6 May 2026 Lisa Jayne Townsend · Prevention of Future Deaths report South Wales Central
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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
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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.
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× 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 Cwm Taf Morgannwg University Local Health Board; 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 Cwm Taf Morgannwg University Local Health Board; 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
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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 Require early consultant-to-consultant referral to the University Hospital of Wales HPB team for specialist advice and transfer decisions.
Verbatim wording from the response “We have now changed our pathway and follow up for patients with this complication. Please see the new guidelines of clinicians as set out below.” Source location Response from Cwm Taf Morganwg University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transfer indicated patients promptly to the University Hospital of Wales HPB team and coordinate timely acceptance while avoiding unnecessary delays.
Verbatim wording from the response “We have now changed our pathway and follow up for patients with this complication. Please see the new guidelines of clinicians as set out below.” Source location Response from Cwm Taf Morganwg University Health Board
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27 Feb 2026 SUMMER RAE MANT · Prevention of Future Deaths report South Wales Central
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Concerns raised 1 Lack of standardised crash trolleys across hospital settings View source
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SUMMER RAE MANT · Prevention of Future Deaths report
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; 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
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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 Review resuscitation trolley arrangements across acute hospital sites to identify layout, presentation and human-factors risks.
Verbatim wording from the response “The Health Board has undertaken a comprehensive review of resuscitation trolley arrangements across all acute hospital sites. This confirmed that whilst the contents of cardiac arrest drug trays are standardised in line with Resuscitation Council guidance, there remained variation in visual layout and presentation, particularly at Princess of Wales Hospital (POW), which presents a recognised human factors risk in time-critical situations. In response, immediate action has been taken to align POW paediatric resuscitation trolleys with the established model used at Prince Charles Hospital and Royal Glamorgan Hospital. This includes the removal of red paediatric drug boxes and the introduction of a clear tray system to improve visibility and rapid access to emergency medication.” Source location Response from Cwm Taf Morgannwg University Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce interim resuscitation trolley orientation arrangements for medical staff unfamiliar with the standardised layout.
Verbatim wording from the response “The Health Board has also strengthened training and induction arrangements to address human factors risks associated with staff unfamiliarity. Whilst nursing staff already receive resuscitation trolley orientation as part of induction and mandatory training, gaps were identified within medical induction, particularly for rotational and out-of-hours staff. In response, work is underway with Medical Education to embed resuscitation trolley orientation within formal induction programmes for all incoming medical staff. Interim arrangements have been introduced to provide immediate assurance, alongside the development of updated training resources, including visual guides and instructional materials, to support consistent staff familiarisation with the standardised trolley layout.” Source location Response from Cwm Taf Morgannwg University Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed resuscitation trolley orientation in formal induction for incoming medical staff and develop supporting visual and instructional resources.
Verbatim wording from the response “The Health Board has also strengthened training and induction arrangements to address human factors risks associated with staff unfamiliarity. Whilst nursing staff already receive resuscitation trolley orientation as part of induction and mandatory training, gaps were identified within medical induction, particularly for rotational and out-of-hours staff. In response, work is underway with Medical Education to embed resuscitation trolley orientation within formal induction programmes for all incoming medical staff. Interim arrangements have been introduced to provide immediate assurance, alongside the development of updated training resources, including visual guides and instructional materials, to support consistent staff familiarisation with the standardised trolley layout.” Source location Response from Cwm Taf Morgannwg University Health
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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 Standardise resuscitation trolley layouts and visual guidance across paediatric, neonatal and other clinical environments through a phased rollout.
Verbatim wording from the response “The Health Board has undertaken a comprehensive review of resuscitation trolley arrangements across all acute hospital sites. This confirmed that whilst the contents of cardiac arrest drug trays are standardised in line with Resuscitation Council guidance, there remained variation in visual layout and presentation, particularly at Princess of Wales Hospital (POW), which presents a recognised human factors risk in time-critical situations. In response, immediate action has been taken to align POW paediatric resuscitation trolleys with the established model used at Prince Charles Hospital and Royal Glamorgan Hospital. This includes the removal of red paediatric drug boxes and the introduction of a clear tray system to improve visibility and rapid access to emergency medication.” Source location Response from Cwm Taf Morgannwg University Health
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31 Jul 2025 Lewis Rhys Thomas Petryszyn · Prevention of Future Deaths report South Wales Central
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Concerns raised 1 Absence of specified prescribed timeframes for intervention, ongoing support and case load allocation for prisoners at risk of substance misuse 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
Lewis Rhys Thomas Petryszyn · 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
Lewis Rhys Thomas Petryszyn died in his shared cell at HMP Parc on 15 April 2022 after inhaling synthetic cannabinoids without intending to end his life. The principal concern was the absence of specified timeframes for intervention, ongoing support and case-load allocation for prisoners at risk of substance misuse, creating a risk of delayed support and intervention.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Absence of specified prescribed timeframes for intervention, ongoing support and case load allocation for prisoners at risk of substance misuse
Wider context from the report “(1) There was, and remains, an absence of specified prescribed timeframes in policies and procedures within which intervention, ongoing support, and/or case load allocation to/from Dyfodol must occur for prisoners likely to be at risk of substance misuse.
(2) The absence of prescribed timeframes poses the real risk of delayed support and intervention to drug users
” Open source report
6 Mar 2025 Annette Lewis · Prevention of Future Deaths report South Wales Central
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Concerns raised 1 Failure to implement a “Failed Discharge” policy View source
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AI-generated summary
Annette Lewis · 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
Annette Lewis re-presented to hospital with worsening abdominal pain and was discharged without full consideration of her symptoms and test results. She was declared deceased at home on 18 April 2023; the medical cause of death was recorded as peritonitis and upper gastrointestinal haemorrhage due to a perforated pyloric ulcer. The principal concern was that she should have been referred for surgical review rather than discharged, and that a proposed “Failed Discharge” policy had no definitive implementation timescale.
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× 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to implement a “Failed Discharge” policy
Wider context from the report “Annette should have been referred for surgical review rather than being discharged.
Work on a “Failed Discharge” policy has been ongoing for some time. When implemented, patients re-attending Emergency Departments in similar circumstances would be automatically and swiftly filtered to the appropriate specialist team , which would reduce the risks for those individual patients and reduce the pressures and the consequent risk of errors within Emergency Departments. Progress with this policy has been difficult and there is no definitive timescale for implementation.
” 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 Implement operational general surgery guidelines for patients returning to emergency departments after discharge, and embed them in governance, staff induction and accessible policy resources.
Verbatim wording from the response “1. General Surgery Policy
CTM now has active and up to date guidelines to prevent recurrence of what happened in Mrs Lewis’ case. This is a General Surgery policy that applies to the General Surgeons as well as to the Emergency Department (who have also had it discussed and shared” Source location Response from Cwm Taf Morgannwg University Health Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing guidelines, policies and awareness measures are considered sufficient to prevent further similar patient presentations.
Verbatim wording from the response “widely – please see below in Emergency Department section). The Guidelines for care and treatment for patients who return to an Emergency Department (ED) within CTM UHB with general surgical conditions following discharge from hospital within CTM UHB were approved at Quality & Safety Committee on the 25th March 2025. These guidelines are operational across the Health Board. It was discussed at the Surgical Governance Meeting (pan-health board) on 13th March 2025 department Morbidity and Mortality meeting, and the new policy was shared with the entire team by email. Those involved have reflected and evidenced this as part of their appraisal. Finally, this policy has been included in our induction presentation to all new starters. It is available on the Health Board SharePoint where all Guidelines and Policies are located for rapid access by colleagues.” Source location Response from Cwm Taf Morgannwg University Health Board
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17 Jan 2025 Jackson Yeow · Prevention of Future Deaths report South Wales Central
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Concerns raised 2 Failure to provide emergency department care in appropriate clinical spaces View source Delays in discharging medically fit patients for non-medical reasons View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jackson Yeow · 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
Jackson Yeow, aged 16, became seriously unwell with abdominal pain and vomiting and later developed diabetic ketoacidosis and other complications. He waited approximately 9½ hours for an ambulance after his family called 999, and died on 9 April 2022. Concerns included delays in ambulance handovers associated with emergency department overcrowding, corridor care, and delayed discharge of medically fit patients.
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× 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide emergency department care in appropriate clinical spaces
Wider context from the report “Although the Cwm Taf Morgannwg University Health Board did not provide direct care to Jackson Yeow during the period within scope, it provided the evidence of a consultant in emergency medicine to the inquest on the issue of delays in ambulance handovers at the Princess of Wales Hospital, Bridgend. That evidence directly identified the following matters of concern:
(1) Care for patients in the emergency department is frequently provided in the corridor and other non clinical spaces , which:
(a) Impedes efficient clinical assessment, causing clinicians to take longer performing tasks and rendering clinical care more difficult;
(b) Impedes the ability of staff to recognize a patient’s deteriorating condition;
(c) Increases patient morbidity through environmental factors compromising a patient’s ability to sleep, hygiene and nutrition.
(d) May slow the process of ambulance handovers.
(2) Care in corridors and other non clinical spaces has been normalized, which in the opinion of the consultant who gave evidence is unsafe .
(3) When conducted routinely, care in corridors and other non clinical spaces reduces the capacity of the Emergency Department so that should acuity escalate, it is likely to cause delays to the release of ambulances.
(4) The underlying obstacle to improving flow through the hospital and relieving pressure on the Emergency Department is the significant number of patients who are medically fit to be discharged but whose discharge is delayed due to non medical reasons.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Delays in discharging medically fit patients for non-medical reasons
Wider context from the report “Although the Cwm Taf Morgannwg University Health Board did not provide direct care to Jackson Yeow during the period within scope, it provided the evidence of a consultant in emergency medicine to the inquest on the issue of delays in ambulance handovers at the Princess of Wales Hospital, Bridgend. That evidence directly identified the following matters of concern:
(1) Care for patients in the emergency department is frequently provided in the corridor and other non clinical spaces, which:
(a) Impedes efficient clinical assessment, causing clinicians to take longer performing tasks and rendering clinical care more difficult;
(b) Impedes the ability of staff to recognize a patient’s deteriorating condition;
(c) Increases patient morbidity through environmental factors compromising a patient’s ability to sleep, hygiene and nutrition.
(d) May slow the process of ambulance handovers.
(2) Care in corridors and other non clinical spaces has been normalized, which in the opinion of the consultant who gave evidence is unsafe.
(3) When conducted routinely, care in corridors and other non clinical spaces reduces the capacity of the Emergency Department so that should acuity escalate, it is likely to cause delays to the release of ambulances.
(4) The underlying obstacle to improving flow through the hospital and relieving pressure on the Emergency Department is the significant number of patients who are medically fit to be discharged but whose discharge is delayed due to non medical reasons .
” 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 a ring-fenced emergency-department escalation space and activate site-wide responses when its capacity is exceeded.
Verbatim wording from the response “The float nurse role has been strengthened to provide continuous monitoring of patients in non-clinical spaces. Additionally, DATIX incident reporting is used to capture any patient safety concerns, ensuring rapid escalation to the appropriate senior staff for immediate action. Any patient safety concerns are escalated immediately with prompt transfer of patients to a more clinically appropriate area. This is supported by a ring-fenced escalation space within the ED at POW. Once this space is breached initiates a site based response to on-board patients into pre-identified areas across the site in order to balance risk.” Source location Response from Cwm Taf Morgannwg University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue the STAMP acute-medicine transformation programme to improve hospital flow and support discharge planning across the organisation.
Verbatim wording from the response “Additionally, the STAMP (Strategic Transformation of Acute Medicine Programme) and OPTIMISE programmes have been introduced to improve patient flow across CTM. The Optimise programme utilises real-time digital tools, such as Red2Green and eWhiteboards, to ensure patients are placed in the right clinical area as quickly as possible. Early implementation of these initiatives across Royal Glamorgan and Prince Charles Hospital have significantly reduced patient delays and improved overall care efficiency and the next phase of roll out includes POW site.” Source location Response from Cwm Taf Morgannwg University Health Board
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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 operate a centralised Discharge Hub for patient flow and community bed allocation.
Verbatim wording from the response “To tackle delayed discharges, CTMUHB has implemented:
- The Discharge to Recover then Assess (D2RA) model, ensuring that patients who no longer require acute care are moved to the most appropriate setting as quickly as possible.
- We have also developed the Discharge Hub as a centralised resource for patient flow and community bed allocation.
- The Safe2Start meeting is now embedded pan CTM where twice a day the site is reviewed as a whole with real time demand and capacity being reviewed. Here clinical priorities are discussed and decisions are made in relation to patient flow, on boarding and balancing risk to ensure each area is safe to start.” Source location Response from Cwm Taf Morgannwg University Health Board
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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 capital programme for a dedicated ambulatory bay, including feasibility, costing and timeframe work.
Verbatim wording from the response “We are committed to ongoing improvement across our Emergency Departments and working towards the eradication of corridor care unless in extremis. As part of this work the leadership team are working in collaboration with the POW site based team to develop a capital programme to create a dedicated ambulatory bay. The scoping for this work has already happened and capital colleagues are working through feasibility, costing and timeframes for this work. This is a priority to reduce the reliance on non-clinical spaces and to improve patient experience within the ED.” Source location Response from Cwm Taf Morgannwg University Health Board
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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 Discharge to Recover then Assess model to move patients no longer requiring acute care into appropriate settings promptly.
Verbatim wording from the response “- Ongoing work with Welsh Ambulance Service Trust (WAST) on optimum clinical patient pathways and the Discharge to Recover then Assess (D2RA) Hub, which has improved discharge planning and increased hospital capacity to accept new admissions.” Source location Response from Cwm Taf Morgannwg University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen float-nurse monitoring, senior review, safety huddles and escalation processes for patients receiving care in non-clinical spaces.
Verbatim wording from the response “CTMUHB recognises that corridor care presents significant challenges to efficient clinical assessment and patient safety. We are actively working to reduce reliance on non-clinical spaces through investment in additional nursing staff, transformation programmes and improvements in patient flow, and the implementation of enhanced escalation processes.” Source location Response from Cwm Taf Morgannwg University Health Board
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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 Roll out the Optimise patient-flow programme to the Princess of Wales site using real-time tracking, eWhiteboards, Red2Green and SAFER board rounds.
Verbatim wording from the response “Additionally, the STAMP (Strategic Transformation of Acute Medicine Programme) and OPTIMISE programmes have been introduced to improve patient flow across CTM. The Optimise programme utilises real-time digital tools, such as Red2Green and eWhiteboards, to ensure patients are placed in the right clinical area as quickly as possible. Early implementation of these initiatives across Royal Glamorgan and Prince Charles Hospital have significantly reduced patient delays and improved overall care efficiency and the next phase of roll out includes POW site.” Source location Response from Cwm Taf Morgannwg University Health Board
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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 a dedicated BRATZ assessment area to support rapid triage and safe, efficient ambulance handovers.
Verbatim wording from the response “Corridor care can contribute to delays in ambulance handovers. To mitigate this, we have implemented:
- A fully recruited nursing workforce, reducing the reliance on agency staff and ensuring a consistent, well-trained team is available to manage ambulance arrivals efficiently and make dynamic risk-based decisions on ensuring timely handover of patients and release of ambulance resources.
- We have made significant improvements at POW on ambulance handover times over the past 18 months and we are committed to ongoing improvement in this area.
- A dedicated BRATZ assessment area, where patients are triaged quickly to allow for safe and efficient handovers.” Source location Response from Cwm Taf Morgannwg University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue collaboration with local-authority partners to improve social-care availability and reduce delayed discharges.
Verbatim wording from the response “We continue to work in collaboration with local authority partners to improve social care availability and prevent unnecessary delays.” Source location Response from Cwm Taf Morgannwg University Health Board
Open published response
17 Sep 2024 Sara GRINNELL · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Failure to consider alternative contact methods for urgent gynaecology appointments View source Delays in contacting patients for urgent gynaecology appointments View source Failure to account for earlier referrals and existing delays when reassessing urgency of gynaecology contact View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sara GRINNELL · 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
Sara Grinnell experienced excessive vaginal bleeding and menorrhagia, with repeated referrals to gynaecology before being diagnosed with endometrial cancer in June 2021. A planned hysterectomy was postponed, her treatment options became palliative, and she died on 11 April 2022. The principal concerns were delays exceeding 22 weeks in contacting her after an urgent referral, reliance on written correspondence without further contact methods, insufficient regard to earlier referrals, and a 24-month delay between urgent referral and diagnosis.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to consider alternative contact methods for urgent gynaecology appointments
Wider context from the report “(1) Following an ultrasound scan performed in June 2019, and urgent referral to the Gynaecology Department, there was extensive delay in excess of 22 weeks in attempting to contact the patient with an urgent appointment.
(2) The means of contacting the patient for an Urgent Gynaecology appointment was via written correspondence without further consideration of other means via telephone, email, or via G.P.
(3) When the G.P re-referred the patient to the Gynaecology Department due to ongoing and worsening symptoms, there was a lack of regard to earlier referrals and the extensive delay that had already occurred and a missed opportunity to escalate the urgency of contact.
(3) As a consequence, this resulted a significant delay of 24 months between the urgent referral to Gynaecology Department and eventual 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Delays in contacting patients for urgent gynaecology appointments
Wider context from the report “(1) Following an ultrasound scan performed in June 2019, and urgent referral to the Gynaecology Department, there was extensive delay in excess of 22 weeks in attempting to contact the patient with an urgent appointment .
(2) The means of contacting the patient for an Urgent Gynaecology appointment was via written correspondence without further consideration of other means via telephone, email, or via G.P.
(3) When the G.P re-referred the patient to the Gynaecology Department due to ongoing and worsening symptoms, there was a lack of regard to earlier referrals and the extensive delay that had already occurred and a missed opportunity to escalate the urgency of contact.
(3) As a consequence, this resulted a significant delay of 24 months between the urgent referral to Gynaecology Department and eventual 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to account for earlier referrals and existing delays when reassessing urgency of gynaecology contact
Wider context from the report “(1) Following an ultrasound scan performed in June 2019, and urgent referral to the Gynaecology Department, there was extensive delay in excess of 22 weeks in attempting to contact the patient with an urgent appointment.
(2) The means of contacting the patient for an Urgent Gynaecology appointment was via written correspondence without further consideration of other means via telephone, email, or via G.P.
(3) When the G.P re-referred the patient to the Gynaecology Department due to ongoing and worsening symptoms, there was a lack of regard to earlier referrals and the extensive delay that had already occurred and a missed opportunity to escalate the urgency of contact .
(3) As a consequence, this resulted a significant delay of 24 months between the urgent referral to Gynaecology Department and eventual diagnosis.
” 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 Repatriate the service-level agreement with SBUHB to improve Bridgend-area access and waiting times.
Verbatim wording from the response “Repatriate Service Level Agreement with SBUHB” Source location Response from Cwn Taf Morgannwg University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen harm reviews through robust clinical MDT review of patients waiting more than 104 days.
Verbatim wording from the response “Improve harm review process” Source location Response from Cwn Taf Morgannwg University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint a cancer tracker for gynaecology services to improve cross-site tracking.
Verbatim wording from the response “Appoint cancer tracker for Gynae services to improve efficiency across sites” Source location Response from Cwn Taf Morgannwg University Health Board
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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 Gynae Hub with integrated assessment, cancer, diagnostic and outpatient services.
Verbatim wording from the response “Opening of Gynae Hub at RGH | The Gynae Hub passed through three stages until it is fully operational since July 2024.” Source location Response from Cwn Taf Morgannwg University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop additional ultrasound one-stop clinics for urgent suspected cancer patients awaiting scans.
Verbatim wording from the response “Develop extra scan clinics to tackle the back log created as a result of sonographer sickness and reduced activity | Additional ultrasound scan clinics for USC waiting patients.” Source location Response from Cwn Taf Morgannwg University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Secure administrative support to coordinate expansion of the Gynaecology Rapid Access Service across the Bridgend population.
Verbatim wording from the response “Secure administrative support for expansion of the Gynaecology Rapid Access service (GRAS) to include Bridgend population (patients presented with postmenopausal bleeding are current seen at NPTH)” Source location Response from Cwn Taf Morgannwg University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop additional hysteroscopy sessions within the Gynae Hub to expand rapid-access cancer capacity.
Verbatim wording from the response “Develop extra Hysteroscopy sessions in the newly developed Hub (in process) | Additional hysteroscopy sessions will expand the existing Gynae Cancer Rapid access service (GRAS), creating enough capacity to repatriate Bridgend PMB USC cases back to CTM.” Source location Response from Cwn Taf Morgannwg University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update triage procedures and implement electronic triage to support consistent 24–48-hour allocation.
Verbatim wording from the response “Improve triaging process; update the triage proforma, agreement of daily triage allocation; implementation of electronic triage (WPRS)” Source location Response from Cwn Taf Morgannwg 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 Hold CTM gynaecology cancer oversight meetings to review performance, patients, escalations and waiting times.
Verbatim wording from the response “Establish CTM Gynae cancer oversight meetings (implemented from 11th May)” Source location Response from Cwn Taf Morgannwg 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 The 22-week wait was within the official referral-to-treatment timeframe; only urgent suspected cancer referrals triggered a faster pathway.
Verbatim wording from the response “The Welsh Government has established clear guidelines for managing referral-to-treatment waiting times to ensure timely access to care. Under the mandate issued in December 2009, all referrals to secondary care are expected to be addressed within 26 weeks for at least 95% of cases.” Source location Response from Cwn Taf Morgannwg 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 Written correspondence was considered adequate and effective; no evidence showed alternative contact methods would have increased appointment attendance.
Verbatim wording from the response “Our primary communication method with Ms. Grinnell has consistently been written correspondence. We made three documented attempts to reach her on November 21st, November 28th, and December 12th, 2019. Historically, written communication has been effective, as evidenced by Ms. Grinnell’s response to a January 2018 letter, which she received and then attended the scheduled appointment.” Source location Response from Cwn Taf Morgannwg 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 Health Board disputes that the re-referral met urgent suspected cancer criteria, stating the case was reviewed by the GP and a specialist.
Verbatim wording from the response “3) When the G.P. re-referred the patient to the Gynaecology Department due to ongoing and worsening symptoms, there was a lack of regard to earlier referrals and the extensive delay that had already occurred and a missed opportunity to escalate the urgency of contact.” Source location Response from Cwn Taf Morgannwg University Health Board
Open published response
25 Jun 2024 Isobel Lilian Stapleton · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Delays in access to necessary psychotherapy View source Failure to provide mental health practitioners with easy access to all relevant clinical records View source Unavailability of clinical psychologist access for direct inpatient assessment and treatment at Royal Glamorgan Hospital View source Unavailability of easy access for Welsh mental health practitioners to NHS England clinical records View source Unavailability of clinical psychologist access for direct home treatment assessment and treatment in Merthyr Tydfil View source Failure to ensure mental health practitioners are aware of all relevant clinical records View source See 3 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
Isobel Lilian Stapleton · 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
Isobel Lilian Stapleton, aged 32, was admitted to hospital for assessment and discharged to her father’s home with home treatment support. On 9 July 2022, she sustained likely self-inflicted injuries at home and died despite paramedic attendance; the inquest concluded that she died from suicide. Concerns included limited access to complete clinical records and a lack of clinical psychologist access for inpatient and home treatment teams, with psychotherapy waiting lists lasting months.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Delays in access to necessary psychotherapy
Wider context from the report “(5) The Home treatment team covering Merthyr Tydfil does not have access to a clinical psychologist to provide direct assessment and treatment of a patient. The waiting list for any necessary psychotherapy is months in length .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide mental health practitioners with easy access to all relevant clinical records
Wider context from the report “(1) Mental health practitioners are not easily able to access all of a patient's relevant clinical records pending the introduction of a “Once for Wales” solution, for which there is currently no timetable for implementation.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of clinical psychologist access for direct inpatient assessment and treatment at Royal Glamorgan Hospital
Wider context from the report “(4) The inpatient hospital team at the Royal Glamorgan Hospital did and does not have access to a clinical psychologist to provide direct assessment and treatment of a 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of easy access for Welsh mental health practitioners to NHS England clinical records
Wider context from the report “(3) Mental health practitioners in Wales currently have no way easily to access NHS England clinical records .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of clinical psychologist access for direct home treatment assessment and treatment in Merthyr Tydfil
Wider context from the report “(5) The Home treatment team covering Merthyr Tydfil does not have access to a clinical psychologist to provide direct assessment and treatment of a patient . The waiting list for any necessary psychotherapy is months in length.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure mental health practitioners are aware of all relevant clinical records
Wider context from the report “(2) Mental health practitioners may not be aware of the existence of all such records , some of which may be in paper .
” 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 a contingency business case with implementation timescales and deployment plans for procuring a mental-health information solution.
Verbatim wording from the response “As a contingency measure we are also working with colleagues in another Health Board to accelerate the procurement and implementation of a Mental Health solution should the Connecting Care business case not be approved in the near future. CTMUHB are working on a business case for this which will include timescales and deployments plans, it is expected that we will be ready to procure in the Autumn of 2024.” Source location Response from Cwm Taf Morgannwg 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 disseminate the Clinical Information Access and Recording Matrix and accompanying procedure across mental-health and learning-disability services.
Verbatim wording from the response “As a mitigation for the multiple record system that are still in place across the Mental Health and Learning Disability (MHLD) Care Group the Health Board developed a Clinical Information Access and Recording Matrix (CIARM) in August 2023 for clinical team/staff access for all systems across the MHLD Care Group. This informs all clinical staff of how to access patient clinical risk and discharge planning information both in and out of hours and is the primary tool by which the MHLD Care Group mitigates the potential risks inherent with our present multiple systems.” Source location Response from Cwm Taf Morgannwg 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 working with the national Connecting Care programme to deliver an integrated mental-health information solution as a priority.
Verbatim wording from the response “The Health Board has continued to work with the National programme for Connecting Care, with an aim to deliver a fully integrated Mental Health solution as a priority. A Business Case was due to be submitted at the end of July 2024 for an alternative national solution but at the time of writing this response it has not been received by Welsh Government.” Source location Response from Cwm Taf Morgannwg 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 psychological-professional sessions to the Royal Glamorgan Hospital mental-health unit.
Verbatim wording from the response “There is no designated clinical psychology provision for the Royal Glamorgan Hospital Mental health Unit (RGH MHU). In an attempt to mitigate this, the following has been put in place:” Source location Response from Cwm Taf Morgannwg 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 and plan implementation of a national integrated mental-health records solution through workshops and related planning exercises.
Verbatim wording from the response “I can report that the Health Board had approved prioritisation of the implementation of the national Care Director solution under the Welsh Community Care Information System (WCCIS) programme. As a result, throughout Spring and Summer 2023 the Health Board commenced a series of workshops and planning exercises, supported by local authority colleagues and the national team within Digital Health Care Wales (DHCW). However, during this time, significant operational issues with the Care Director system identified by an early implementing neighbouring Health Board raised questions about future implementation. In addition, we noted that Care Director as a national solution will be withdrawn in January 2026, so all organisations are reviewing” Source location Response from Cwm Taf Morgannwg 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 a dedicated psychological professional for direct assessment and treatment across all three crisis-resolution home-treatment teams.
Verbatim wording from the response “Since June 2024, there is a dedicated psychological professional available for direct assessment and treatment into all three of the CRHTTs. There is no” Source location Response from Cwm Taf Morgannwg 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 Invest resources to address the psychological-therapy waiting-list backlog across primary and secondary mental-health services.
Verbatim wording from the response “waiting list in these services, and the Psychologists and Psychological Therapists work closely with the team as soon as a need for input is identified. There has been significant investment of resource to address the backlog of people waiting for psychological therapies in both Primary and Secondary mental health services. This has reduced the number of people waiting over 52 weeks from 221 in May 2023 to 109 in May 2024.” Source location Response from Cwm Taf Morgannwg University Health Board
Open published response
28 May 2024 Clara Novella Winter · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Failure to maintain fluid balance charts View source Failure to fully roll out required staff training View source Failure to ensure timely escalation by staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Clara Novella Winter · 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
Clara Novella Winter underwent elective laparoscopic cholecystectomy and subsequently developed an incarcerated ischaemic bowel with perforation, requiring emergency surgery. She died on 19 November 2022 after being unable to recover. Concerns were raised about post-operative care, including the timeliness of escalation and maintenance of fluid balance charts; related staff training had not been fully rolled out because of resourcing issues.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain fluid balance charts
Wider context from the report “1. The Health Board accepted that significant learning was required by staff regarding timeliness of escalation and maintenance of fluid balance charts and recommended that all registered nurses from surgical wards should attend an ‘Acutely Unwell’ study day, before the end of 2023.
2. This ‘significant learning’ has not been fully rolled out due to resourcing issues. No completion date could be provided to me because the training is not considered to be compulsory.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to fully roll out required staff training
Wider context from the report “1. The Health Board accepted that significant learning was required by staff regarding timeliness of escalation and maintenance of fluid balance charts and recommended that all registered nurses from surgical wards should attend an ‘Acutely Unwell’ study day, before the end of 2023.
2. This ‘significant learning’ has not been fully rolled out due to resourcing issues. No completion date could be provided to me because the training is not considered to be compulsory.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely escalation by staff
Wider context from the report “1. The Health Board accepted that significant learning was required by staff regarding timeliness of escalation and maintenance of fluid balance charts and recommended that all registered nurses from surgical wards should attend an ‘Acutely Unwell’ study day, before the end of 2023.
2. This ‘significant learning’ has not been fully rolled out due to resourcing issues. No completion date could be provided to me because the training is not considered to be compulsory.
” 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 Standardise the Acutely Unwell Course on ESR and increase monthly capacity to 25–30 training places from September 2024.
Verbatim wording from the response “From September 2024 the Acutely Unwell Course will be a CTM UHB standardised course available on ESR (Electronic Staff Record) for staff to book and have a larger capacity of training numbers of 25-30 spaces per month. The course is promoted via posters and staff email and all ward managers and senior nurses are encouraged to book staff members onto the course.” Source location Response from Cwm Taf Morgannwg 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 Promote the Acutely Unwell Course through posters and staff email and encourage ward managers and senior nurses to book staff.
Verbatim wording from the response “From September 2024 the Acutely Unwell Course will be a CTM UHB standardised course available on ESR (Electronic Staff Record) for staff to book and have a larger capacity of training numbers of 25-30 spaces per month. The course is promoted via posters and staff email and all ward managers and senior nurses are encouraged to book staff members onto the course.” Source location Response from Cwm Taf Morgannwg 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 full outreach staffing complement to run monthly training and complete Acutely Unwell Course attendance for surgical-ward staff by the end of 2024.
Verbatim wording from the response “The Acutely Unwell Patient study day is facilitated by the outreach teams within Cwm Taf Morgannwg UHB. The course runs monthly within Prince Charles, Royal Glamorgan and Princess of Wales hospitals. Registered nurses are booked on by the ward manager. It is a one-off, non-mandatory course but it is advisable that staff complete at least every 3 years.” Source location Response from Cwm Taf Morgannwg University Health Board
Open published response
Concerns raised 1 Failure to provide assessing practitioners with immediate and comprehensive access to relevant mental health records across localities View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paige Jeannette ALLEN · 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
Paige Jeannette Allen died after falling from Southerndown Cliffs in the early hours of 21 April 2021, following an emergency services rescue attempt. The concern was that mental health practitioners assessing patients in crisis across different Cwm Taf Morgannwg University Health Board localities might not have immediate access to relevant medical records, potentially increasing the risk of incomplete or insufficient assessments.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide assessing practitioners with immediate and comprehensive access to relevant mental health records across localities
Wider context from the report “Whilst I did not find that the matter of concern outlined below was directly causative of, nor contributory to, Miss Allen’s death, my concern broadly is that those patients who contact mental health services in Cwm Taf Morgannwg University Health Board (CTMUHB), especially at the time of crisis may be assessed without the assessing practitioner having immediate & comprehensive access to relevant and proximate medical records, notes & plans (such as WARRN assessments, & Care & Treatment Plans).
More particularly, the evidence indicated that should a patient present to mental health services in the Bridgend locality, but have their secondary mental health care managed in either the Merthyr/Cynon locality or the Rhondda/Taff/Ely locality or vice versa, the assessing practitioner will not immediately i.e. at the time of assessment, have access to that patient’s FACE records.
My concern is that this has the potential to deprive the assessing practitioner of pertinent and proximate material which may increase the risk of an incomplete or insufficient assessment.
That being potentially significant in informing the assessing practitioner of his/her action/planning for that individual in crisis.
Whilst I received evidence that CTMUHB has pledged to adopt a system, which it is believed will ameliorate the current situation, I am concerned that until such time as the same is available and immediately accessible across the three localities, the risk identified persists.
Interim measures may wish to be considered to mitigate the risk identified.
” 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 Standardise management of required paper records.
Verbatim wording from the response “Chaired by the Clinical Service Group manager for Merthyr and Cynon Locality, with a multidisciplinary group from across CTM, the HQCR has aligned this work with the recommendations and learning from recent external reviews most particularly the May 2022 Healthcare Inspectorate of Wales (HIW) Review of Discharge Arrangements for Adults from Inpatient Mental Health Services within CTMUHB. A programme of work is underway to:” Source location Response from Cwm Taf Morgannwg 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 Use secure email inboxes for information sharing between RGH and Bridgend mental health teams.
Verbatim wording from the response “The HQCR group has undertaken process mapping regarding passing patient information between Community Mental Health Team (CMHT) and Inpatient for admission and discharge developing flow diagrams that have been shared across the Care Group. They have also developed a number of user guides on how to access and use FACE/w-drive when accessing RTE and M&C records. At present the Mental Health teams will continue to use email to share information between RGH and Bridgend but now a secure email inbox is used at all times to ensure confidentiality but also simplifying access and gathering of information.” Source location Response from Cwm Taf Morgannwg 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 the unified-record business case using implementation lessons to determine required resources and approach.
Verbatim wording from the response “The business case is in the process of review, with the lessons from Aneurin Bevan seen as key to fully understanding the resources and approach required to best move forward with minimal delay. In addition the Health Board is working in partnership with Health Education Improvement Wales to develop digital champion roles to influence and lead digital workforce transformation.” Source location Response from Cwm Taf Morgannwg 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 Scope phasing out paper notes and maximise existing digital systems before implementing the single electronic record.
Verbatim wording from the response “Chaired by the Clinical Service Group manager for Merthyr and Cynon Locality, with a multidisciplinary group from across CTM, the HQCR has aligned this work with the recommendations and learning from recent external reviews most particularly the May 2022 Healthcare Inspectorate of Wales (HIW) Review of Discharge Arrangements for Adults from Inpatient Mental Health Services within CTMUHB. A programme of work is underway to:” Source location Response from Cwm Taf Morgannwg 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 distribute user guides for accessing and using FACE and shared-drive records.
Verbatim wording from the response “The HQCR group has undertaken process mapping regarding passing patient information between Community Mental Health Team (CMHT) and Inpatient for admission and discharge developing flow diagrams that have been shared across the Care Group. They have also developed a number of user guides on how to access and use FACE/w-drive when accessing RTE and M&C records. At present the Mental Health teams will continue to use email to share information between RGH and Bridgend but now a secure email inbox is used at all times to ensure confidentiality but also simplifying access and gathering of information.” Source location Response from Cwm Taf Morgannwg 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 the national Welsh Community Care Information System strategic programme with Digital Health and Care Wales and other health boards.
Verbatim wording from the response “A business case has been developed and endorsed by the Executive. There are however challenges with the preferred national system. The Health Board is working closely with Digital Health and Care Wales and other Health Boards as part of the review of the national strategic programme for the Welsh Community Care Information System. The outcome of this review will influence timescales for WCCIS implementation for the Health Board.” Source location Response from Cwm Taf Morgannwg 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 endorse a business case for a unified electronic record system.
Verbatim wording from the response “In relation to the longer term work to develop safe systems for sharing information, I would like to provide assurance that the Executive and Board are committed to the implementation of a unified electronic record system for the Mental Health and Learning Disabilities Care Group, which includes Child and Adolescent Mental Health Services.” Source location Response from Cwm Taf Morgannwg 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 Review paper and electronic archives and systems and standardise approved inpatient and outpatient care-planning documentation.
Verbatim wording from the response “The immediate mitigating actions of the HQCR included the review of all paper and electronic archives and systems to ensure that there was a congruence of all care planning documentation for inpatients and outpatients. This ensures, through the use of only approved Inpatient Management Plan and Care and Treatment Plan (CTP), that all staff are clear on what documents should be available to them when seeking them out. In addition, governance measures were introduced to limit access to any patient information held on the W and T electronic drives, with senior level authorisation required in order to gain access,” Source location Response from Cwm Taf Morgannwg 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 and distribute the Clinical Information Access and Recording Matrix and accompanying standard operating procedure across mental health clinical teams.
Verbatim wording from the response “As a mitigation for the multiple record system that are still in place across the CTM Mental Health service the HQCR Workstream has developed a Clinical Information Access and Recording matrix (CIARM) for clinical team /staff access (“who accesses what system for what purpose”) for all systems across the mental health service. This informs all clinical staff of how to access patient clinical risk and discharge planning information both in and out of hours and is the primary tool by which the care Group will mitigate the potential risks inherent with our present multiple systems.” Source location Response from Cwm Taf Morgannwg 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 Plan the pre-implementation phase for transferring existing community mental health users to a Health Board Welsh Community Care Information System.
Verbatim wording from the response “Currently, planning is underway for a pre implementation phase to bring all existing users, mainly within the CMHT’s who currently use WCCIS via the local authorities, over to a Health Board WCCIS system. The timescale for this is approx. 6 months, however CTM will be meeting with Aneurin Bevan University Health Board on 27 July 2023 to capture lessons learnt from their implementation” Source location Response from Cwm Taf Morgannwg 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 Map information transfer between community and inpatient teams and share admission and discharge flow diagrams across the Care Group.
Verbatim wording from the response “The HQCR group has undertaken process mapping regarding passing patient information between Community Mental Health Team (CMHT) and Inpatient for admission and discharge developing flow diagrams that have been shared across the Care Group. They have also developed a number of user guides on how to access and use FACE/w-drive when accessing RTE and M&C records. At present the Mental Health teams will continue to use email to share information between RGH and Bridgend but now a secure email inbox is used at all times to ensure confidentiality but also simplifying access and gathering of information.” Source location Response from Cwm Taf Morgannwg 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 Implementation of the integrated electronic record was delayed by infrastructure and resource issues, while national programme review affected implementation timescales.
Verbatim wording from the response “A business case has been developed and endorsed by the Executive. There are however challenges with the preferred national system. The Health Board is working closely with Digital Health and Care Wales and other Health Boards as part of the review of the national strategic programme for the Welsh Community Care Information System. The outcome of this review will influence timescales for WCCIS implementation for the Health Board.” Source location Response from Cwm Taf Morgannwg University Health Board
Open published response
20 Mar 2022 Mr. Donald Vernon Compton · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 5 Failure to detect prescribing and dispensing errors at discharge View source Failure of the electronic prescribing tool to require review of known allergies View source Lack of knowledge about constituent components of commonly prescribed drugs View source Failure to implement Amiodarone dose down-titration View source Failure to record antibiotic allergies using the relevant drug and constituent-drug names 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
Mr. Donald Vernon Compton · 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
Donald Vernon Compton, aged 87, was admitted to hospital after developing Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis and Covid-19, and died on 14 February 2021. The principal concerns were prescribing and dispensing errors involving Co-trimoxazole despite a known trimethoprim allergy, including failures by hospital staff and a GP to identify the risk. A separate medication error involving excessive amiodarone dosing was also identified.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to detect prescribing and dispensing errors at discharge
Wider context from the report “Prescribing and dispensing errors
1. At the time, the All Wales electronic prescribing tool (eDAL) permitted prescribers to avoid reading the section concerning known allergies;
2. The commonly prescribed antibiotic Co-trimoxazole comprises two constituent drugs trimethoprim and sulfamethoxazole. Allergies were not noted as Co-trimoxazole but to the constituent drug, trimethoprim.
3. Prescribing hospital doctors; overseeing pharmacist; and ward nurses all failed to pick up on this discharge prescribing and dispensing error suggesting drug safety on discharge is an area for scrutiny and input to ensure a similar error is avoided a patient safety is maximised.
4. That the Torbay GP also made an error in prescribing Co-trimoxazole to Mr. Compton in the knowledge he was allergic to trimethoprim indicates the lack of specific knowledge about this antibiotic and its constituent elements. It may also reflect a more general lack of knowledge about constituent components of commonly prescribed drugs.
5. A different prescribing error was made in respect of this same patient whilst under the care of RGH. The down titration of Amiodarone was overlooked resulting in too high a dose being administered over several days.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the electronic prescribing tool to require review of known allergies
Wider context from the report “Prescribing and dispensing errors
1. At the time, the All Wales electronic prescribing tool (eDAL) permitted prescribers to avoid reading the section concerning known allergies ;
2. The commonly prescribed antibiotic Co-trimoxazole comprises two constituent drugs trimethoprim and sulfamethoxazole. Allergies were not noted as Co-trimoxazole but to the constituent drug, trimethoprim.
3. Prescribing hospital doctors; overseeing pharmacist; and ward nurses all failed to pick up on this discharge prescribing and dispensing error suggesting drug safety on discharge is an area for scrutiny and input to ensure a similar error is avoided a patient safety is maximised.
4. That the Torbay GP also made an error in prescribing Co-trimoxazole to Mr. Compton in the knowledge he was allergic to trimethoprim indicates the lack of specific knowledge about this antibiotic and its constituent elements. It may also reflect a more general lack of knowledge about constituent components of commonly prescribed drugs.
5. A different prescribing error was made in respect of this same patient whilst under the care of RGH. The down titration of Amiodarone was overlooked resulting in too high a dose being administered over several days.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge about constituent components of commonly prescribed drugs
Wider context from the report “Prescribing and dispensing errors
1. At the time, the All Wales electronic prescribing tool (eDAL) permitted prescribers to avoid reading the section concerning known allergies;
2. The commonly prescribed antibiotic Co-trimoxazole comprises two constituent drugs trimethoprim and sulfamethoxazole. Allergies were not noted as Co-trimoxazole but to the constituent drug, trimethoprim.
3. Prescribing hospital doctors; overseeing pharmacist; and ward nurses all failed to pick up on this discharge prescribing and dispensing error suggesting drug safety on discharge is an area for scrutiny and input to ensure a similar error is avoided a patient safety is maximised.
4. That the Torbay GP also made an error in prescribing Co-trimoxazole to Mr. Compton in the knowledge he was allergic to trimethoprim indicates the lack of specific knowledge about this antibiotic and its constituent elements . It may also reflect a more general lack of knowledge about constituent components of commonly prescribed drugs .
5. A different prescribing error was made in respect of this same patient whilst under the care of RGH. The down titration of Amiodarone was overlooked resulting in too high a dose being administered over several days.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to implement Amiodarone dose down-titration
Wider context from the report “Prescribing and dispensing errors
1. At the time, the All Wales electronic prescribing tool (eDAL) permitted prescribers to avoid reading the section concerning known allergies;
2. The commonly prescribed antibiotic Co-trimoxazole comprises two constituent drugs trimethoprim and sulfamethoxazole. Allergies were not noted as Co-trimoxazole but to the constituent drug, trimethoprim.
3. Prescribing hospital doctors; overseeing pharmacist; and ward nurses all failed to pick up on this discharge prescribing and dispensing error suggesting drug safety on discharge is an area for scrutiny and input to ensure a similar error is avoided a patient safety is maximised.
4. That the Torbay GP also made an error in prescribing Co-trimoxazole to Mr. Compton in the knowledge he was allergic to trimethoprim indicates the lack of specific knowledge about this antibiotic and its constituent elements. It may also reflect a more general lack of knowledge about constituent components of commonly prescribed drugs.
5. A different prescribing error was made in respect of this same patient whilst under the care of RGH. The down titration of Amiodarone was overlooked resulting in too high a dose being administered over several days .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to record antibiotic allergies using the relevant drug and constituent-drug names
Wider context from the report “Prescribing and dispensing errors
1. At the time, the All Wales electronic prescribing tool (eDAL) permitted prescribers to avoid reading the section concerning known allergies;
2. The commonly prescribed antibiotic Co-trimoxazole comprises two constituent drugs trimethoprim and sulfamethoxazole. Allergies were not noted as Co-trimoxazole but to the constituent drug, trimethoprim .
3. Prescribing hospital doctors; overseeing pharmacist; and ward nurses all failed to pick up on this discharge prescribing and dispensing error suggesting drug safety on discharge is an area for scrutiny and input to ensure a similar error is avoided a patient safety is maximised.
4. That the Torbay GP also made an error in prescribing Co-trimoxazole to Mr. Compton in the knowledge he was allergic to trimethoprim indicates the lack of specific knowledge about this antibiotic and its constituent elements. It may also reflect a more general lack of knowledge about constituent components of commonly prescribed drugs.
5. A different prescribing error was made in respect of this same patient whilst under the care of RGH. The down titration of Amiodarone was overlooked resulting in too high a dose being administered over several days.
” Open source report
28 Jan 2022 Manon Edie Jones · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 5 Impaired ability of admission clinicians to assess patients View source Unavailability of community care records to clinicians on admission View source Failure to establish safe levels of observations View source Failure to enter clinical records contemporaneously in a single clinical record View source Failure to safeguard patients on admission 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
Manon Edie Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Manon Edie Jones, aged 16, died from ligaturing shortly after being admitted to a mental health unit following self-harm and a deterioration in her mental health. The report identified concerns that clinicians did not have access to relevant community and hospital records, that clinical records were not entered contemporaneously in a single record, and that this impaired assessment, observation decisions and safeguarding.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Impaired ability of admission clinicians to assess patients
Wider context from the report “(3) The absence of a single in and outpatient clinical record impaired the ability of the clinicians at the unit on admission to be able to assess Manon , fix a safe levels of observations, and safeguard her.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of community care records to clinicians on admission
Wider context from the report “(1) The clinicians assessing Manon on admission to Ty Llidiard did not have available to them the records of her care made in the community by the Crisis team, the Community Intensive Treatment team or the University Hospital of 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to establish safe levels of observations
Wider context from the report “(3) The absence of a single in and outpatient clinical record impaired the ability of the clinicians at the unit on admission to be able to assess Manon, fix a safe levels of observations , and safeguard her.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to enter clinical records contemporaneously in a single clinical record
Wider context from the report “(2) The Clinical records in the Ty Llidiard Unit were not all entered contemporaneously in a single clinical record
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to safeguard patients on admission
Wider context from the report “(3) The absence of a single in and outpatient clinical record impaired the ability of the clinicians at the unit on admission to be able to assess Manon, fix a safe levels of observations, and safeguard her .
” Open source report
21 Dec 2021 Eva Eileen WHEELER · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Lack of a clear and robust process for documenting, requesting and chasing-up emergency ambulances View source Lack of protocol-based provision for joint discussion between on-call medical and surgical registrars View source Lack of a protocol to inform relevant staff when an emergency ambulance is awaited so that appropriate patients are kept nil by mouth View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Eva Eileen WHEELER · 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
Eva Eileen Wheeler, aged 82, was an inpatient receiving rehabilitation after a soft tissue hip injury when she developed sigmoid volvulus, leading to abdominal perforation and her death on 17 February 2020. Concerns included a communication error that meant an emergency ambulance was not called for transfer to a major hospital, the patient was given lunch rather than being kept nil by mouth, and there was no clear protocol for joint discussion between medical and surgical registrars.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear and robust process for documenting, requesting and chasing-up emergency ambulances
Wider context from the report “(1) The communication error between staff led to a failure to contact an emergency ambulance to transfer a critically ill patient to a major hospital. Since this incident, computerisation has largely replaced written notes in this Trust, and evidence from staff did not satisfy me that any changes were embedded on the ground. I am concerned that there is not a clear and robust process in place for documenting, requesting and chasing-up emergency ambulances throughout YCC ;
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of protocol-based provision for joint discussion between on-call medical and surgical registrars
Wider context from the report “(3) The on-call Medical Registrar at Prince Charles Hospital was contacted for advice, since doctors do not work at YCC overnight. Had the on-call Surgical Registrar been consulted, there may have been an earlier diagnosis of suspected sigmoid volvulus. Bowel obstructions are relatively common in an elderly patient cohort, so I question whether provision for joint discussion between the registrars should be built into a protocol .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol to inform relevant staff when an emergency ambulance is awaited so that appropriate patients are kept nil by mouth
Wider context from the report “(2) A consequence of the communication error (above) was that Mrs Wheeler was given lunch, rather than being kept nil by mouth prior to proposed surgical assessment. There should be a protocol to inform relevant staff when an emergency ambulance is awaited, so that where appropriate, the patient is kept nil by mouth ;
” 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 Revise the process for managing patients awaiting emergency ambulances, specifying nil-by-mouth instructions, documentation, and notification responsibilities.
Verbatim wording from the response “A consequence of the communication error (above) was that Mrs Wheeler was given lunch, rather than being kept nil by mouth prior to proposed surgical assessment. There should be a protocol to inform relevant staff when an emergency ambulance is awaited, so that where appropriate, the patient is kept nil by mouth.” Source location 2021-0424-Response-from-Cwm-Taf-Morgannwg-University-Health-Board_Published
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 and explore whether joint registrar discussions should be incorporated into the process for acutely unwell patients.
Verbatim wording from the response “The on-call Medical Registrar at Prince Charles Hospital was contacted for advice, since doctors do not work at YCC overnight. Had the on-call Surgical Registrar been consulted, there may have been an earlier diagnosis of suspected sigmoid volvulus. Bowel obstructions are relatively common in an elderly patient cohort, so I question whether provision for joint discussion between the registrars should be built into a protocol.” Source location 2021-0424-Response-from-Cwm-Taf-Morgannwg-University-Health-Board_Published
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 re-education for registered nursing and medical staff on the revised acutely unwell patient transfer process.
Verbatim wording from the response “Additionally, a programme of re-education is in the process of being taken forward to ensure that all Registered Nursing staff and Medical staff are fully conversant with the revised process. Paper copies of the revised process will also be laminated and displayed by the nurses station for ease of reference at all times.” Source location 2021-0424-Response-from-Cwm-Taf-Morgannwg-University-Health-Board_Published
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 staff knowledge and understanding of the revised transfer process after completing re-education.
Verbatim wording from the response “Furthermore, staff knowledge and understanding of the process will be monitored by undertaking an audit following completion of the re-education process. This will be undertaken by the Senior Nurse with responsibility for the wards within Ysbyty Cwm Cynon.” Source location 2021-0424-Response-from-Cwm-Taf-Morgannwg-University-Health-Board_Published
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 Laminate and display copies of the revised transfer process at nurses’ stations for continuous reference.
Verbatim wording from the response “Additionally, a programme of re-education is in the process of being taken forward to ensure that all Registered Nursing staff and Medical staff are fully conversant with the revised process. Paper copies of the revised process will also be laminated and displayed by the nurses station for ease of reference at all times.” Source location 2021-0424-Response-from-Cwm-Taf-Morgannwg-University-Health-Board_Published
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 Revise the process for transferring acutely unwell patients, clarifying staff responsibilities, process stages, and documentation of verbal instructions.
Verbatim wording from the response “With regards to the first matter, the existing process for the “Transfer of an Acutely Unwell Patient” has been reviewed and revised with a view to:-” Source location 2021-0424-Response-from-Cwm-Taf-Morgannwg-University-Health-Board_Published
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 established process between on-call teams is considered sufficient, so no shared discussion protocol is required.
Verbatim wording from the response “Having reviewed the process which currently exists between the on call teams, there have been no reported incidents in relation this well-established process and it is therefore concluded that there is no requirement for an “on call shared discussion protocol” to be developed.” Source location 2021-0424-Response-from-Cwm-Taf-Morgannwg-University-Health-Board_Published
Open published response
Concerns raised 2 Delays in placing paper referrals in patient notes View source Reliance on paper referrals for internal hospital referrals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Robert Wright · 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 Wright, aged 80, died at Prince Charles Hospital on 26 July 2019 after his condition deteriorated; post-mortem examination identified necrotising cholecystitis caused by gallstones. The principal concern was that a hospital referral for consideration of cholecystectomy was not available to the consultant surgeon because paper referrals were routinely added to patient notes only shortly before clinic appointments, creating a risk that clinicians may not have all relevant information.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Delays in placing paper referrals in patient notes
Wider context from the report “(1) While outpatient referrals from a GP would have been available to the surgeon via an IT system, his evidence was that referrals within the Hospital were made on paper
(2) Those paper referrals were routinely not placed on the patient’s notes until 2-3 days prior to the clinic , in this case many weeks after being made .
(3) In these circumstances there is clearly a risk that a clinician will not have available to them all of the relevant evidence regarding a patient’s referrals and condition
(4) A busy consultant clinician should not in any event be placed in the position of having to look back through paper records to find a referral for a related condition which he had no reason to expect had been made.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Reliance on paper referrals for internal hospital referrals
Wider context from the report “(1) While outpatient referrals from a GP would have been available to the surgeon via an IT system, his evidence was that referrals within the Hospital were made on paper
(2) Those paper referrals were routinely not placed on the patient’s notes until 2-3 days prior to the clinic, in this case many weeks after being made.
(3) In these circumstances there is clearly a risk that a clinician will not have available to them all of the relevant evidence regarding a patient’s referrals and condition
(4) A busy consultant clinician should not in any event be placed in the position of having to look back through paper records to find a referral for a related condition which he had no reason to expect had been made.
” 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 Plan and develop online presentation, triage and vetting of hospital referrals for Consultant review.
Verbatim wording from the response “With regards to the first matter, referrals from General Practice are available on an IT system, however, these referrals are presented to the Consultant body for review on paper. The paper referrals are then triaged and patients are assigned to the appropriate clinics on an appropriate pathway.” Source location 2021-0374-Response-from-Cwm-Taf-University-Health-Board_Published
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 Train staff to access patient information through the electronic record and related online systems.
Verbatim wording from the response “The clinic letters, with the triage outcome, are placed in the patient’s notes and are available for the Consultant team prior to the patient’s appointment in clinic. However, if the referral letter were not actually present in the patient’s physical notes, the medical team would refer to the Welsh Clinical Portal where the referrals are evident. We wish to note that we have moved towards the electronic patient record and a large number of patient’s records are no longer available in clinics in a paper format as we recognise that relying on paper is a risk. These notes are available to medical staff online and our staff have received training onto how to access information as required.” Source location 2021-0374-Response-from-Cwm-Taf-University-Health-Board_Published
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 transitioning patient records to electronic access, reducing reliance on paper records.
Verbatim wording from the response “The clinic letters, with the triage outcome, are placed in the patient’s notes and are available for the Consultant team prior to the patient’s appointment in clinic. However, if the referral letter were not actually present in the patient’s physical notes, the medical team would refer to the Welsh Clinical Portal where the referrals are evident. We wish to note that we have moved towards the electronic patient record and a large number of patient’s records are no longer available in clinics in a paper format as we recognise that relying on paper is a risk. These notes are available to medical staff online and our staff have received training onto how to access information as required.” Source location 2021-0374-Response-from-Cwm-Taf-University-Health-Board_Published
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 missing referral information probably would not have changed the patient’s outcome.
Verbatim wording from the response “This is true and in this patient’s case, he was already on a waiting list for a cholecystectomy. Had this information been available, this would have probably not changed the outcome.” Source location 2021-0374-Response-from-Cwm-Taf-University-Health-Board_Published
Open published response
Concerns raised 4 Deficient root cause analysis failing to identify and address oxygen-supply monitoring issues View source Lack of formal procedures for recording oxygen-supply expiry times View source Incomplete training in oxygen administration View source Failure to monitor and assist unaccompanied patients dependent on finite oxygen supplies before depletion 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
Thomas William Browne · 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
Thomas William Browne, a highly vulnerable patient dependent on non-invasive oxygen ventilation, was found collapsed in a hospital toilet on 17 July 2018 after being left there unaccompanied. His oxygen cylinder was exhausted when he was found, and the inquest concluded that he died from natural causes. Concerns included the absence of systems to monitor patients dependent on finite oxygen supplies, deficiencies in the root cause analysis, incomplete oxygen-administration training, and the lack of formal procedures for recording when oxygen supplies would expire.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Deficient root cause analysis failing to identify and address oxygen-supply monitoring issues
Wider context from the report “(2) The root cause analysis was accepted in evidence by the Trust to be deficient in that it did not identify and address this 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of formal procedures for recording oxygen-supply expiry times
Wider context from the report “(4) There are no formal procedures for recording the time that the finite supply of Oxygen to patients will expire .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Incomplete training in oxygen administration
Wider context from the report “(3) Training in the administration of Oxygen remains incomplete .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor and assist unaccompanied patients dependent on finite oxygen supplies before depletion
Wider context from the report “(1) Although on the evidence at the Inquest, a finding was made that Mr Browne died from natural causes, the evidence gives rise to the concern that patients may be left unaccompanied while being dependent upon a finite supply of Oxygen , where no systems are in place for ensuring that they are monitored and assisted before such supplies run out .
” Open source report
9 Mar 2020 Darren John Goddard · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 8 Delays in admission to Critical Care View source Failure to recognise the adverse effects of sepsis when they occur View source Premature post-operative discharge from the recovery unit View source Failure to provide timely and appropriate antibiotics View source Failure to provide timely and appropriate fluids View source Failure at triage to escalate referrals for medical review within 10 minutes of admission View source Misleading emphasis on flu-like symptoms in TRUS elective surgery consent and information provision View source Inaccuracy in the provided 1% sepsis incidence risk information View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Darren John Goddard · 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
Darren John Goddard underwent an elective trans-rectal ultrasound of the prostate and subsequently developed sepsis, becoming acutely unwell and dying on 18 April 2019. The principal concerns included delayed recognition and treatment of sepsis, delays in triage, antibiotics, fluids and critical care, and the information provided about sepsis risks and symptoms following the procedure.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Delays in admission to Critical Care
Wider context from the report “(6) Delay in admission to Critical Care .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the adverse effects of sepsis when they occur
Wider context from the report “(3) Premature discharge post-operatively from the recovery unit with the missed opportunity to recognise the adverse effect of sepsis when they 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Premature post-operative discharge from the recovery unit
Wider context from the report “(3) Premature discharge post-operatively from the recovery unit with the missed opportunity to recognise the adverse effect of sepsis when they 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely and appropriate antibiotics
Wider context from the report “(5) Subsequent failure to provide timely and appropriate fluids and antibiotics .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely and appropriate fluids
Wider context from the report “(5) Subsequent failure to provide timely and appropriate fluids and antibiotics.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure at triage to escalate referrals for medical review within 10 minutes of admission
Wider context from the report “(4) The failure at triage to escalate this referral to seeing a doctor within 10 mins of admission .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Misleading emphasis on flu-like symptoms in TRUS elective surgery consent and information provision
Wider context from the report “(1) TRUS elective surgery ‘consenting’ and information provision (oral and in written format) places a misleading emphasis on flu-like symptoms as adverse effects .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Inaccuracy in the provided 1% sepsis incidence risk information
Wider context from the report “(2) The accuracy of the 1% risk of sepsis incidence provided .
” 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 Introduce point-of-care venous blood-gas testing to identify abnormal lactate results for early sepsis identification.
Verbatim wording from the response “████████ will also ensure that point of care testing for venous blood gases is introduced in order to identify abnormal lactate results, which are key to the early identification of sepsis.” Source location 2020-0060-Response-from-Dr-Hopkins-Redacted
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 Standardize sepsis terminology and remove “rarely” from the TRUS biopsy consent form.
Verbatim wording from the response “1. Review and provide definite warnings (oral and written) of sepsis when consenting patients to TRUS, and upon their discharge.” Source location 2020-0060-Response-from-Dr-Hopkins-Redacted
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 Use a single BAUS discharge leaflet without a specified post-procedure discharge timeframe.
Verbatim wording from the response “2. Avoid patients being discharged prematurely” Source location 2020-0060-Response-from-Dr-Hopkins-Redacted
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 ongoing Sepsis training on the Sepsis 6 bundle and NEWS documentation, escalation and implementation to medical and nursing staff.
Verbatim wording from the response “3. Further training of Triage nursing staff and doctors of the sepsis 6 bundle and” Source location 2020-0060-Response-from-Dr-Hopkins-Redacted
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 Further sepsis training for medical and nursing staff is currently paused because of COVID-19 activity.
Verbatim wording from the response “████████ recently appointed Clinical lead for the Accident and Emergency Department has reinstated ongoing Sepsis training for medical and nursing staff, both agency and substantive. This is currently on hold however due to COVID-19 activity.” Source location 2020-0060-Response-from-Dr-Hopkins-Redacted
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 Discharge is considered safe when patients feel well, pass urine, tolerate fluids, and have stable observations; no fixed observation period is specified.
Verbatim wording from the response “There are no known recommendations from professional organisations as to the time period for which patients must be observed prior to discharge. Occasionally men feel light-headed, and bleeding may occur, and patients are generally asked to wait until staff are sure that neither of these occurrences have taken place. The majority of patients will leave before one hour has elapsed after their procedure, as long as they are feeling well, are able to pass urine and can tolerate oral fluids. Patients will also have their observations taken and these will need to be stable just prior to discharge. It is unlikely that patients will show any evidence of sepsis within this first hour. The Sepsis Trust confirms that patients may show signs of sepsis up to 30 days post procedures. Mr Goddard’s passing has reminded us all that sepsis can develop rapidly.” Source location 2020-0060-Response-from-Dr-Hopkins-Redacted
Open published response
Concerns raised 1 Failure to clinically review the urgency of patients when appointments are cancelled View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Connor William 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
Connor William Davies was found suspended by a ligature at a residential address on 13 April 2019 and died by hanging; the inquest recorded a verdict of suicide. The principal concern was that repeated cancellations of his mental health appointments did not trigger clinical review for urgent referral, creating a risk that patients in serious need could fall through the net.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to clinically review the urgency of patients when appointments are cancelled
Wider context from the report “(1) Mr Davies was seen by a consultant psychiatrist in November 2018 and a follow up appointment made for January 2019. That appointment was cancelled and another made for March 2019. That too was cancelled and a further appointment made for June 2019 but before he could attend Mr Davies killed himself.
████████ who gave evidence confirmed that when appointments are cancelled there is no clinical input as to the need of individual patients for more urgent referrals and thus a patient who is in serious need of an appointment may ‘fall through the net’ as may have been the case here.
████████ told me that he had endeavoured to put in place a system whereby this could be avoided but, to his knowledge, it is not yet operating .
” 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 appointment-cancellation processes to ensure urgent referral needs receive appropriate clinical input.
Verbatim wording from the response “Synopsis of Concern: To review the existing processes that determine the appropriate priority for booking of appointments, to ensure allocation of clinics across the appropriate level of clinicians.” Source location 2019-0412-Response-by-University-Health-Board
Open published response
24 Sep 2019 Annette Susan HEWINS · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Failure to perform NEWS observations on time View source Lack of a policy for managing opiate-dependent patients in the acute admission setting View source Inconsistent timing of FACE record entries following patient interaction View source Inadequate recording of patient condition in 15-minute observation charts View source Failure to complete NEWS chart fields correctly View source Ad hoc requesting and documentation of ECGs 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
Annette Susan HEWINS · 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
Annette Susan Hewins was detained under the Mental Health Act on 7 February 2017 for assessment and treatment of psychotic symptoms and opiate withdrawal. She was found unconscious in hospital on 8 February 2017 and died despite resuscitation; the post-mortem identified extensive coronary artery atherosclerosis as the likely cause of death. Concerns included inconsistent clinical record-keeping, incorrectly completed NEWS charts, missed observations, inadequate documentation and requesting of an ECG, insufficient detail in observation records, and the absence of a Trust policy for managing opiate-dependent patients in acute admissions.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to perform NEWS observations on time
Wider context from the report “(3) Missed Observations – It transpired that NEWS observations ought to have been undertaken at around 7.30am on 8.2.17. There was no record that they had . Whilst there appeared to be systems in place to prompt Nurses/HCA’s to undertake the observations on time – enhanced observations recorded on a white board & the NEWS charts of those patients receiving enhanced observations being separated on the Nursing station, these did not achieve the desired outcome here . It is suggested that more robust ( possibly linked to FACE) procedures should be considered to ensure the observations are performed on time
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy for managing opiate-dependent patients in the acute admission setting
Wider context from the report “(6) Consideration should be given to the creation & use of a policy within the Trust for managing opiate dependant patients in the acute admission setting . Whilst the absence of such a policy is unlikely to have altered the outcome here, it was agreed by the Head of Mental Health Nursing that such a policy would be worthy of consideration, to assist clinicians & nurses faced with treating such patients. Such policies are in place in the Aneurin Bevan UHB & C & V UHB, as well as several HB’s in England
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Inconsistent timing of FACE record entries following patient interaction
Wider context from the report “(1) There appeared to be some inconsistency as to approach to be taken amongst the Nursing staff/Health Care Assistant as to when entries should be made in the FACE records following interaction with a patient . It is considered that some guidance/training on this issue would be of benefit to promote greater consistency
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of patient condition in 15-minute observation charts
Wider context from the report “(5) It was considered that some of the detail provided by Nurses/HCA’s when completing the 15 minute observations chart was inadequate . In particular entries such as “bed”. It was accepted that such information was inadequate & a brief addendum adding the condition of the patient was desirable – i.e. recording not simply where a patient was located at the time, but also their state – calm, agitated, sleeping, etc. It was felt that guidance/training on the appropriate completion of these observation charts was indicated, so that patterns of physical & mental health symptoms could be assessed.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to complete NEWS chart fields correctly
Wider context from the report “(2) Erroneously completed NEWS charts – it transpired that Nursing Staff/HCA’s were using the frequency of observation box, to record the time observations were carried out . This may require guidance/training to remind staff completing the NEWS charts of the importance of ensuring the appropriate boxes are completed .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Ad hoc requesting and documentation of ECGs
Wider context from the report “(4) ECG Requests – ████████ plan on 8.2.17 was for an ECG to be undertaken. There was no evidence that it had, or had been requested – not documented . The system in place for requesting ECG’s – routine or otherwise appeared somewhat ad hoc and it is suggested that a more robust system for documenting & requesting ECG’s should be considered & implemented.
” Open source report
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 Cwm Taf Morgannwg University Local Health Board; 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 Cwm Taf Morgannwg University Local Health Board; 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
Concerns raised 10 Unclear communication of the required caesarean section category View source Lack of clear responsibility for identifying and ameliorating staffing and acuity risks View source Risk of institutional stress to maternity services following unit merger View source Failure to use the escalation policy View source Insufficient staffing capacity for patient acuity View source Failure to complete NEWS charts and partograms and maintain adequate records View source Failure to provide consultant attendance View source Lack of clear clinical leadership View source Inability of junior staff to challenge or review clinical decisions View source Poor standard of CTG interpretation View source See 7 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. 15
Action
Deliver Royal College of Midwives-supported clinical leadership and team-working study days.
Stated plannedThe respondent said that this action was planned when they made their response on 28 July 2019. View source
Action
Provide multidisciplinary PROMPT training and reflection opportunities focused on emergency communication and caesarean-section decision-making.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019. View source
Action
Implement the Birthrate Plus labour-ward acuity system and support staff to use it for timely escalation.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019. View source
Action
Recruit additional midwifery staff and monitor midwifery and medical staffing monthly.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019. View source
Action
Introduce competency-based assessment for CTG interpretation and monitor training compliance.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019. View source
Action
Complete a Birth Rate Plus assessment of workforce needs for the new unit.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019. View source
Action
Communicate caesarean-section urgency requirements through case feedback, newsletters and clinical review meetings.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2019. View source
Action
Provide monthly clinical supervision for midwives focused on record-keeping standards.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019. View source
Action
Implement an organisational development plan supporting multidisciplinary teamwork and clinical leadership in maternity services.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019. View source
Action
Increase consultant cover through recruitment of three consultants and provide 60-hour labour-ward presence.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2019. View source
Action
Implement All Wales intrapartum fetal surveillance standards, including minimum CTG training.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2019. View source
Action
Deliver mandatory training on communication, record keeping, documentation and escalation, with compliance monitoring.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019. View source
Action
Audit maternity record keeping, NEWS charts and risk-assessment completion, share findings and address identified deficiencies.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019. View source
Action
Implement an escalation policy, incident-reporting process and senior-midwife out-of-hours escalation rota.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2019. View source
Action
Audit caesarean-section categorisation through the 2019/20 clinical audit plan.
Stated plannedThe respondent said that this action was planned when they made their response on 28 July 2019. View source See 12 more actions
×
AI-generated summary
Jenson James Francis · 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
Jenson James Francis was delivered by caesarean section and developed chorioamnionitis and funisitis in the context of maternal sepsis. The report records cardio-pulmonary failure following a failure to deliver him in good time and states that he was exposed to the effects of developing maternal sepsis. Principal concerns included poor CTG interpretation and training, unclear clinical leadership and communication, inadequate records, insufficient staffing and escalation, and wider systemic shortcomings in the maternity unit.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Unclear communication of the required caesarean section category
Wider context from the report “(3) There was unclear communication as to whether a category 1 or 2 caesarean section was required.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for identifying and ameliorating staffing and acuity risks
Wider context from the report “(5) There were insufficient staffing levels, and very high acuity, despite which there was no consultant attendance and the escalation policy was not used. There was evidence that there was no clear line of responsibility for identifying this and ameliorating it .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Risk of institutional stress to maternity services following unit merger
Wider context from the report “(6) The recent merger of the maternity units of the Prince Charles and the Royal Glamorgan hospitals, while potentially creating a future single centre of expertise, does risk causing a period of institutional stress to maternity services which have exhibited some significant shortcomings.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to use the escalation policy
Wider context from the report “(5) There were insufficient staffing levels, and very high acuity, despite which there was no consultant attendance and the escalation policy was not used . There was evidence that there was no clear line of responsibility for identifying this and ameliorating it.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity for patient acuity
Wider context from the report “(5) There were insufficient staffing levels, and very high acuity , despite which there was no consultant attendance and the escalation policy was not used. There was evidence that there was no clear line of responsibility for identifying this and ameliorating it.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to complete NEWS charts and partograms and maintain adequate records
Wider context from the report “(4) NEWS charts and partograms were not completed , and there was a poor standard of record keeping .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consultant attendance
Wider context from the report “(5) There were insufficient staffing levels, and very high acuity, despite which there was no consultant attendance and the escalation policy was not used. There was evidence that there was no clear line of responsibility for identifying this and ameliorating it.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of clear clinical leadership
Wider context from the report “(1) The root cause analysis characterises the presence of a “dysfunctional team without a clear leader.” Evidence at the Inquest and in the report of the Royal College of Obstetricians and Gynaecologists dated 16th April 2019 identified a culture of unclear clinical leadership and a perceived inability on the part of more junior staff to challenge or review decisions.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Inability of junior staff to challenge or review clinical decisions
Wider context from the report “(1) The root cause analysis characterises the presence of a “dysfunctional team without a clear leader.” Evidence at the Inquest and in the report of the Royal College of Obstetricians and Gynaecologists dated 16th April 2019 identified a culture of unclear clinical leadership and a perceived inability on the part of more junior staff to challenge or review decisions .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Poor standard of CTG interpretation
Wider context from the report “(2) There was a poor standard of CTG interpretation , with insufficient training and review
” 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 Royal College of Midwives-supported clinical leadership and team-working study days.
Verbatim wording from the response “There is an Organisational Development Action Plan to focus on many areas of the multiprofessional teams in maternity services. Within the plan there is support for multidisciplinary team working and clinical leadership. Included in the plan are two study days in July and October 2019 supported by the Royal College of Midwives to improve clinical leadership and team working within the department. The mandatory professional training days include sessions on communication, record keeping and documentation and escalation. This plan focuses on individual team members as well as groups. PROMPT is now fully implemented into the Health Board with all staff booked for training before the end of March 2020. Training compliance is monitored through the HB Maternity Improvement Board.” Source location 2019-0158-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 Provide multidisciplinary PROMPT training and reflection opportunities focused on emergency communication and caesarean-section decision-making.
Verbatim wording from the response “The importance of ensuring the team communicate the level of urgency for caesarean section has been communicated to all staff via feedback on cases – newsletters and at clinical review meetings. The multidisciplinary team attend PROMPT training on a monthly basis which has a clear focus on the management of emergency clinical situations with clear team communication. Clinical incident review meetings and multidisciplinary reflection sessions gives an opportunity to review clinical decision making and communication in relation to the level of urgency of a caesarean section. Monitoring of the categorisation of caesarean section is included on the clinical audit plan for 2019/20.” Source location 2019-0158-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 the Birthrate Plus labour-ward acuity system and support staff to use it for timely escalation.
Verbatim wording from the response “Birthrate plus acuity system for labour ward has been implemented into the unit and staff are currently being supported to use this to support timely escalation.” Source location 2019-0158-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 Recruit additional midwifery staff and monitor midwifery and medical staffing monthly.
Verbatim wording from the response “Staffing has significantly improved since August 2018 with ongoing recruitment of midwifery staff. The merger of the two units has assisted in managing any staffing shortfalls as we are no longer providing cover for two units.” Source location 2019-0158-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 Introduce competency-based assessment for CTG interpretation and monitor training compliance.
Verbatim wording from the response “The Health Board has implemented the All Wales Intrapartum Fetal Surveillance Standards which includes a minimum of 6 hours of taught training on CTG monitoring & interpretation. WRP are supporting the introduction of a competency based assessment for CTG interpretation. Training compliance is being monitored through Maternity Improvement Board.” Source location 2019-0158-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 Complete a Birth Rate Plus assessment of workforce needs for the new unit.
Verbatim wording from the response “Midwifery and medical staffing are being reported on a monthly basis via the Maternity Improvement Board. We are currently undergoing a Birth Rate Plus Assessment of our workforce needs in the new unit. The final assessment report will be available in September 2019.” Source location 2019-0158-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 Communicate caesarean-section urgency requirements through case feedback, newsletters and clinical review meetings.
Verbatim wording from the response “The importance of ensuring the team communicate the level of urgency for caesarean section has been communicated to all staff via feedback on cases – newsletters and at clinical review meetings. The multidisciplinary team attend PROMPT training on a monthly basis which has a clear focus on the management of emergency clinical situations with clear team communication. Clinical incident review meetings and multidisciplinary reflection sessions gives an opportunity to review clinical decision making and communication in relation to the level of urgency of a caesarean section. Monitoring of the categorisation of caesarean section is included on the clinical audit plan for 2019/20.” Source location 2019-0158-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 Provide monthly clinical supervision for midwives focused on record-keeping standards.
Verbatim wording from the response “The maternity services have commenced a record keeping audit as part of the audit plan. The findings of the audit will be shared with all staff and actions taken where improvements need to be taken. The senior midwives are undertaking assurance audits on the maternity wards monitoring the standards of records and completion of NEWS charts and other risk assessments. Any areas identified at the time of the monthly assurance audits are being managed at the time of finding an error or incomplete record. Clinical Supervisors for Midwives are conducting monthly group supervision sessions with a focus on the standard of record keeping.” Source location 2019-0158-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 an organisational development plan supporting multidisciplinary teamwork and clinical leadership in maternity services.
Verbatim wording from the response “There is an Organisational Development Action Plan to focus on many areas of the multiprofessional teams in maternity services. Within the plan there is support for multidisciplinary team working and clinical leadership. Included in the plan are two study days in July and October 2019 supported by the Royal College of Midwives to improve clinical leadership and team working within the department. The mandatory professional training days include sessions on communication, record keeping and documentation and escalation. This plan focuses on individual team members as well as groups. PROMPT is now fully implemented into the Health Board with all staff booked for training before the end of March 2020. Training compliance is monitored through the HB Maternity Improvement Board.” Source location 2019-0158-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 Increase consultant cover through recruitment of three consultants and provide 60-hour labour-ward presence.
Verbatim wording from the response “Consultant cover has increased significantly and the Health Board has recently recruited 3 new consultants. There is 60 hour labour ward presence on the labour ward since the merger.” Source location 2019-0158-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 All Wales intrapartum fetal surveillance standards, including minimum CTG training.
Verbatim wording from the response “The Health Board has implemented the All Wales Intrapartum Fetal Surveillance Standards which includes a minimum of 6 hours of taught training on CTG monitoring & interpretation. WRP are supporting the introduction of a competency based assessment for CTG interpretation. Training compliance is being monitored through Maternity Improvement Board.” Source location 2019-0158-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 mandatory training on communication, record keeping, documentation and escalation, with compliance monitoring.
Verbatim wording from the response “There is an Organisational Development Action Plan to focus on many areas of the multiprofessional teams in maternity services. Within the plan there is support for multidisciplinary team working and clinical leadership. Included in the plan are two study days in July and October 2019 supported by the Royal College of Midwives to improve clinical leadership and team working within the department. The mandatory professional training days include sessions on communication, record keeping and documentation and escalation. This plan focuses on individual team members as well as groups. PROMPT is now fully implemented into the Health Board with all staff booked for training before the end of March 2020. Training compliance is monitored through the HB Maternity Improvement Board.” Source location 2019-0158-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 Audit maternity record keeping, NEWS charts and risk-assessment completion, share findings and address identified deficiencies.
Verbatim wording from the response “The maternity services have commenced a record keeping audit as part of the audit plan. The findings of the audit will be shared with all staff and actions taken where improvements need to be taken. The senior midwives are undertaking assurance audits on the maternity wards monitoring the standards of records and completion of NEWS charts and other risk assessments. Any areas identified at the time of the monthly assurance audits are being managed at the time of finding an error or incomplete record. Clinical Supervisors for Midwives are conducting monthly group supervision sessions with a focus on the standard of record keeping.” Source location 2019-0158-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 an escalation policy, incident-reporting process and senior-midwife out-of-hours escalation rota.
Verbatim wording from the response “There is a new escalation policy and staff are incident reporting times of high acuity this is being monitored via datix reporting. There is a senior midwife on call rota to support staff with any concerns in clinical practice out of hours and for concerns about escalation.” Source location 2019-0158-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 Audit caesarean-section categorisation through the 2019/20 clinical audit plan.
Verbatim wording from the response “The importance of ensuring the team communicate the level of urgency for caesarean section has been communicated to all staff via feedback on cases – newsletters and at clinical review meetings. The multidisciplinary team attend PROMPT training on a monthly basis which has a clear focus on the management of emergency clinical situations with clear team communication. Clinical incident review meetings and multidisciplinary reflection sessions gives an opportunity to review clinical decision making and communication in relation to the level of urgency of a caesarean section. Monitoring of the categorisation of caesarean section is included on the clinical audit plan for 2019/20.” Source location 2019-0158-Response-by-University-Health-Board
Open published response
Concerns raised 2 Failure to complete investigations and inquests View source Failure to ensure doctors who have worked in the UK remain traceable and accountable when their conduct is questioned View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jennifer Louise Handy · 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
Jennifer Louise Handy was born at 26 weeks plus 4 days gestation at home on 10th April 2017 and was too premature to survive. The report raised concerns that the doctor involved could not be traced or held to account, which diminished the quality and completeness of the investigation and limited his ability to learn from the issues identified.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to complete investigations and inquests
Wider context from the report “No account in any format was ever provided by Dr A, the Registrar who treated Mrs Handy on 9th April 2017 and sent her home with laxatives and paracetamol. He left the UK in April 2017 to return to his native Sri Lanka to work and thereafter could not be traced.
It is unacceptable that any doctor who has worked in the UK should not be easily traceable and held to account where their conduct is in question.
The risk of future deaths arises as the quality of this investigation/inquest was diminished because it was incomplete , and the doctor in question has been unable to learn from the issues raised.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure doctors who have worked in the UK remain traceable and accountable when their conduct is questioned
Wider context from the report “No account in any format was ever provided by Dr A, the Registrar who treated Mrs Handy on 9th April 2017 and sent her home with laxatives and paracetamol. He left the UK in April 2017 to return to his native Sri Lanka to work and thereafter could not be traced.
It is unacceptable that any doctor who has worked in the UK should not be easily traceable and held to account where their conduct is in question.
The risk of future deaths arises as the quality of this investigation/inquest was diminished because it was incomplete, and the doctor in question has been unable to learn from the issues raised.
” 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 Contact the Assistant Medical Director for Professional Regulation and Standards when a departing doctor may have ongoing GMC concerns.
Verbatim wording from the response “Learning for the Health Board
The Claims Team were unaware there was an investigation by the GMC, that the Registrar had surrendered his license to practice, and he had relocated to Sri Lanka. From here on, if a doctor has left the Health Board, contact will be made with the Assistant Medical Director for Professional Regulation and Standards to establish whether there are any ongoing concerns/issues in relation to the GMC.” Source location 2019-0121-Response-by-University-Health-Board
Open published response
Concerns raised 12 Institutional stress in maternity services with significant shortcomings View source Labour ward coordinator decisions made without full information on patients awaiting transfer View source Failure to use the escalation policy View source Poor standard of multidisciplinary team assessment View source Lack of band 7 midwife and obstetric team leadership View source Insufficient staffing levels View source Poor provision of information on patient handover View source Failure to analyse reviewed cases for common themes and trends View source Poor safety briefing View source Culture of not performing ARM at night View source Reluctance of mid-ranking midwife staff to challenge labour ward coordinator decisions View source Incomplete action plans annexed to root cause analyses View source See 9 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. 11
Action
Conduct nightly out-of-hours consultant discussions with Labour Ward coordinators, alongside daily Obstetric Team ward rounds.
Stated completedThe respondent said that this action was complete when they made their response on 24 May 2019. View source
Action
Undertake two leadership study days to improve clinical leadership and team working within the department.
Stated plannedThe respondent said that this action was planned when they made their response on 24 May 2019. View source
Action
Continue preparing and monitoring the paediatric, neonatal and obstetric service changes associated with the site merger.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019. View source
Action
Review 43 cases, identify common themes and trends, and incorporate the learning into the overarching maternity action plan.
Stated completedThe respondent said that this action was complete when they made their response on 24 May 2019. View source
Action
Implement and operate an escalation policy enabling midwives to contact the on-call Obstetric Consultant and Senior Midwife directly.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019. View source
Action
Implement live acuity-based capture and review of delays to planned activity, with escalation and weekly incident oversight.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019. View source
Action
Update and monitor individual and overarching maternity services improvement action plans through governance boards.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019. View source
Action
Recruit additional midwives through continuous advertising while monitoring staffing levels through the Assurance Board.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019. View source
Action
Implement the organisational development plan and continue multidisciplinary work to improve challenge, openness, culture and team working.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019. View source
Action
Implement an electronic whiteboard with red flags and accurate admission data to support timely multidisciplinary review of Labour Ward transfers.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019. View source
Action
Deliver and audit the maternity quality improvement programme for safety briefings, handover and multidisciplinary assessment.
Stated completedThe respondent said that this action was complete when they made their response on 24 May 2019. View source See 8 more actions
×
AI-generated summary
Calary Fern Davis · 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
Calary Fern Davis was delivered by emergency Caesarean Section on 31st December 2017 after fetal bradycardia caused hypoxic ischaemic encephalopathy and very serious brain damage, and she later died from that condition. The report identified concerns about failures in the induction pathway, including a lack of planned obstetric review, delay in artificial rupture of membranes, insufficient staffing and leadership, poor communication and safety briefings, and a culture against performing artificial rupture of membranes at night.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Institutional stress in maternity services with significant shortcomings
Wider context from the report “(2) It was accepted at Inquest that the merger of the maternity units of the two hospitals, while potentially creating a future single centre of expertise, does risk causing a period of institutional stress to maternity services which have exhibited some significant shortcomings .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Labour ward coordinator decisions made without full information on patients awaiting transfer
Wider context from the report “(6) Decisions by those coordinators were made without full information as to the clinical needs of the patients awaiting transfer to the labour ward
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to use the escalation policy
Wider context from the report “(8) There were insufficient staffing levels, despite which the escalation policy was not used .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Poor standard of multidisciplinary team assessment
Wider context from the report “(7) There was a poor standard of safety briefing, provision of information on patient handover and multi-disciplinary team assessment
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of band 7 midwife and obstetric team leadership
Wider context from the report “(9) There was a lack of band 7 midwife and obstetric team leadership .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing levels
Wider context from the report “(8) There were insufficient staffing levels , despite which the escalation policy was not used.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Poor provision of information on patient handover
Wider context from the report “(7) There was a poor standard of safety briefing, provision of information on patient handover and multi-disciplinary team assessment
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to analyse reviewed cases for common themes and trends
Wider context from the report “(3) There is a review of 43 such cases which was said to be considering them individually rather than analysing common themes and trends .
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Poor safety briefing
Wider context from the report “(7) There was a poor standard of safety briefing , provision of information on patient handover and multi-disciplinary team assessment
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Culture of not performing ARM at night
Wider context from the report “(4) In ████████’s case, proceeding to ARM would have been possible but there was a culture in the unit not to perform it at night
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Reluctance of mid-ranking midwife staff to challenge labour ward coordinator decisions
Wider context from the report “(5) There was a reluctance from mid ranking midwife staff to challenge decisions made by the labour ward coordinators
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Incomplete action plans annexed to root cause analyses
Wider context from the report “(1) The action plan annexed to the root cause analysis remained incomplete . It is understood that this arises in part from the merger of the maternity services of the Royal Glamorgan and the Prince Charles Hospitals.
” 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 Conduct nightly out-of-hours consultant discussions with Labour Ward coordinators, alongside daily Obstetric Team ward rounds.
Verbatim wording from the response “5. Decisions by those coordinators were made without full information as to the clinical needs of the patients awaiting transfer to the Labour Ward.
A new electronic whiteboard is being implemented. This will have red flags to identify and review women in a timely manner. The whiteboard allows for accurate data capture of all inpatients and the date and time of admission. This is a proven quality improvement programme which ensures a multidisciplinary approach in patient safety. Consultants are calling the Labour Ward out of hours and discussing each case with both the Middle Grade and the Band 7 Midwife Co-ordinator to ensure plans are in place and support is given. This is occurring at 10pm every night in addition to the daily ward rounds undertaken by the Obstetric Team.” Source location 2019-0043-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 Undertake two leadership study days to improve clinical leadership and team working within the department.
Verbatim wording from the response “8. There was a lack of Band 7 Midwife and Obstetric Team leadership.
The Organisational Development Action Plan and two planned leadership study days in June and July 2019 are being undertaken to improve clinical leadership and team working within the department. The Organisational Development Plan will focus on multidisciplinary team working and clinical leadership. Our mandatory training includes communication, documentation and escalation as part of the yearly updates.” Source location 2019-0043-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 Continue preparing and monitoring the paediatric, neonatal and obstetric service changes associated with the site merger.
Verbatim wording from the response “Work has been ongoing for the last five years in preparation for the Paediatric, Neonatal and Obstetric change to services. This is monitored monthly through the Service Change Board as part of the South Wales Programme.” Source location 2019-0043-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 43 cases, identify common themes and trends, and incorporate the learning into the overarching maternity action plan.
Verbatim wording from the response “2. There is a review of 43 such cases which was said to be considering them individually rather than analysing common themes and trends.
The 43 cases have been reviewed, common themes and trends identified and these have been incorporated into the overarching action plan for maternity services. A review of all neonatal and stillbirths from January 2016 was undertaken to offer assurance that all cases had been through the governance process and enabled learning. The review has been undertaken with a multidisciplinary approach and monitored weekly through the Maternity Assurance Group. The review of these cases has been overseen by the Welsh Government Delivery Unit. The Delivery Unit has undertaken a review of the methodology applied to ensure a system learning from the incidents.” Source location 2019-0043-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 operate an escalation policy enabling midwives to contact the on-call Obstetric Consultant and Senior Midwife directly.
Verbatim wording from the response “4. There was a reluctance from mid ranking midwife staff to challenge decisions made by the labour ward coordinators.
The Health Board has developed an Organisational Development Plan addressing human factors and to work with all staff grades to develop a positive culture of challenge and openness. The Health Board also implemented a new Escalation Policy with work specifically focussed on midwives being able to jump call to the Obstetric Consultant and Senior Midwife on call. The Clinical Supervisor for Midwives is undertaking escalation work within group settings.” Source location 2019-0043-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 live acuity-based capture and review of delays to planned activity, with escalation and weekly incident oversight.
Verbatim wording from the response “3. In Mrs Davis’ case proceeding to Artificial Rupture of Membranes would have been possible but there was a culture in the unit not to perform this at night.
All delays for planned activity are now monitored and datix reported. The Health Board is introducing a live acuity tool which allows for delays to be captured. The Senior Midwife is responsible for ensuring that all delays are escalated. This is then reviewed during the weekly incident reporting meeting. The Organisational Development Plan is centred around addressing custom and practice leading to ineffective cultures. The plan has already been implemented and work will continue with all disciplines through the year.” Source location 2019-0043-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 Update and monitor individual and overarching maternity services improvement action plans through governance boards.
Verbatim wording from the response “Actions implemented:
The action plan annexed to the root cause analysis remained incomplete. It is understood that this arises in part from the merger of the Maternity Services of the Royal Glamorgan and the Prince Charles Hospitals.
A corrective Action Plan for Improvement was developed following Calary Davis’ death. This has been updated to reflect the concerns identified within the Regulation 28 Report. The individual action plan has a completion date of August 2019, however, work is ongoing for the overarching maternity services action plan. All plans will be monitored through the Improvement Board and the Quality Safety Board.” Source location 2019-0043-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 Recruit additional midwives through continuous advertising while monitoring staffing levels through the Assurance Board.
Verbatim wording from the response “7. There were insufficient staffing levels, despite which, the escalation policy was not used.
Staffing has significantly improved since August 2018. We have a rolling advert for recruitment of midwives and this is monitored closely. The merger of the two units assists with the difficulties of the shortfall. Currently the Health Board has a vacancy of 15 WTE Midwives with midwifery staffing now at 90% of the required midwifery levels for the service. Staffing is monitored weekly through our Assurance Board and a Senior Midwife on call rota is in place and was implemented in July 2018. Please refer also to point 5.” Source location 2019-0043-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 the organisational development plan and continue multidisciplinary work to improve challenge, openness, culture and team working.
Verbatim wording from the response “3. In Mrs Davis’ case proceeding to Artificial Rupture of Membranes would have been possible but there was a culture in the unit not to perform this at night.
All delays for planned activity are now monitored and datix reported. The Health Board is introducing a live acuity tool which allows for delays to be captured. The Senior Midwife is responsible for ensuring that all delays are escalated. This is then reviewed during the weekly incident reporting meeting. The Organisational Development Plan is centred around addressing custom and practice leading to ineffective cultures. The plan has already been implemented and work will continue with all disciplines through the year.” Source location 2019-0043-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 an electronic whiteboard with red flags and accurate admission data to support timely multidisciplinary review of Labour Ward transfers.
Verbatim wording from the response “5. Decisions by those coordinators were made without full information as to the clinical needs of the patients awaiting transfer to the Labour Ward.
A new electronic whiteboard is being implemented. This will have red flags to identify and review women in a timely manner. The whiteboard allows for accurate data capture of all inpatients and the date and time of admission. This is a proven quality improvement programme which ensures a multidisciplinary approach in patient safety. Consultants are calling the Labour Ward out of hours and discussing each case with both the Middle Grade and the Band 7 Midwife Co-ordinator to ensure plans are in place and support is given. This is occurring at 10pm every night in addition to the daily ward rounds undertaken by the Obstetric Team.” Source location 2019-0043-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 and audit the maternity quality improvement programme for safety briefings, handover and multidisciplinary assessment.
Verbatim wording from the response “6. There was a poor standard of safety briefing, provision of information on patient handover and multi-disciplinary team assessment.
A quality improvement programme to ensure handover and safety briefings are delivered to a high standard, has been incorporated into our maternity action plan. The action plan is monitored weekly through our Assurance meetings and audits are undertaken from the Senior Midwifery Team. All safety briefings are retained for audit purposes. These are working well and have a multidisciplinary focus, which is improving communication and team working.” Source location 2019-0043-Response-by-University-Health-Board
Open published response
Concerns raised 3 Lack of updated and documented pain scores before discharge View source Lack of formal guidance for prescribing oramorph to discharging patients View source Lack of documented post-dose observations after oramorph administration View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Janice Mary 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
Janice Mary Davies fell out of bed at home on 19 April 2018, sustaining fractured ribs, and was treated with oramorph before being discharged. She died at home in the early hours of 21 April 2018; the medical cause included morphine toxicity, bilateral rib fractures, chronic obstructive pulmonary disease and chronic kidney disease. Concerns included missing post-dose observations and pain-score documentation, and a lack of formal guidance for prescribing oramorph to patients being discharged.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of updated and documented pain scores before discharge
Wider context from the report “(2) There was an absence of an updated & documented pain score prior to discharge . Most significantly, this, on the evidence of ████████ would have been desirable/required to inform the prescribing clinician, ████████ of the most appropriate prescription of oramorph to be given to the deceased upon discharge.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of formal guidance for prescribing oramorph to discharging patients
Wider context from the report “(3) Most significantly, there appeared, on the evidence, to be an absence of formal guidance or instruction-- written or otherwise to clinicians in the Accident & Emergency Department regarding the prescribing of oramorph to discharging patients . This would appear then to give rise to potential inconsistencies in the prescribing of oramorph to discharging patients. Not only in terms of prescribed dosages, but also in respect of the extent of the supply. The deceased was prescribed 40 mls per day & given a supply lasting two weeks. ████████ evidence was that in the absence of clear evidence as to the deceased's tolerance to morphine, he would be uncomfortable with this dosage & supply. His evidence was that a prescription of 20 mls per day, & a supply for 5 days (then review by GP if symptoms persisted/to assess the patient's reaction to the oramorph) was more appropriate in the circumstances.
” 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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of documented post-dose observations after oramorph administration
Wider context from the report “(1) There was an absence of documented (despite indicated) observations of the deceased post her doses of oramorph at around 13:55 hrs & 15.40 hrs on 19.4.18.
” 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 corrective Action Plan for Improvement addressing the concerns identified in the Regulation 28 report.
Verbatim wording from the response “1. Action taken to plan and monitor improvements
A corrective Action Plan for Improvement has been developed which reflects the concerns identified within the Regulation 28 Report.” Source location 2018-0409-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 a Standard Operating Procedure governing the appropriate use of oral opioid medication for acute pain.
Verbatim wording from the response “2) A Standard Operating Procedure has been implemented to advise on the appropriate use of oral opioid medication in acute pain. A copy is attached.” Source location 2018-0409-Response-by-University-Health-Board
Open published response
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 Cwm Taf Morgannwg University Local Health Board; 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 Cwm Taf Morgannwg University Local Health Board; 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 Cwm Taf Morgannwg University Local Health Board; 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 Cwm Taf Morgannwg University Local Health Board; 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
8 Feb 2018 Howard Winter · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Failure to escalate neck or back pain findings to a doctor for reassessment, investigation and diagnosis View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Howard Winter · 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
Howard Winter, a resident of Daffodils CH with vascular dementia and frequent falls, fell on 23 August 2017, sustained a serious head injury, was diagnosed with a spinal fracture on 11 September, developed pneumonia and died in hospital on 16 September 2017. The principal concern was that recorded neck and back pain following his initial attendances was not escalated to a doctor for reassessment, investigation and diagnosis, potentially contributing to an adverse outcome if repeated.
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 Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate neck or back pain findings to a doctor for reassessment, investigation and diagnosis
Wider context from the report “████████ gave evidence at the Inquest that on the 26.8.17 an auxiliary nurse had recorded in the nursing notes – “pain in neck/back – unable to score”. There was no evidence – written or otherwise, to demonstrate an escalation of this finding to a doctor for re-assessment, investigation & diagnosis.
████████ evidence to the Inquest was that this ought to have occurred .
Whilst this apparent absence of escalation may not necessarily have affected the outcome for Mr Winter, were it to be repeated now, or in the future, the outcome for the patient involved could be potentially causative of/contribute towards death/adverse outcome .
” 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 Conduct two Health Board-wide audits of NEWS score completion and escalation.
Verbatim wording from the response “1. Two audits have been undertaken across the Health Board to measure how the NEWS scores are completed and escalated.” Source location 2018-0040-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 Progress improvement work in priority clinical areas identified through the NEWS audit.
Verbatim wording from the response “The audit has identified the need for further education and training as well as raising awareness amongst nursing and medical staff in relation to accurate documentation and escalation. The audit has also identified priority clinical areas for improvement work which will be progressed.” Source location 2018-0040-Response-by-University-Health-Board
Open published response
7 Sep 2017 David Michael Sewell · Prevention of Future Deaths report South Wales Central
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Concerns raised 1 Lack of a robust system to ensure people with mental health problems are seen and receive appropriate care View source
Responses linked to these concerns
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David Michael Sewell · 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 Michael Sewell was found in the bath at his home in the early hours of 5 June 2017 with injuries to his arms and holding a razor. He had a history of mental health difficulties, including previous self-harm and an overdose, and the inquest concluded that the cause of death was transection of the left brachial artery and recorded a conclusion of suicide. The principal concern was the apparent lack of a robust system to ensure that people with mental health problems were seen and appropriately cared for, including further efforts to re-engage Mr Sewell after he did not respond to a letter.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust system to ensure people with mental health problems are seen and receive appropriate care
Wider context from the report “1) When Mr Sewell attended for the appointment with the Psychiatrist he was told by the main reception that they were unaware of a Health Worker of that name and he left the building. He was contacted by telephone on 3 occasions on the 16th and 17th August but displayed hostility towards members of the team. His case was discussed by the Multi-Disciplinary Team on the 18th August 2016 who decided to write a letter him which was sent on the 26th August inviting him to make contact or otherwise he would be discharged from the Team as care. He did not respond to that letter and no further follow up was made.
The concern the evidence revealed relates to the apparent lack of a robust system to ensure that individuals with mental health problems, who may have experienced psychotic episodes as Mr Sewell had, are seen and appropriate care delivered . It was apparent from the evidence that after the letter was sent inviting him to make contact he was simply discharged from the case load with no further efforts or steps being made to try and re-engage him . There was clearly a need to do so.
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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 Notify main reception staff to identify Mental Health appointments and direct or assist confused attendees appropriately.
Verbatim wording from the response “To reduce this potential for confusion in the future the Adult Mental Health Directorate management teams have written to colleagues who are responsible for staffing the main reception (and their managers). Within this letter it reminds staff that people arriving for appointments that are not on the main system should be asked if the appointment is with the Mental Health Team and if so direct accordingly. Also to be alert to the fact that people may be confused on the matter and require more attention. (letter attached).” Source location 2017-0229-Response-by-University-Health-Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The disengagement policy was followed and discharge was reasonable, so no further engagement action was considered available.
Verbatim wording from the response “A review of the Disengagement Policy for Mental Health has been conducted, and it concluded that all stages of the policy were followed and it was reasonable at this time to discharge Mr Sewell as he clearly had no intention to meaningfully engage with the service. As consideration for Mental Health Act detention had been undertaken, the team wrote to Mr Sewell at the time as telephone contact was clearly antagonising the situation, to further offer a service.” Source location 2017-0229-Response-by-University-Health-Board
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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 Mental Health Act detention was not considered available, and community services were judged appropriate based on the presenting condition.
Verbatim wording from the response “The Mental Health Directorate Management Team have reviewed the case and the circumstances of Mr Sewell’s engagement. As you state a referral was received at the Community Mental Health Team (CMHT) following assessment by the Psychiatric Liaison Service. The referral was sent to the CMHT following a detailed assessment on the 4th August 2017 that included consideration for detention under the Mental Health Act (MHA, 1983) which stated that Mr Sewell would not be detainable. It was therefore the professional view of the CMHT that this was not an option at the time of the presenting condition and that community services were deemed the appropriate course of action.” Source location 2017-0229-Response-by-University-Health-Board
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Addressed to “Cwm Taf Health Board”, a former name of Cwm Taf Morgannwg University Local Health Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations