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 Community Mental Health Services for Older People, Llandough Hospital; 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 Community Mental Health Services for Older People, Llandough Hospital; 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 Community Mental Health Services for Older People, Llandough Hospital; 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 Community Mental Health Services for Older People, Llandough Hospital; 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
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations