Concerns raised 3 Lack of a protocol requiring intravenous lines to be labelled View source Failure to keep investigative test and scan results with patients' medical notes View source Unavailability of labels for intravenous lines View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Geoffrey Parry · 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
Geoffrey Parry underwent major surgery for aggressive bladder cancer on 1 May 2015, developed infection and pneumonia, and died on 29 June 2015. Concerns included an ECG result being unavailable to anaesthetists before surgery and an unlabelled intravenous noradrenaline line becoming disconnected in intensive care, causing a significant drop in blood pressure and the need for cardiopulmonary resuscitation.
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 protocol requiring intravenous lines to be labelled
Wider context from the report “During the evidence it became clear that whilst in intensive care an intravenous line administering noradrenaline was disconnected from Mr Parry which caused his blood pressure to drop significantly to the point of requiring cardiopulmonary resuscitation. The evidence indicated that it was likely this line was disconnected by one of the attending nurses by “accident” as the line was not labelled as best practise dictates. The evidence revealed that there were no labels for the line to be labelled with and there is no protocol requiring intravenous lines to be labelled to ensure that they are not accidentally disconnected , for example, when other drugs are administered. The evidence clearly showed that if the noradrenaline line had been clearly labelled it would not have been disconnected as the nurses and medical team within the critical care unit would fully appreciate the implication to the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cardiff & Vale University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to keep investigative test and scan results with patients' medical notes
Wider context from the report “During the evidence it transpired that an ECG test which was undertaken on 21st April 2015 was not available to the reviewing consultant anaesthetists prior to surgery. The evidence suggested that there was a problem within the hospital, not specific to ECG tests whereby results from investigative tests and scans are not kept with the patient's medical notes . In this instance, it appeared that there was a facility for the result of the ECG to be electronically uploaded onto the hospital computer system but this had not happened . The evidence at the hearing suggested that this was not an uncommon problem . In this case the unavailability of the scan was not in any way causative of Mr Parry's death but could have been.
” 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 labels for intravenous lines
Wider context from the report “During the evidence it became clear that whilst in intensive care an intravenous line administering noradrenaline was disconnected from Mr Parry which caused his blood pressure to drop significantly to the point of requiring cardiopulmonary resuscitation. The evidence indicated that it was likely this line was disconnected by one of the attending nurses by “accident” as the line was not labelled as best practise dictates. The evidence revealed that there were no labels for the line to be labelled with and there is no protocol requiring intravenous lines to be labelled to ensure that they are not accidentally disconnected, for example, when other drugs are administered. The evidence clearly showed that if the noradrenaline line had been clearly labelled it would not have been disconnected as the nurses and medical team within the critical care unit would fully appreciate the implication to the patient.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standard operating procedure for managing intravenous infusion lines.
Verbatim wording from the response “An improvement plan has been put in place to strengthen intravenous infusion labelling practice and is being implemented and monitored by the Critical Care department. An audit of current practice undertaken in November 2015 demonstrates satisfactory compliance but with further room for improvement. A standard operating procedure regarding the management of intravenous infusion line is now in development. Appropriate moisture resistant stickers have been sourced to improve line labelling procedures. The Practice Educator team have implemented training sessions and posters to highlight the incident and arising issues to staff.” Source location 2015-0400-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 staff training sessions and posters addressing intravenous line labelling risks.
Verbatim wording from the response “An improvement plan has been put in place to strengthen intravenous infusion labelling practice and is being implemented and monitored by the Critical Care department. An audit of current practice undertaken in November 2015 demonstrates satisfactory compliance but with further room for improvement. A standard operating procedure regarding the management of intravenous infusion line is now in development. Appropriate moisture resistant stickers have been sourced to improve line labelling procedures. The Practice Educator team have implemented training sessions and posters to highlight the incident and arising issues to staff.” Source location 2015-0400-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review systems and processes for storing ECG investigations.
Verbatim wording from the response “• An ECG test undertaken on 21 April 2015 was not available to the reviewing consultant anaesthetist prior to surgery. The evidence suggested that there was a problem within the hospital, not specific to ECG tests whereby results from investigative tests and scans are not kept with the patient’s medical notes. In this instance, it appeared that there was a facility for the result of the ECG to be electronically uploaded onto the hospital computer system but this had not happened.” Source location 2015-0400-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and monitor an improvement plan for intravenous infusion labelling.
Verbatim wording from the response “An improvement plan has been put in place to strengthen intravenous infusion labelling practice and is being implemented and monitored by the Critical Care department. An audit of current practice undertaken in November 2015 demonstrates satisfactory compliance but with further room for improvement. A standard operating procedure regarding the management of intravenous infusion line is now in development. Appropriate moisture resistant stickers have been sourced to improve line labelling procedures. The Practice Educator team have implemented training sessions and posters to highlight the incident and arising issues to staff.” Source location 2015-0400-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 Source moisture-resistant stickers to improve intravenous line labelling.
Verbatim wording from the response “An improvement plan has been put in place to strengthen intravenous infusion labelling practice and is being implemented and monitored by the Critical Care department. An audit of current practice undertaken in November 2015 demonstrates satisfactory compliance but with further room for improvement. A standard operating procedure regarding the management of intravenous infusion line is now in development. Appropriate moisture resistant stickers have been sourced to improve line labelling procedures. The Practice Educator team have implemented training sessions and posters to highlight the incident and arising issues to staff.” Source location 2015-0400-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review ECG machines for MUSE connectivity and improved patient identification.
Verbatim wording from the response “In order to strengthen use of the MUSE system across the Health Board a number of actions are planned. An improvement plan to support this is in development and will address numerous areas including:” Source location 2015-0400-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review MUSE usage and supporting infrastructure capacity for increased ECG activity.
Verbatim wording from the response “In order to strengthen use of the MUSE system across the Health Board a number of actions are planned. An improvement plan to support this is in development and will address numerous areas including:” Source location 2015-0400-Response-by-University-Health-Board
Open published response
Concerns raised 3 Insufficient staffing capacity for safe patient oversight View source Failure to maintain complete and consistent nursing and clinical records View source Failure to undertake nursing observations in accordance with required procedures and guidance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elsie May Hayward · 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
Elsie May Hayward was admitted to hospital after a fall at home and was being treated for sepsis. During her admission, she sustained four falls, including a likely fall from her bed that caused a head injury and subdural haematoma; her condition deteriorated and she died three days later. Concerns included overstretched staffing, inadequate post-head-injury observations, and omissions and inconsistencies in clinical records and communication.
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 Insufficient staffing capacity for safe patient oversight
Wider context from the report “1. On the 7th January 2015 medical staff were having to care for 50% more patients over what is generally considered to be safe staffed patient ratio . The evidence showed that the team was significantly overstretched and as a result were not able to oversee the care to this lady. Because of the pressures on the team it is likely that there were deficiencies in the care afforded to her which may have contributed to her repeated 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 maintain complete and consistent nursing and clinical records
Wider context from the report “3. There were extensive omissions in the note taking and a clear inconsistency between the “nursing notes” and “clinical notes” resulting in confusion and breakdown of communication between the nursing staff and the medical 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 Failure to undertake nursing observations in accordance with required procedures and guidance
Wider context from the report “2. Despite clear guidance and directive the nursing observations on the deceased following her head injury were not undertaken in accordance with the Health Boards procedure and the N.I.C.E. national guidance .
” 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 Remove real-time documentation so that one clinical note is used.
Verbatim wording from the response “The omissions and inconsistencies in notetaking has been recognised and immediate action has been taken to remove the “core-care plan” and staff will now write individualized care plans for all patients. Further checks have been made in all other areas within Medicine to ensure the core care plan is not being used. The “real time” documentation has also been removed so that only one clinical note is in use.” Source location 2015-0224-Response-by-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 Maintain a process for covering short-term sickness and absence vacancies to protect staffing levels.
Verbatim wording from the response “• The Clinical Director for Internal Medicine has worked with the junior doctors, led by the Chief Resident (SpR) to agree a process for covering vacancies due to short term sickness/absence to ensure that staffing is not compromised” Source location 2015-0224-Response-by-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 Use cross-Clinical-Board medical staffing during extreme pressure to increase capacity in pressured areas.
Verbatim wording from the response “• In times of extreme pressure, the Medical Director makes representation to all Clinical Boards to make sure that as many medical staff are undertaking generic medical duties as possible to increase capacity in areas which are under more pressure.” Source location 2015-0224-Response-by-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 Work with the Royal College of Physicians to agree staffing requirements and standards for managing medical outlier patients.
Verbatim wording from the response “Currently there are no national recognised standards for medical staffing levels although this is currently being considered by the Royal College of Physicians (RCP) and the UHB will work with the RCP to agree staff requirements and standards for the medical management of patients who are outliers.” Source location 2015-0224-Response-by-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 Audit known fallers with head injuries for compliance with NICE guidance and UHB falls-management policies.
Verbatim wording from the response “There will be a planned audit by the end of July 2015 of any known patient fallers with a head injury to give assurance that staff are complying with the requirements of the NICE Guidance and relevant UHB policies for the management of patients following falls.” Source location 2015-0224-Response-by-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 Disseminate head-injury NICE guidance to ward sisters across the Medicine Clinical Board.
Verbatim wording from the response “More recently, Welsh Government has issued Patient Safety Notice PSN/009/April 2015 - Awareness of NICE Clinical Guidelines on head injuries - and this has been issued to all Clinical Boards to remind them of the importance of this particular guidance. Within the medicine Clinical Board, Lead and senior nurses will ensure further dissemination of this information to ward sisters by the end of May 2015.” Source location 2015-0224-Response-by-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 Remove the core care plan and require individualised care plans for all patients.
Verbatim wording from the response “The omissions and inconsistencies in notetaking has been recognised and immediate action has been taken to remove the “core-care plan” and staff will now write individualized care plans for all patients. Further checks have been made in all other areas within Medicine to ensure the core care plan is not being used. The “real time” documentation has also been removed so that only one clinical note is in use.” Source location 2015-0224-Response-by-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 Continue participating in the all-Wales programme to progress a single electronic patient record.
Verbatim wording from the response “The UHB, in line with all other Health Boards in Wales does not have a single electronic patient record in place but will continue with all Wales work to progress this agenda which would inevitably bring significant patient safety benefits. The continuous improvement plan has been presented and discussed at the Medicine Clinical Board formal Board meeting and has also been shared at the UHB Quality, Safety and Patient Experience Committee meeting. The Directorate is required to regularly review the improvement plan and provide assurance to the various quality and safety monitoring mechanisms. An update on progress will be presented at the September 2015 Quality, Safety and Patient Experience Committee.” Source location 2015-0224-Response-by-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 Continue prioritising patient flow and monitoring multidisciplinary workload pressures, managing identified risks through the Risk Register.
Verbatim wording from the response “Additionally the UHB continues to prioritise issues of patient flow and monitors workload pressures for the multi-disciplinary team and recognises associated risks. The Medicine Clinical Board (MCB) will continue to work with the UHB patient flow work stream in order to safely manage patient flow through the organisation. Risks identified will be managed via the Risk Register and acted upon accordingly.” Source location 2015-0224-Response-by-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 Develop and disseminate a new care plan across clinical areas using Falls Focus Group champions as required.
Verbatim wording from the response “The Medicine Clinical Board representatives at the Vulnerable Adult Risk Management Group (VARMG) will support the development and dissemination of a new care plan to all clinical areas, utilising champions from the newly formed Falls Focus Group as required.” Source location 2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Open published response
Concerns raised 4 Failure to ensure accurate information on whiteboards View source Potential continued use of DNR red star systems on whiteboards in Welsh Health Board areas View source Lack of standardisation in information put on whiteboards View source Reliance on whiteboard information instead of patients’ notes 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
John Elvet Morgan · 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 Elvet Morgan, who had Alzheimer’s dementia, was admitted for respite care and collapsed on 30 August 2013. Staff did not resuscitate him because they relied on an erroneous red DNR star left on the ward whiteboard, although no DNR agreement or form existed; the post-mortem report showed pulmonary embolism. The concerns identified included reliance on whiteboard information instead of patient notes, human error in recording information, and the possible use of similar DNR systems elsewhere in 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 Failure to ensure accurate information on whiteboards
Wider context from the report “(1) The Whiteboard (or PSAG) is in use throughout Wales as a quick reference guide to the patients on the ward. It was introduced as part of the “Transforming Care at the bedside “TCAB” programme. Dr ███████ Clinical Director for the University Hospital for Wales Board, confirmed that the information which is put on the whiteboard is a matter for local discretion. While the red “DNR” star system has been removed from the whiteboards in use in Cardiff and the Vale Local Health Board he could not say whether similar systems are not in use elsewhere in Wales.
(2) The whiteboard system is a useful reference point for patient care but there is a danger that the information held on the whiteboard is relied upon instead of the patient’s notes.
(3) Human error may mean that erroneous information is held on the whiteboard to the detriment of patient care .
(4) A similar DNR “red star” system may be in use on whiteboards in other Health Board areas in Wales with the possibility that a similar chain of events may occur elsewhere in Wales.
” 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 Potential continued use of DNR red star systems on whiteboards in Welsh Health Board areas
Wider context from the report “(1) The Whiteboard (or PSAG) is in use throughout Wales as a quick reference guide to the patients on the ward. It was introduced as part of the “Transforming Care at the bedside “TCAB” programme. Dr ███████ Clinical Director for the University Hospital for Wales Board, confirmed that the information which is put on the whiteboard is a matter for local discretion. While the red “DNR” star system has been removed from the whiteboards in use in Cardiff and the Vale Local Health Board he could not say whether similar systems are not in use elsewhere in Wales .
(2) The whiteboard system is a useful reference point for patient care but there is a danger that the information held on the whiteboard is relied upon instead of the patient’s notes.
(3) Human error may mean that erroneous information is held on the whiteboard to the detriment of patient care.
(4) A similar DNR “red star” system may be in use on whiteboards in other Health Board areas in Wales with the possibility that a similar chain of events may occur elsewhere in Wales.
” 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 standardisation in information put on whiteboards
Wider context from the report “(1) The Whiteboard (or PSAG) is in use throughout Wales as a quick reference guide to the patients on the ward. It was introduced as part of the “Transforming Care at the bedside “TCAB” programme. Dr ███████ Clinical Director for the University Hospital for Wales Board, confirmed that the information which is put on the whiteboard is a matter for local discretion . While the red “DNR” star system has been removed from the whiteboards in use in Cardiff and the Vale Local Health Board he could not say whether similar systems are not in use elsewhere in Wales.
(2) The whiteboard system is a useful reference point for patient care but there is a danger that the information held on the whiteboard is relied upon instead of the patient’s notes.
(3) Human error may mean that erroneous information is held on the whiteboard to the detriment of patient care.
(4) A similar DNR “red star” system may be in use on whiteboards in other Health Board areas in Wales with the possibility that a similar chain of events may occur elsewhere in Wales.
” 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 Reliance on whiteboard information instead of patients’ notes
Wider context from the report “(1) The Whiteboard (or PSAG) is in use throughout Wales as a quick reference guide to the patients on the ward. It was introduced as part of the “Transforming Care at the bedside “TCAB” programme. Dr ███████ Clinical Director for the University Hospital for Wales Board, confirmed that the information which is put on the whiteboard is a matter for local discretion. While the red “DNR” star system has been removed from the whiteboards in use in Cardiff and the Vale Local Health Board he could not say whether similar systems are not in use elsewhere in Wales.
(2) The whiteboard system is a useful reference point for patient care but there is a danger that the information held on the whiteboard is relied upon instead of the patient’s notes .
(3) Human error may mean that erroneous information is held on the whiteboard to the detriment of patient care.
(4) A similar DNR “red star” system may be in use on whiteboards in other Health Board areas in Wales with the possibility that a similar chain of events may occur elsewhere in Wales.
” Open source report
Pin
Request correction
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