individual consultants to determine their own requirements in this regard. As their employers, the Health Board, has an overarching obligation to ensure that competent staff are employed and to maintain high professional standards.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to use and record clear, continuing sepsis terminology in suspected sepsis patients
Wider context from the report “(3) Guidance and instruction to both clinicians and nurses as to the appropriate use (and recording) of terminology should be considered in suspected sepsis patients. There was a degree of confusion in both the A & E & Paediatric Departments caused by the interchangeable use of sepsis and bacterial infection as to what treatment should be initiated/progressed depending on which description was used. If sepsis is suspected, that clear and continuing reference ought to be maintained, if, and until it is superseded by an alternative 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinician and nurse use of the NICE Sepsis risk stratification tool for children aged under 5 years
Wider context from the report “(2) There needs to be a greater understanding of, and reference to the NICE Sepsis risk stratification tool: children aged under 5 years in hospital by Clinicians and Nurses in both the A & E & Paediatric depts. Whilst it is appreciated that the finalisation of a bespoke sepsis tool, based upon the UK Sepsis Trust’s Tools and Pathways is awaited, until such time as its adopted, the Health Board needs to address apparent lapses in the understanding of what is required upon diagnosis of a potentially septic baby/child, particularly in the period between triage and admission to the ward. Specifically, the importance of stabilising the patient prior to transfer by completing a full septic screen. Furthermore, the Inquest highlighted gaps in the understanding and knowledge of agency nurses as to the septic screen and the steps to be followed. The Health Board needs a clear policy (and to ensure this is implemented & followed) to ensure that agency nurses are up to date with their training and understanding in this area of practice.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to consider alternative antibiotic administration routes when cannulation is unsuitable
Wider context from the report “(4) In suspected sepsis patients, particularly babies, guidance and instruction needs to be emphasised to clinicians & nurses as to alternative methods of administration of antibiotics. Evidence at Inquest demonstrated that there were failures to consider alternatives to cannulation for IV antibiotics, such as intra-muscularly or intra-osseously .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a full septic screen and stabilise potentially septic babies and children before ward transfer
Wider context from the report “(2) There needs to be a greater understanding of, and reference to the NICE Sepsis risk stratification tool: children aged under 5 years in hospital by Clinicians and Nurses in both the A & E & Paediatric depts. Whilst it is appreciated that the finalisation of a bespoke sepsis tool, based upon the UK Sepsis Trust’s Tools and Pathways is awaited, until such time as its adopted, the Health Board needs to address apparent lapses in the understanding of what is required upon diagnosis of a potentially septic baby/child, particularly in the period between triage and admission to the ward . Specifically, the importance of stabilising the patient prior to transfer by completing a full septic screen . Furthermore, the Inquest highlighted gaps in the understanding and knowledge of agency nurses as to the septic screen and the steps to be followed. The Health Board needs a clear policy (and to ensure this is implemented & followed) to ensure that agency nurses are up to date with their training and understanding in this area of practice.
” Open source report
22 Aug 2019 Mr. Christopher Summerhayes · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Potential contraindication to clozapine from familial lipid disorder View source Failure to account for concomitant medications when dosing clozapine View source Failure to account for smoking cessation when managing clozapine levels View source Failure to distinguish clozapine overdose signs from unresolved schizophrenia symptoms View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr. Christopher Summerhayes · 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. Christopher Summerhayes was found deceased at his home address after a significant medical history including double scoliosis, treatment-resistant schizophrenia and a complex regime of around 12 daily medications. The concerns included the prescription of clozapine alongside other medications, substantial weight gain and possible effects on his cardiovascular system, as well as a possible familial lipid disorder. The inquest concluded that the medical cause of death was ischaemic heart disease, with a narrative determination referring to atypical early-onset coronary artery atherosclerosis and complex prescribed medications.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Potential contraindication to clozapine from familial lipid disorder
Wider context from the report “(1) In relation to Christopher Summerhayes, Clozapine was prescribed as a concomitant medication alongside approximately 11 other drugs including another anti-psychotic medication. Either alone or interaction with other prescribed medication, a large increase in weight occurred to >101kg (BMI 33.1) (reported side effect of clozapine) which had a ‘knock-on’ effect for his cholesterol and lipid levels and cardiovascular system. The usual dose is 200-450mg daily with the maximum dose being 900mg (BNF) which does not consider concomitant medications. Signs of prescription overdose include collapse and hallucinations which could be mistaken for unresolved symptoms of schizophrenia i.e. lack of drug efficacy encouraging dose increase. Blood levels of clozapine may rise in response to smoking cessation which Mr. Summerhayes had advised we was commencing.
(2) He may have suffered from a familial lipid disorder (present in other family members) which had it been confirmed would likely to have contraindicated Clozapine.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to account for concomitant medications when dosing clozapine
Wider context from the report “(1) In relation to Christopher Summerhayes, Clozapine was prescribed as a concomitant medication alongside approximately 11 other drugs including another anti-psychotic medication. Either alone or interaction with other prescribed medication, a large increase in weight occurred to >101kg (BMI 33.1) (reported side effect of clozapine) which had a ‘knock-on’ effect for his cholesterol and lipid levels and cardiovascular system. The usual dose is 200-450mg daily with the maximum dose being 900mg (BNF) which does not consider concomitant medications. Signs of prescription overdose include collapse and hallucinations which could be mistaken for unresolved symptoms of schizophrenia i.e. lack of drug efficacy encouraging dose increase. Blood levels of clozapine may rise in response to smoking cessation which Mr. Summerhayes had advised we was commencing.
(2) He may have suffered from a familial lipid disorder (present in other family members) which had it been confirmed would likely to have contraindicated Clozapine.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to account for smoking cessation when managing clozapine levels
Wider context from the report “(1) In relation to Christopher Summerhayes, Clozapine was prescribed as a concomitant medication alongside approximately 11 other drugs including another anti-psychotic medication. Either alone or interaction with other prescribed medication, a large increase in weight occurred to >101kg (BMI 33.1) (reported side effect of clozapine) which had a ‘knock-on’ effect for his cholesterol and lipid levels and cardiovascular system. The usual dose is 200-450mg daily with the maximum dose being 900mg (BNF) which does not consider concomitant medications. Signs of prescription overdose include collapse and hallucinations which could be mistaken for unresolved symptoms of schizophrenia i.e. lack of drug efficacy encouraging dose increase. Blood levels of clozapine may rise in response to smoking cessation which Mr. Summerhayes had advised we was commencing.
(2) He may have suffered from a familial lipid disorder (present in other family members) which had it been confirmed would likely to have contraindicated Clozapine.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish clozapine overdose signs from unresolved schizophrenia symptoms
Wider context from the report “(1) In relation to Christopher Summerhayes, Clozapine was prescribed as a concomitant medication alongside approximately 11 other drugs including another anti-psychotic medication. Either alone or interaction with other prescribed medication, a large increase in weight occurred to >101kg (BMI 33.1) (reported side effect of clozapine) which had a ‘knock-on’ effect for his cholesterol and lipid levels and cardiovascular system. The usual dose is 200-450mg daily with the maximum dose being 900mg (BNF) which does not consider concomitant medications. Signs of prescription overdose include collapse and hallucinations which could be mistaken for unresolved symptoms of schizophrenia i.e. lack of drug efficacy encouraging dose increase. Blood levels of clozapine may rise in response to smoking cessation which Mr. Summerhayes had advised we was commencing.
(2) He may have suffered from a familial lipid disorder (present in other family members) which had it been confirmed would likely to have contraindicated Clozapine.
” 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 Promote polypharmacy reviews through secondary-care pharmacy and primary-care medicines-management teams.
Verbatim wording from the response “The All Wales Medicines Strategy Group has produced a number of guidance documents to promote polypharmacy reviews. These documents can be viewed on their website which is www.awmsg.org” Source location 2019-0263-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 pharmacy and specialist mental-health pharmacist support for medicines management and prescribing.
Verbatim wording from the response “The Pharmacy Directorate has a system in place of dedicated pharmacists aligned to clinical directorates and Clinical Boards to provide a source of support and expertise in medicines management. A specialist mental health pharmacist supports prescribing in in-patient mental health settings. The Primary Care and Intermediate Care Clinical Board has a Medicines Management and Prescribing Team who support related issues in primary care settings.” Source location 2019-0263-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 NICE-aligned physical-health monitoring arrangements for patients taking Clozapine.
Verbatim wording from the response “Guidance from the National Institute of Health and Care Excellence (NICE) for assessing physical health of patients on Clozapine is available on their website (www.nice.org.uk) and monitoring arrangements are in place in line with this guidance.” Source location 2019-0263-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 Medicines Management Incentive Scheme to improve recording of medicines across care settings, including staff education and retrospective recording of complex medicines.
Verbatim wording from the response “The Primary Care and Intermediate Care team established a Medicines Management Incentive Scheme with GPs to ensure that medicines prescribed across care settings are added to the GP record so there is a complete medicines record for patients on the GP systems. The driver for this project was to promote patient safety but it has seen cost-benefits. Education is provided to staff within GP practices who are then required to identify their local process to ensure that a patient’s medication history is accurately updated prospectively. Practices have also been asked to retrospectively add certain complex medicines to the GP systems to ensure they are clearly recorded.” Source location 2019-0263-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 an interface between PARIS and PMS to improve information transfer and introduce medicines transcribing and electronic discharge using the Welsh Clinical Portal.
Verbatim wording from the response “A project proposal is in development by Mental Health Clinical Board, Pharmacy and Information Technology to develop an interface between PARIS (patient management and information software in use in Mental Health and community services) and PMS (patient management system) to improve the transfer of information. The project aims to improve the interface between these systems and introduce Medicines Transcribing and e-Discharge to mental health wards with use of the Welsh Clinical Portal.” Source location 2019-0263-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 Maintain the Medicines Code and its medicines-reconciliation responsibilities for doctors, pharmacy staff and other prescribers.
Verbatim wording from the response “The UHB has a Medicines Code in place and this was updated in 2018. It contains a section on medicines reconciliation. It sets out the responsibilities of various healthcare professionals in this process, including doctors, the pharmacy team and other prescribers.” Source location 2019-0263-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 Existing medicines reconciliation, pharmacist support, NICE monitoring and promoted polypharmacy reviews address medication interaction and prescribing risks.
Verbatim wording from the response “The UHB has a Medicines Code in place and this was updated in 2018. It contains a section on medicines reconciliation. It sets out the responsibilities of various healthcare professionals in this process, including doctors, the pharmacy team and other prescribers.” Source location 2019-0263-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 Mandated Clozapine monitoring, ZTAS reporting and primary-care record checks are considered sufficient for shared prescribing and information exchange.
Verbatim wording from the response “I am able to advise that there is a requirement for patients taking Clozapine to be registered with a service to monitor the medicine during the course of their treatment with it. Additionally, when a patient who is taking Clozapine dies or ceases to take it, the manufacturer supplying the medication must be informed. The monitoring service currently in place for Cardiff and Vale University Health Board is via the Zaponex Treatment Access System (ZTAS) which is provided by the medicine’s manufacturer that we currently use, called Leyden Delta. The necessary information was shared at the time via ZTAS.” Source location 2019-0263-Response-by-University-Health-Board
Open published response
10 Jun 2019 Glenys Button · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Lack of backup neurosurgical specialist capacity to field referrals View source Failure of the neurosurgical referral system to provide timely and reliable communication 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
Glenys Button · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Glenys Button, aged 78, died at Royal Glamorgan Hospital on 5 November 2018 after sustaining a head injury, including a basal skull fracture, pneumocephalus and brain bleed, following a likely accidental fall at home. The report raised concerns about delays, miscommunication, confusion and inadequate documentation in referrals to on-call neurosurgery, including uncertainty and changes over her potential transfer to Cardiff.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of backup neurosurgical specialist capacity to field referrals
Wider context from the report “(1) There are a high number of referrals to the single rota’d on-call neurosurgical specialist registrar every day. The system for making and receiving the referrals is not fit for purpose, with inefficient delays, miscommunications and confusion occurring. The use of the UHW switchboard and bleeping the doctor is archaic, and does not utilise technology as it should. Further, if the on-call doctor is in surgery or dealing with an emergency, there is no back up doctor to field the referrals, which can often be time critical.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of the neurosurgical referral system to provide timely and reliable communication
Wider context from the report “(1) There are a high number of referrals to the single rota’d on-call neurosurgical specialist registrar every day. The system for making and receiving the referrals is not fit for purpose, with inefficient delays, miscommunications and confusion occurring. The use of the UHW switchboard and bleeping the doctor is archaic, and does not utilise technology as it should. Further, if the on-call doctor is in surgery or dealing with an emergency, there is no back up doctor to field the referrals, which can often be time critical.
” Open source report
15 Jan 2019 John Preece · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Risk to medically unwell mental health patients View source Failure to plan and maintain required continued observations View source Lack of staff knowledge and understanding of falls management and head injury recognition View source Lack of staff training and knowledge in conducting neuro observations 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
John Preece · 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 Preece, who had early onset dementia and was prone to seizures, suffered a witnessed seizure and fall on 9 September 2015, sustaining a serious head injury. He was not closely monitored and received incomplete and inappropriate physical and neurological observations before being admitted to hospital, where he died in the early hours of 10 September 2015. The principal concerns were inadequate falls management and neuro-observation knowledge and training, lack of forward planning and monitoring, and delayed medical assistance for medically unwell mental health 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Risk to medically unwell mental health patients
Wider context from the report “(5) Evidence given at the inquest showed that the health board had considered the introduction of the NEWS scoring system (National Early Warning System) for the Mental Health Directorate but felt unable to introduce it as the mental health unit did not sit within/alongside a district general hospital. The obvious concern being that against a background of poor training and poor management medically unwell mental health patients are 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to plan and maintain required continued observations
Wider context from the report “(2) There was a clear lack of knowledge amongst all staff, both registered nurses and support workers as to how to conduct neuro observations despite the evidence showing that guidance in the form of health board policy and also a “wall chart” was available to be consulted.
(3) There was no forward planning for the continued observations of Mr Preece throughout the day on 9th September 2015 and as a result he was simply put to bed and not closely monitored as the circumstances required .
(4) The evidence revealed that none of the registered nursing staff were trained either during their basic nurse training or subsequently upon employment within the health board, on how to conduct neuro observations and that together with a failure to appreciate an obvious head injury meant that not only observations conducted but that no medical assistance was sought for at least ten hours.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge and understanding of falls management and head injury recognition
Wider context from the report “(1) There was a clear lack of understanding and basic knowledge of falls management by both trained nurses and support workers in circumstances in which it should have been obvious that Mr Preece sustained a head injury . The evidence clearly revealed that there was knowledge of a head injury following his seizure and fall. Even if that were not the case a head injury should have been suspected .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training and knowledge in conducting neuro observations
Wider context from the report “(2) There was a clear lack of knowledge amongst all staff, both registered nurses and support workers as to how to conduct neuro observations despite the evidence showing that guidance in the form of health board policy and also a “wall chart” was available to be consulted.
(3) There was no forward planning for the continued observations of Mr Preece throughout the day on 9th September 2015 and as a result he was simply put to bed and not closely monitored as the circumstances required.
(4) The evidence revealed that none of the registered nursing staff were trained either during their basic nurse training or subsequently upon employment within the health board, on how to conduct neuro observations and that together with a failure to appreciate an obvious head injury meant that not only observations conducted but that no medical assistance was sought for at least ten hours.
” 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 Use a new neuro-observation chart and restrict neuro-observation performance to registered nurses under UHB policy.
Verbatim wording from the response “A new neuro observation chart was introduced in August 2018 and it is now UHB policy that only registered nurses perform this task.” Source location 2019-0019-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 Include neuro-observation procedures in the undergraduate nursing curriculum.
Verbatim wording from the response “In 2015 undergraduate nurse training did not cover how to perform neuro observations but this task has now been added to the curriculum and as mentioned above, training on how to perform neuro observations is now included in falls training within the UHB.” Source location 2019-0019-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 falls-simulation training suite providing workshops on falls prevention, post-fall care, unwitnessed falls and head-injury response.
Verbatim wording from the response “The UHB has recently opened a falls simulation training suite in the University Hospital of Wales (UHW) and there are plans for a further suite to be sited in University Hospital Llandough. All qualified and support staff are encouraged to attend simulation workshops on falls prevention management and post fall care. The training covers the management of an unwitnessed fall including how to respond to a head injury.” Source location 2019-0019-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 rolling falls-management training covering risk reduction, post-fall care, unwitnessed falls and neuro-observations to mental-health nursing staff.
Verbatim wording from the response “Mental Health Clinical Board run a bespoke falls training programme which has been developed by the Practice Nurse Educators within the Mental Health Services for Older People (MHSOP) Directorate. The sessions specifically include training on falls risk management (to identify measures to reduce the risk of a patient falling), post falls management, responding to an unwitnessed or witnessed fall and performing neuro observations. This training is delivered on a rolling programme and so far, approximately 75% of nurses (both qualified and unqualified) within MHSOP” Source location 2019-0019-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 The evidence showed staff knew about the head injury, disputing the concern that there was a lack of understanding or basic falls-management knowledge.
Verbatim wording from the response “1. There was a clear lack of understanding and basic knowledge of falls management in both trained and support workers in circumstances in which it should have been obvious that Mr Preece sustained a head injury. The evidence clearly revealed that there was knowledge of a head injury following his seizure and fall. Even if that were not the case a head injury should have been suspected.” Source location 2019-0019-Response-by-University-Health-Board
Open published response
18 Dec 2018 Mrs Ruth Ellen Edwards · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 5 Failure to communicate accurate overdose information to liaison psychiatry View source Failure to arrange psychiatric liaison assessment and professional follow-up after overdose View source Inadequate risk history-taking during clinical consultation View source Failure to perform suitably frequent medication reviews View source Availability of many boxes of different repeat-prescribed tablets posing an overdose risk 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
Mrs Ruth Ellen 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
Mrs Ruth Ellen Edwards died at home on 31 August 2018 after hanging herself from an attic ladder, following a long history of mental health problems and previous suicide attempts. Concerns included her discharge after a drug overdose without psychiatric liaison assessment, inadequate risk assessment and inaccurate communication about the overdose, and potentially insufficient medication reviews despite access to many medications at home.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate accurate overdose information to liaison psychiatry
Wider context from the report “(2) The consultation at the UHW on 23rd August was poor. The history-taking was inadequate, as it did not reveal the true extent of Mrs Edwards’ risk in terms of previous suicide attempts and deep-seated mental health problems. Furthermore, inaccurate information was communicated to liaison psychiatry: they were told that Mrs Edwards had taken 2 tablets, when she had taken 20.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange psychiatric liaison assessment and professional follow-up after overdose
Wider context from the report “(1) Mrs Edwards’ discharge from hospital following overdose on 23rd August to see GP was surprising. It was expected in these circumstances that Mrs Edwards would have been transferred to Llandough Hospital for a psychiatric liaison assessment. Instead, responsibility for any further assessment and treatment of Mrs Edwards was passed entirely to Mrs Edwards and her family.
A less capable family/individual may not have pursued help and fallen through the cracks. Furthermore, had Mrs Edwards been hospitalised, her treatment may have been different.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Inadequate risk history-taking during clinical consultation
Wider context from the report “(2) The consultation at the UHW on 23rd August was poor. The history-taking was inadequate, as it did not reveal the true extent of Mrs Edwards’ risk in terms of previous suicide attempts and deep-seated mental health problems. Furthermore, inaccurate information was communicated to liaison psychiatry: they were told that Mrs Edwards had taken 2 tablets, when she had taken 20.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to perform suitably frequent medication reviews
Wider context from the report “(3) The GP practice may not have performed suitably frequent medication reviews with Mrs Edwards. Many boxes of different tablets were found at the family home, many on repeat prescription, posing an overdose 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Availability of many boxes of different repeat-prescribed tablets posing an overdose risk
Wider context from the report “(3) The GP practice may not have performed suitably frequent medication reviews with Mrs Edwards. Many boxes of different tablets were found at the family home, many on repeat prescription, posing an overdose risk.
” 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 Remind staff through Clinical Board quality, safety and experience structures to take complete, diligent mental-health histories using all available information.
Verbatim wording from the response “The care and attention to detail taken by doctors and other healthcare professionals when taking histories and information from mental health patients.” Source location 2018-0395-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 the Bristol Matrix to identify patients requiring psychiatric assessment, supported by established staff training.
Verbatim wording from the response “The identification of patients who require immediate psychiatric assessments and review by specialist teams.” Source location 2018-0395-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 Raise medication-review frequency as a practice issue with the Primary, Community and Intermediate Care Clinical Board for consideration.
Verbatim wording from the response “The GP practice may not have performed suitable frequent medication reviews with Mrs Edwards. Many boxes of different tablets were found at the family home. Many on repeat prescription posing an overdose risk.” Source location 2018-0395-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 Existing Bristol Matrix procedures and established training are considered sufficient to identify patients requiring immediate psychiatric assessment.
Verbatim wording from the response “The identification of patients who require immediate psychiatric assessments and review by specialist teams.” Source location 2018-0395-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 Home treatment with frequent specialist input was considered appropriate, balancing admission risks and the patient's unwillingness to be admitted.
Verbatim wording from the response “The UHB would absolutely concur that some families may not have been in a position to provide ongoing support, but the judgement that Mrs Edwards might remain at home with regular and frequent input from the REACT team was made with the conscious participation and agreement of all, including the team, the patient and the family.” Source location 2018-0395-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 The documentation error stating two tablets were taken did not influence the clinical decision because clinicians knew twenty tablets had been taken.
Verbatim wording from the response “The consultation at the UHW on 23 August was poor. The history taking was inadequate as it did not reveal the true extent of Mrs Edwards risk in terms of previous suicide attempts and deep seated mental health problems. Furthermore, inaccurate information was communicated to liaison psychiatry; they were told that Mrs Edwards had taken 2 tablets when she had taken 20.” Source location 2018-0395-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 Medication review for patients managed in primary care is a matter for the GP practice and Primary, Community and Intermediate Care Clinical Board.
Verbatim wording from the response “The GP practice may not have performed suitable frequent medication reviews with Mrs Edwards. Many boxes of different tablets were found at the family home. Many on repeat prescription posing an overdose risk.” Source location 2018-0395-Response-by-University-Health-Board
Open published response
12 Nov 2018 Joseph Page · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 5 Failure of PODS receiving, utilisation and storage arrangements to prevent future deaths View source Failure to ensure all doctors and nurses understand revised PODS policy requirements View source Delays and uncertainty in updating and implementing PODS policies View source Failure to secure patients’ PODS while awaiting ward admission View source Failure to follow PODS policies on wards View source See 2 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
Joseph Page · 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
Joseph Page, who had significant co-morbidities, was admitted to hospital on 15 March 2018 and died on 23 March 2018 after deliberately taking a mixed overdose of prescription medication. His medication was accessible and unsecured, contrary to hospital policies. The report identified concerns about the storage and handling of patients’ own drugs in the Emergency Department and on Ward B5, and about the implementation and communication of revised policies.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of PODS receiving, utilisation and storage arrangements to prevent future deaths
Wider context from the report “(4) Whilst the specific events that unfolded in relation to Mr Page on the morning of 23.3.18 may have been unforeseeable, the current arrangements/policies in place for the receiving, utilising and storing of PODS at UHW, Cardiff, could give rise to a risk of future deaths in a variety of different ways.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure all doctors and nurses understand revised PODS policy requirements
Wider context from the report “(5) Once completed the exercise of implementing the new Policy & Code needs to be thorough and extensive to ensure that all doctors & nurses throughout the Cardiff & Vale University Health Board (whether full time, part-time or Agency/locum) not only are aware of the revised Policy/Code, but clear on its interpretation/requirements.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays and uncertainty in updating and implementing PODS policies
Wider context from the report “(3) I received evidence that the Patient Property Policy and Medicines Code were in the process of being updated to address (1) & (2), but this exercise not expected to be completed until March 2019 . Thereafter, & on the evidence of it was not clear when implementation of the updated policies would take effect .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to secure patients’ PODS while awaiting ward admission
Wider context from the report “(1) In the Emergency Department, and whilst patients were awaiting admission to a Ward, their PODS remained with them unsecured in a bay (or similar) . Exposing the medication to potential further use/mis-use by the patient, another patient or relative, or theft and mis-use.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to follow PODS policies on wards
Wider context from the report “(2) On ward B5, the policies in place at the time in relation to PODS were not followed , allowing Mr Page’s medication to remain unsecured on the Ward , exposing the medication as in (1) above.
” Open source report
7 Aug 2018 Mr. Steven John Welch · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Lack of employed interventional radiologists to provide tertiary support View source Lack of software enabling electronic transfer of radiology for external review and consultation View source Failure to provide rapid A&E review for head injury patients with reducing or fluctuating Glasgow Coma Scores View source Delays in transferring patients to hospitals or specialist centres providing neurosurgical diagnosis and treatment 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
Mr. Steven John Welch · 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. Steven John Welch was found at home on 26 December 2017 after a reported fall and head injury, and was later diagnosed with a subarachnoid haemorrhage, hydrocephalus and an aneurysm. His condition deteriorated during delays in assessment, neurosurgical admission and transfer of radiology images for specialist review; he was transferred to Southmead Hospital but died from a pulmonary embolism, with deep vein thrombosis and subarachnoid haemorrhage also recorded in the medical cause of death. The principal concerns included delayed emergency assessment and neurosurgical treatment, lack of interventionist radiology cover, and inadequate facilities for transferring radiological images to hospitals outside Wales.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of employed interventional radiologists to provide tertiary support
Wider context from the report “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following:
i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays;
ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital;
iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay;
iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of software enabling electronic transfer of radiology for external review and consultation
Wider context from the report “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following:
i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays;
ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital;
iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay;
iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to provide rapid A&E review for head injury patients with reducing or fluctuating Glasgow Coma Scores
Wider context from the report “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following:
i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays ;
ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital;
iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay;
iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients to hospitals or specialist centres providing neurosurgical diagnosis and treatment
Wider context from the report “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following:
i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays;
ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital ;
iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay;
iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation.
” Open source report
30 Jul 2018 Mr Richard Thomas Peter Barrett · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Failure to request police assistance for welfare checks when ambulance resources are constrained View source Delays in making and chasing-up welfare calls View source Failure to re-categorise incidents when welfare-call information indicates increased risk View source Failure of demand analysis to accurately estimate required ambulance capacity View source Unrealistic target turnaround time for ambulances at A&E View source Failure of call handlers to establish relevant overdose risk information View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Richard Thomas Peter Barrett · 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 20 April 2018, Mr Richard Thomas Peter Barrett took a large overdose of medication with alcohol, called 999 for help, and died before an ambulance reached his flat. Concerns included underestimated ambulance demand, delays in welfare checks and ambulance dispatch, unrealistic hospital turnaround targets, and the failure to ask police to conduct a welfare check.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to request police assistance for welfare checks when ambulance resources are constrained
Wider context from the report “(4) The police could have been asked to perform a welfare check.
Evidence showed that the Ambulance Trust is pessimistic in assuming that the police are also under-resourced and would not be able to assist in such a task. Here the police were not even asked if they could help. Had he been found earlier, whether by police or ambulance, there is a chance that the deceased may have been able to be given first aid and had a better chance of survival.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Delays in making and chasing-up welfare calls
Wider context from the report “(2) There does not seem to be a reliable system for the making and chasing-up of ‘welfare calls’.
Evidence showed that it was not until 2 hours 45 minutes after the initial call that an attempt was made to ring the patient back . It was known that the patient had taken a massive overdose of sleeping tablets at 01:50. It was not enquired by the call handler as to whether he had also taken alcohol, or whether he was alone. When there was no response from his telephone at 05:13 there was a missed opportunity to re-categorise the incident.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to re-categorise incidents when welfare-call information indicates increased risk
Wider context from the report “(2) There does not seem to be a reliable system for the making and chasing-up of ‘welfare calls’.
Evidence showed that it was not until 2 hours 45 minutes after the initial call that an attempt was made to ring the patient back. It was known that the patient had taken a massive overdose of sleeping tablets at 01:50. It was not enquired by the call handler as to whether he had also taken alcohol, or whether he was alone. When there was no response from his telephone at 05:13 there was a missed opportunity to re-categorise the incident .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of demand analysis to accurately estimate required ambulance capacity
Wider context from the report “(1) ‘Demand analysis’ seriously underestimated the number of ambulances required in Cardiff and the Vale that night.
Evidence showed that only 7 ambulances were available up until 2am, then 5 available up until 3am . Also 7 hours of ambulance time was lost during the period 02:26 – 06:30 due to delays at A&E.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Unrealistic target turnaround time for ambulances at A&E
Wider context from the report “(3) The target turnaround time for ambulances at A&E is wildly unrealistic.
Evidence showed that both the University Hospital of Wales and Llandough Hospital were averaging 3 times the target of 15 minutes that night with the longest turnaround being over 100 minutes . Such delay must have a knock-on effect upon the ‘demand analysis’.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of call handlers to establish relevant overdose risk information
Wider context from the report “(2) There does not seem to be a reliable system for the making and chasing-up of ‘welfare calls’.
Evidence showed that it was not until 2 hours 45 minutes after the initial call that an attempt was made to ring the patient back. It was known that the patient had taken a massive overdose of sleeping tablets at 01:50. It was not enquired by the call handler as to whether he had also taken alcohol, or whether he was alone. When there was no response from his telephone at 05:13 there was a missed opportunity to re-categorise the incident.
” 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 Remind clinical contact centre leads to handle Protocol 23 overdose cases promptly.
Verbatim wording from the response “Following this specific incident, an email was sent to the Clinicians on the Clinical Support Desk on the 15th May 2018 by the CCC Clinical Lead. The email identified the importance of attempting to review protocol 23 (overdose) calls when there were delays in responding as these may be time critical. If there was no reply the clinicians should use their critical thinking skills to determine how likely unconsciousness or death would be based on what the patient is recorded as having taken and act accordingly.” Source location 2018-0249-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 Raise overdose welfare checks with police and seek a formal memorandum-of-understanding extension.
Verbatim wording from the response “We have a memorandum of understanding with the Police which does specify circumstances in which the Trust should contact the Police. Welfare checks are not included within that document. The Trust does meet with the Police as part of the joint emergency services network. The Trust will raise this issue with the Police at these joint meetings and seek an increase to the specific circumstances to include overdose cases. We will write to you further once that meeting has taken place and update in relation to the matter.” Source location 2018-0249-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 and model the Optima Predict demand-and-capacity planning project.
Verbatim wording from the response “In addition the Trust’s Planning & Performance Directorate since July 2018 have been working on a project in relation to Optima Predict.” Source location 2018-0249-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 Demand-related capacity constraints make it challenging to undertake a robust welfare-call procedure consistently.
Verbatim wording from the response “The welfare call is undertaken by an identified member of Clinical Contact Centre (CCC) staff from either the call taking or dispatch function depending on who has the most capacity. The Demand Management Plan identifies that ‘It is recognised that delays are often a reflection of demand and as such capacity to undertake a robust welfare call procedure is challenging. Every effort should be made to facilitate this process to maintain good customer practice where possible’. All callers are informed to ring back if the patient’s condition deteriorates.” Source location 2018-0249-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 Existing systems cannot reliably identify whether overdose patients are alone or filter waiting incidents specifically by protocol.
Verbatim wording from the response “The advice of the Clinical Control Centre Technical Manager has been sought and she has confirmed that unfortunately currently there is no searchable way of identifying if the patient is on their own. The queue also cannot be filtered to a specific protocol, however it is possible to view the codes whilst the incident is waiting on the Recall Waiting Call queue and as mentioned cases relating to overdose will have a code that starts with the number 23.” Source location 2018-0249-Response-by-University-Health-Board
Open published response
21 Apr 2017 David Thomas Evans · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Failure to conduct FAST ultrasound examinations under supervision when required View source Failure to ensure necessary training for FAST ultrasound examination View source Failure to routinely store records of FAST ultrasound examinations View source Failure to ensure appropriate escalation of care for symptomatic patients with FAST-ultrasound-identified AAA 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
David Thomas 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
David Thomas Evans presented with severe abdominal pain and an ultrasound scan revealed an aortic diameter of 40mm, but no further investigation was conducted and he was discharged. He was later admitted with a ruptured aortic aneurysm, underwent emergency surgery, and died later that day from complications following a ruptured thoraco-abdominal aneurysm. Concerns included inadequate training and supervision for the FAST ultrasound examination, the routine non-retention of scan records, and insufficient escalation of care when a symptomatic patient has an identified abdominal aortic aneurysm.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct FAST ultrasound examinations under supervision when required
Wider context from the report “(1) The evidence revealed that the Dr that conducted the Focussed Assessment with Sonography for Trauma (FAST) Ultrasound examination had not completed the necessary training and should have conducted the scan under supervision .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure necessary training for FAST ultrasound examination
Wider context from the report “(1) The evidence revealed that the Dr that conducted the Focussed Assessment with Sonography for Trauma (FAST) Ultrasound examination had not completed the necessary training and should have conducted the scan under supervision.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely store records of FAST ultrasound examinations
Wider context from the report “(2) The evidence revealed that records of FAST ultrasound examinations are not routinely stored preventing evaluation of scans to be undertaken after the event .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure appropriate escalation of care for symptomatic patients with FAST-ultrasound-identified AAA
Wider context from the report “(3) The evidence revealed that when an Abdominal Aortic Aneurysm (AAA) is identified in the emergency department by a FAST ultrasound examination and a patient is symptomatic there should always be an appropriate escalation of care .
” Open source report
3 Feb 2017 David Robert Griffiths · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Lack of specific training for new medical and nursing staff in intercostal drain insertion View source Unavailability of real-time ultrasound guidance for fluid chest drain insertion View source Lack of local cardiothoracic department protocols for intercostal drain insertion 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
David Robert Griffiths · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Robert Griffiths died after a pleural drain inserted to treat a pleural effusion penetrated his heart during a procedure at the University Hospital of Wales on 29 September 2016. Concerns included the absence of local protocols and specific training for intercostal drain insertion, and the unavailability of real-time ultrasound guidance despite its support in relevant guidelines.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of specific training for new medical and nursing staff in intercostal drain insertion
Wider context from the report “(1) The evidence revealed that there were no local cardiothoracic department protocols that were available to guide the insertion of intercostal drains and no specific training given to new medical and nursing staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Unavailability of real-time ultrasound guidance for fluid chest drain insertion
Wider context from the report “(2) The British Thoracic Society Guidelines strongly support the use of real time ultrasound guidance when inserting chest drains for fluid. Real time ultrasound guidance was not available in this case .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of local cardiothoracic department protocols for intercostal drain insertion
Wider context from the report “(1) The evidence revealed that there were no local cardiothoracic department protocols that were available to guide the insertion of intercostal drains and no specific training given to new medical and nursing staff.
” Open source report
7 Nov 2016 Maurice ISAACS · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Failure to comprehensively assess and record falls risk and implement a clear care plan View source Failure to ensure trained staff carry out neuro observations in line with policy View source Failure of qualified nurse oversight to identify omitted neuro observations View source Failure to complete all components of neuro observations at the required frequency View source Insufficient ward staffing to manage care demands View source Failure to provide indicated continuous 1:1 supervision for a high falls-risk patient View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maurice ISAACS · 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
Maurice ISAACS, who had dementia and other chronic health conditions, was admitted to hospital after deteriorating and suffered multiple falls. He fell from his bed on 12 June 2016, sustained a head injury and died two days later. Concerns included shortcomings in falls-risk assessment, care planning and supervision, as well as failures in carrying out and overseeing neurological observations after the final fall.
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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to comprehensively assess and record falls risk and implement a clear care plan
Wider context from the report “(1) The investigation into his death revealed shortcomings in the way in which his risk of falls were assessed and recorded . For example, no clear care plan was introduced until after the fourth fall . Although there were some occasions when he was given 1:1 care that was not consistent and despite the increasing number of falls, he was never given true 1:1 supervision / observation. Despite the medical notes showing that this should have been in place at the time of his final fall, the reality on the ward was that he was being observed by a nurse on a 1:4 basis. Despite the ward being staffed to "agreed staffing levels" the evidence showed that on the ground, on occasions, this was simply not enough staff to manage the demands of the ward.
His condition was so variable and unpredictable, and against a background of so many falls, 1:1 care was indicated. The evidence showed that whilst there was a review of his situation after each fall, a more 'holistic' approach, recognising the dangers posed by his unpredictable behaviour, and the causes of that , might have prevented so many falls.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure trained staff carry out neuro observations in line with policy
Wider context from the report “(2) After the final fall, shortcomings were identified in the way that the standard "Neuro Observations" were carried out. They were not carried out in line with Trust Policy . They were conducted by a Health Care Assistant, who had not been trained and who failed to conduct one part of the test for a period of six hours. The omission was not spotted by the qualified nurse whose duty it was to oversee the work of the Healthcare Assistant.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of qualified nurse oversight to identify omitted neuro observations
Wider context from the report “(2) After the final fall, shortcomings were identified in the way that the standard "Neuro Observations" were carried out. They were not carried out in line with Trust Policy. They were conducted by a Health Care Assistant, who had not been trained and who failed to conduct one part of the test for a period of six hours. The omission was not spotted by the qualified nurse whose duty it was to oversee the work of the Healthcare Assistant .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to complete all components of neuro observations at the required frequency
Wider context from the report “(2) After the final fall, shortcomings were identified in the way that the standard "Neuro Observations" were carried out. They were not carried out in line with Trust Policy. They were conducted by a Health Care Assistant, who had not been trained and who failed to conduct one part of the test for a period of six hours . The omission was not spotted by the qualified nurse whose duty it was to oversee the work of the Healthcare Assistant.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient ward staffing to manage care demands
Wider context from the report “(1) The investigation into his death revealed shortcomings in the way in which his risk of falls were assessed and recorded. For example, no clear care plan was introduced until after the fourth fall. Although there were some occasions when he was given 1:1 care that was not consistent and despite the increasing number of falls, he was never given true 1:1 supervision / observation. Despite the medical notes showing that this should have been in place at the time of his final fall, the reality on the ward was that he was being observed by a nurse on a 1:4 basis. Despite the ward being staffed to "agreed staffing levels" the evidence showed that on the ground, on occasions, this was simply not enough staff to manage the demands of the ward .
His condition was so variable and unpredictable, and against a background of so many falls, 1:1 care was indicated. The evidence showed that whilst there was a review of his situation after each fall, a more 'holistic' approach, recognising the dangers posed by his unpredictable behaviour, and the causes of that, might have prevented so many falls.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to provide indicated continuous 1:1 supervision for a high falls-risk patient
Wider context from the report “(1) The investigation into his death revealed shortcomings in the way in which his risk of falls were assessed and recorded. For example, no clear care plan was introduced until after the fourth fall. Although there were some occasions when he was given 1:1 care that was not consistent and despite the increasing number of falls, he was never given true 1:1 supervision / observation . Despite the medical notes showing that this should have been in place at the time of his final fall, the reality on the ward was that he was being observed by a nurse on a 1:4 basis . Despite the ward being staffed to "agreed staffing levels" the evidence showed that on the ground, on occasions, this was simply not enough staff to manage the demands of the ward.
His condition was so variable and unpredictable, and against a background of so many falls, 1:1 care was indicated . The evidence showed that whilst there was a review of his situation after each fall, a more 'holistic' approach, recognising the dangers posed by his unpredictable behaviour, and the causes of that, might have prevented so many falls.
” 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 Health Care Support Workers’ clinical skills, including their role in neurological observations.
Verbatim wording from the response “completion of neurological observations will be undertaken by registered nurses only. The UHB is currently reviewing the clinical skills of Health Care Support Workers and this issue which has arisen in Medicine, will be considered as part of that review. All registered nurses are aware of their UHB and NMC requirements to ensure that neurological observations are undertaken as per UHB policy, and make a clinical decision on the need to escalate to the relevant clinician, dependant on the results of these observations.” Source location 2016-0411-Response-by-Uiniversity-Hospital-of-Wales
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 Benchmark enhanced observational care against other organisations across Wales and England.
Verbatim wording from the response “Nursing staff that have been identified to provide specialling have been informed that they are not to participate in care that would take them away from their role of providing specialling. The Clinical Board are currently undertaking benchmarking of enhanced observational care within other organisations across Wales and England.” Source location 2016-0411-Response-by-Uiniversity-Hospital-of-Wales
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 Carry out the Specialling of Patients project in Medicine Clinical Board wards.
Verbatim wording from the response “The UHB is currently carrying out a project on the ‘Specialling of patients’ which we hope to have in place in the Medicine Clinical Board ward areas in February 2017.” Source location 2016-0411-Response-by-Uiniversity-Hospital-of-Wales
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 Assign responsibility for neurological observations to registered nurses only.
Verbatim wording from the response “The Medicine Clinical Board has undertaken a review of the delegated tasks that are completed by non-registered nursing staff. At this point in time, the Medicine Clinical Board has taken a decision that responsibility for the” Source location 2016-0411-Response-by-Uiniversity-Hospital-of-Wales
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 Restrict staff assigned to specialling to duties that do not take them away from providing specialling.
Verbatim wording from the response “Nursing staff that have been identified to provide specialling have been informed that they are not to participate in care that would take them away from their role of providing specialling. The Clinical Board are currently undertaking benchmarking of enhanced observational care within other organisations across Wales and England.” Source location 2016-0411-Response-by-Uiniversity-Hospital-of-Wales
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commence and regularly review falls care plans for all patients identified as at risk.
Verbatim wording from the response “The Medicine Clinical Board, in conjunction with all Directorates, have put in place the following key changes to identify how risk is assessed and the level of specialling that a patient requires to support a more holistic approach. When completing the falls risk assessment, all patients identified as at risk have a falls care plan commenced. This care plan is reviewed weekly, or more frequently as the patient’s health and requirements change. Since the tragic incident involving Mr I, the Clinical Board recognises the need for more robust discussion of the risk assessment outcome and the need for 1:1 specialling with families/carers. Families and carers are now actively encouraged to share their opinions if they feel 1:1 specialling is not appropriate for their relative or if they may respond poorly to this type of enhanced monitoring.” Source location 2016-0411-Response-by-Uiniversity-Hospital-of-Wales
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss falls risk assessment outcomes and 1:1 specialling requirements with families and carers, incorporating their views.
Verbatim wording from the response “The Medicine Clinical Board, in conjunction with all Directorates, have put in place the following key changes to identify how risk is assessed and the level of specialling that a patient requires to support a more holistic approach. When completing the falls risk assessment, all patients identified as at risk have a falls care plan commenced. This care plan is reviewed weekly, or more frequently as the patient’s health and requirements change. Since the tragic incident involving Mr I, the Clinical Board recognises the need for more robust discussion of the risk assessment outcome and the need for 1:1 specialling with families/carers. Families and carers are now actively encouraged to share their opinions if they feel 1:1 specialling is not appropriate for their relative or if they may respond poorly to this type of enhanced monitoring.” Source location 2016-0411-Response-by-Uiniversity-Hospital-of-Wales
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 Maintain behaviour charts to identify triggers for falls and wandering behaviour.
Verbatim wording from the response “All patients with known cognitive impairment have documentation completed by themselves or by a relative or carer in order to help healthcare staff learn about the patient as a person. We recognise that in the case of Mr I, regrettably, the ‘Reach Out To Me’ document had not been completed. All staff have been reminded of this and it will form part of regular documentation audits. Behaviour charts are maintained to identify any triggers for falls and wandering behaviour. Tools such as Intentional Rounding, which ensures that patients are reviewed every two hours in order to ensure that patients have a drink, are offered toileting in a timely manner are well embedded within all Directorates. Medication reviews are undertaken weekly by the medical team and Pharmacy colleagues to minimise medication interactions and use of sedative medication.” Source location 2016-0411-Response-by-Uiniversity-Hospital-of-Wales
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 daily multidisciplinary Board Rounds providing a patient-centred holistic review.
Verbatim wording from the response “Daily Board Rounds supported by a multi-disciplinary team approach are completed to provide a patient centred holistic review.” Source location 2016-0411-Response-by-Uiniversity-Hospital-of-Wales
Open published response
5 Sep 2016 Dr Imad Hassan · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Lack of a bed management pathway View source Lack of an agreed tertiary-services pathway for unconscious STEMI patients requiring PCI View source Insufficient capacity for admission to designated hospitals for PCI View source Lack of capacity for rescue PCI at designated hospitals View source Lack of an agreed pathway to access adult critical care beds outside Wales View source Lack of a formal backup plan for PCI when designated hospitals cannot accept a patient View source See 3 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
Dr Imad Hassan · 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 17 April 2016, Dr Imad Hassan suffered an out-of-hospital heart attack and cardiac arrest, was resuscitated, and taken to Prince Charles Hospital. He suffered a further cardiac arrest and died at 04:35 on 18 April 2016. The report raised concerns about the lack of a formal backup and transfer pathway for patients requiring PCI when capacity was unavailable at the relevant hospitals, including for unconscious STEMI 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of a bed management pathway
Wider context from the report “3) As per the evidence of ████████ given at inquest, an agreed short term pathway needs to be put in place to access adult critical care beds outside Wales and a bed management pathway put 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed tertiary-services pathway for unconscious STEMI patients requiring PCI
Wider context from the report “4) There is currently no agreed pathway for an unconscious STEMI patient requiring PCI in tertiary services as there is currently for conscious patients with STEMI. Although in the case of Dr Hassan transfer to another hospital for a rescue PCI was not clinically indicated, that may not necessarily be the case in the future, particularly in a patient who has had a short period of unconsciousness and a PCI is clinically indicated.
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity for admission to designated hospitals for PCI
Wider context from the report “2) In such circumstances, a patient meeting the criteria for PCI is unable to undergo that procedure, increasing the risk of his/her death, until there is such capacity for that patient to be admitted to UHW or Morriston Hospitals for PCI .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of capacity for rescue PCI at designated hospitals
Wider context from the report “5) In similar circumstances as pertained on the evening prior to / the morning of Dr Hassan's death such a patient (as described in 4)) may be deprived the opportunity of undergoing rescue PCI due to lack of capacity at either UHW in Cardiff or Morriston in Swansea .
” 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed pathway to access adult critical care beds outside Wales
Wider context from the report “3) As per the evidence of ████████ given at inquest, an agreed short term pathway needs to be put in place to access adult critical care beds outside Wales and a bed management pathway put 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 Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal backup plan for PCI when designated hospitals cannot accept a patient
Wider context from the report “1) In the event that a patient at Prince Charles Hospital is deemed suitable for PCI there is currently no formal back up plan in place , to enable the PCI to proceed, should UHW in Cardiff or Morriston Hospital in Swansea be unable to accept that patient.
” Open source report
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Addressed to Cardiff and Vale NHS Trust, now represented here by Cardiff & Vale University LHB.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations