Recipient

Cwm Taf Morgannwg University Local Health Board

First report 9 Jul 2014•Latest report 6 May 2026

Recipient record

Reports, concerns and published responses

Health and care · Local health board. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 42
Published responses: 60%
Concerns addressed: 65
Stated actions: 171

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

60%published responses found

171stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Cwm Taf Morgannwg University Local Health Board linked to the concerns in each report. Select any concern, action or position to view the source wording.

8 Aug2017
South Wales Central
Concerns raised9
1. Lack of effective tracking of items taken from and returned to patients
2. Lack of routine clinical monitoring of Hydroxychloroquine levels
3. Lack of active input from outside consultants into mental health unit patient care
1. Failure of liaison between dermatologists and other consultants about Hydroxychloroquine toxicity
2. Lack of awareness of Hydroxychloroquine toxic accumulation at recommended doses
3. Delays in rectifying obvious ligature points on mental health units
4. Incomplete description of the risk of combining Lamotrigine or similar drugs with Hydroxychloroquine
5. Lack of awareness among psychiatrists of Hydroxychloroquine mental and toxic side-effects
6. Failure to disseminate risk management policies clearly to frontline staff
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement a safe system for recording items stored in and removed from patient PODS.
  Stated completed
2. Action
  Disseminate risk management policies through ward meetings and obtain individual staff sign-off.
  Stated completed
AI-generated summary

Deidre Harvey · 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

Deidre Harvey died on 19 April 2017 after attaching a dressing gown cord to her neck in a mental health unit bathroom; the cause of death was recorded as hanging. The report raised concerns about coordination between mental-health and outside consultants, management of ligature risks and dangerous items, risk-assessment communication, and the potential toxicity and monitoring of hydroxychloroquine.

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 effective tracking of items taken from and returned to patients
Wider context from the report
“Secretary of State for Health 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Minister for Health, Welsh Assembly Government 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Chief Executive – Cwm Taf University Health Board 1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when. The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient. 2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised. The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion Editor British National Formulary Hydroxychloroquine 1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic. The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine. Royal College of Psychiatrists Hydroxychloroquine 1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis. The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects. In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition British Association of Dermatologists Hydroxychloroquine 1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L. The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose. The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared. CEO Alerts NHS Hydroxychloroquine 1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important. The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers. ”
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 routine clinical monitoring of Hydroxychloroquine levels
Wider context from the report
“Secretary of State for Health 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Minister for Health, Welsh Assembly Government 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Chief Executive – Cwm Taf University Health Board 1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when. The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient. 2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised. The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion Editor British National Formulary Hydroxychloroquine 1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic. The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine. Royal College of Psychiatrists Hydroxychloroquine 1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis. The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects. In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition British Association of Dermatologists Hydroxychloroquine 1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L. The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose. The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared. CEO Alerts NHS Hydroxychloroquine 1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important. The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers. ”
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 active input from outside consultants into mental health unit patient care
Wider context from the report
“Secretary of State for Health 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Minister for Health, Welsh Assembly Government 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Chief Executive – Cwm Taf University Health Board 1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when. The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient. 2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised. The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion Editor British National Formulary Hydroxychloroquine 1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic. The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine. Royal College of Psychiatrists Hydroxychloroquine 1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis. The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects. In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition British Association of Dermatologists Hydroxychloroquine 1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L. The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose. The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared. CEO Alerts NHS Hydroxychloroquine 1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important. The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers. ”
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 liaison between dermatologists and other consultants about Hydroxychloroquine toxicity
Wider context from the report
“Secretary of State for Health 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Minister for Health, Welsh Assembly Government 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Chief Executive – Cwm Taf University Health Board 1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when. The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient. 2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised. The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion Editor British National Formulary Hydroxychloroquine 1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic. The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine. Royal College of Psychiatrists Hydroxychloroquine 1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis. The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects. In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition British Association of Dermatologists Hydroxychloroquine 1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L. The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose. The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared. CEO Alerts NHS Hydroxychloroquine 1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important. The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers. ”
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 awareness of Hydroxychloroquine toxic accumulation at recommended doses
Wider context from the report
“Secretary of State for Health 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Minister for Health, Welsh Assembly Government 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Chief Executive – Cwm Taf University Health Board 1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when. The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient. 2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised. The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion Editor British National Formulary Hydroxychloroquine 1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic. The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine. Royal College of Psychiatrists Hydroxychloroquine 1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis. The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects. In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition British Association of Dermatologists Hydroxychloroquine 1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L. The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose. The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared. CEO Alerts NHS Hydroxychloroquine 1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important. The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers. ”
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 rectifying obvious ligature points on mental health units
Wider context from the report
“Secretary of State for Health 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Minister for Health, Welsh Assembly Government 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Chief Executive – Cwm Taf University Health Board 1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when. The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient. 2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised. The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion Editor British National Formulary Hydroxychloroquine 1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic. The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine. Royal College of Psychiatrists Hydroxychloroquine 1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis. The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects. In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition British Association of Dermatologists Hydroxychloroquine 1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L. The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose. The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared. CEO Alerts NHS Hydroxychloroquine 1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important. The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers. ”
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 description of the risk of combining Lamotrigine or similar drugs with Hydroxychloroquine
Wider context from the report
“Secretary of State for Health 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Minister for Health, Welsh Assembly Government 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Chief Executive – Cwm Taf University Health Board 1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when. The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient. 2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised. The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion Editor British National Formulary Hydroxychloroquine 1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic. The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine. Royal College of Psychiatrists Hydroxychloroquine 1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis. The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects. In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition British Association of Dermatologists Hydroxychloroquine 1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L. The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose. The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared. CEO Alerts NHS Hydroxychloroquine 1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important. The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers. ”
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 awareness among psychiatrists of Hydroxychloroquine mental and toxic side-effects
Wider context from the report
“Secretary of State for Health 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Minister for Health, Welsh Assembly Government 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Chief Executive – Cwm Taf University Health Board 1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when. The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient. 2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised. The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion Editor British National Formulary Hydroxychloroquine 1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic. The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine. Royal College of Psychiatrists Hydroxychloroquine 1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis. The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects. In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition British Association of Dermatologists Hydroxychloroquine 1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L. The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose. The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared. CEO Alerts NHS Hydroxychloroquine 1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important. The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers. ”
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 disseminate risk management policies clearly to frontline staff
Wider context from the report
“Secretary of State for Health 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Minister for Health, Welsh Assembly Government 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Chief Executive – Cwm Taf University Health Board 1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when. The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient. 2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised. The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion Editor British National Formulary Hydroxychloroquine 1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic. The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine. Royal College of Psychiatrists Hydroxychloroquine 1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis. The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects. In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition British Association of Dermatologists Hydroxychloroquine 1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L. The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose. The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared. CEO Alerts NHS Hydroxychloroquine 1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important. The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers. ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement a safe system for recording items stored in and removed from patient PODS.

Verbatim wording from the response
“A safe system of work has been implemented to ensure that staff are recording items stored in and taken from patient PODS.”

Source location
2018-0266-Response-by-University-Health-Board
Page 1 · response
Published 20 July 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Disseminate risk management policies through ward meetings and obtain individual staff sign-off.

Verbatim wording from the response
“Dissemination of risk management policies to frontline staff are now shared by team leaders through ward meetings and staff sign off individually to demonstrate sharing.”

Source location
2018-0266-Response-by-University-Health-Board
Page 1 · response
Published 20 July 2017
Open published response
20 Apr2017
South Wales Central
Concerns raised3
1. Failure to appropriately escalate care in response to deteriorating NEWS scores
2. Failure to ensure surgical teams are aware of patients' history of deep vein thrombosis
3. Delays in clinical review of patients with deteriorating NEWS scores
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

Harold Mullins · 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

Harold Mullins, aged 92, was admitted to hospital after a fall or collapse at home and was found to have a fractured left femur. Following surgical repair, his observations deteriorated, but he was not examined by a clinician in a timely fashion; he later suffered a cardiac arrest and could not be resuscitated. Concerns included the surgical team being unaware of his history of deep vein thrombosis and delays in responding to his deteriorating NEWS scores.

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 appropriately escalate care in response to deteriorating NEWS scores
Wider context from the report
“(1) A review of the care that was received by Mr Mullins revealed that the surgical team were unaware of his history of deep vein thrombosis when undertaking the surgery and caring for him in general. (2) Despite a deteriorating position in relation to his observations (NEWS scores) he was not seen by a clinician in a timely fashion. There appears to be a difficulty in patients being seen in these circumstances appropriately by clinical staff which is a concern given that the purpose of the NEWS score system is to escalate care in cases of deterioration. It is a concern that the clinician contacted initially when the NEWS scores were deteriorating indicated that this was not to be expected given that he had undergone surgery. ”
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 surgical teams are aware of patients' history of deep vein thrombosis
Wider context from the report
“(1) A review of the care that was received by Mr Mullins revealed that the surgical team were unaware of his history of deep vein thrombosis when undertaking the surgery and caring for him in general. (2) Despite a deteriorating position in relation to his observations (NEWS scores) he was not seen by a clinician in a timely fashion. There appears to be a difficulty in patients being seen in these circumstances appropriately by clinical staff which is a concern given that the purpose of the NEWS score system is to escalate care in cases of deterioration. It is a concern that the clinician contacted initially when the NEWS scores were deteriorating indicated that this was not to be expected given that he had undergone surgery. ”
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 clinical review of patients with deteriorating NEWS scores
Wider context from the report
“(1) A review of the care that was received by Mr Mullins revealed that the surgical team were unaware of his history of deep vein thrombosis when undertaking the surgery and caring for him in general. (2) Despite a deteriorating position in relation to his observations (NEWS scores) he was not seen by a clinician in a timely fashion. There appears to be a difficulty in patients being seen in these circumstances appropriately by clinical staff which is a concern given that the purpose of the NEWS score system is to escalate care in cases of deterioration. It is a concern that the clinician contacted initially when the NEWS scores were deteriorating indicated that this was not to be expected given that he had undergone surgery. ”
Open source report
4 Apr2017
South Wales Central
Concerns raised4
1. Lack of clear guidance for nasogastric tube practice in the ITU setting
2. Failure to perform PH testing after nasogastric tube insertion
3. Failure to update and review the nasogastric insertion and positional confirmation guideline
1. Failure to follow the nasogastric tube insertion checklist
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

Robert John Owens · 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 John Owens was admitted to hospital with back pain, developed acute kidney injury and respiratory failure, and was transferred to intensive care. After a naso-gastric tube was replaced and incorrectly positioned, feeding commenced; he became unwell and died on 16 December 2016. The report identified concerns about outdated guidance, failure to follow national pH-testing and x-ray guidance, and inconsistent use of insertion checklists and procedures.

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 clear guidance for nasogastric tube practice in the ITU setting
Wider context from the report
“(3) Contrary to the National Guidance it appears that the check list following insertion of a NG tube was not being followed either although this now represents the policy within the Health Board. The evidence revealed that the practice differs depending on the setting (ward or ITU) and no clear guidance is in place for the ITU setting which, it was suggested, was required because of the particularities of practice in that environment. ”
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 perform PH testing after nasogastric tube insertion
Wider context from the report
“(2) Despite clear National Guidelines from the National Patient Safety Agency (NPSA) advocating the PH testing and x-raying of a patient after the insertion of a tube, these guidelines were never followed. The evidence revealed that it is common practice within the Health Board only to x-ray and not to follow the National Guidance of PH testing. ”
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 update and review the nasogastric insertion and positional confirmation guideline
Wider context from the report
“(1) The Cwm Taf University Health Board Guideline Procedure for Naso Gastric Insertion and Positional Confirmation 2009 had not been updated and reviewed. It was due for review in 2012. ”
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 follow the nasogastric tube insertion checklist
Wider context from the report
“(3) Contrary to the National Guidance it appears that the check list following insertion of a NG tube was not being followed either although this now represents the policy within the Health Board. The evidence revealed that the practice differs depending on the setting (ward or ITU) and no clear guidance is in place for the ITU setting which, it was suggested, was required because of the particularities of practice in that environment. ”
Open source report
16 Mar2017
South Wales Central
Concerns raised3
1. Failure to conduct scheduled neuro observations
2. Failure to accurately calculate NEWS scores and trigger required medical review
3. Failure to continue NEWS observations
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

Clive 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

Clive Davies, who was generally in poor health and had a history of falls, fell down the stairs at home on 22 August 2016 and sustained serious head and neck injuries. He died in hospital on 30 August 2016; concerns included failures in routine NEWS and neurological observations, including an incorrectly calculated NEWS score and missed observations.

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 conduct scheduled neuro observations
Wider context from the report
“(1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations. On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM. The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter. Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been. It was accepted at the inquest that this was a failure for which no explanation was forthcoming. ”
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 accurately calculate NEWS scores and trigger required medical review
Wider context from the report
“(1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations. On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM. The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter. Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been. It was accepted at the inquest that this was a failure for which no explanation was forthcoming. ”
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 continue NEWS observations
Wider context from the report
“(1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations. On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM. The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter. Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been. It was accepted at the inquest that this was a failure for which no explanation was forthcoming. ”
Open source report
5 Sep2016
South Wales Central
Concerns raised6
1. Lack of a bed management pathway
2. Lack of an agreed tertiary-services pathway for unconscious STEMI patients requiring PCI
3. Insufficient capacity for admission to designated hospitals for PCI
1. Lack of capacity for rescue PCI at designated hospitals
2. Lack of an agreed pathway to access adult critical care beds outside Wales
3. Lack of a formal backup plan for PCI when designated hospitals cannot accept a patient
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Develop and further refine an interim specialist cardiology pathway with commissioning and provider organisations.
  Stated in progress
AI-generated summary

Dr Imad Hassan · Prevention of Future Deaths report

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

Report summary

On 17 April 2016, Dr Imad Hassan suffered an out-of-hospital heart attack and cardiac arrest, was resuscitated, and taken to Prince Charles Hospital. He suffered a further cardiac arrest and died at 04:35 on 18 April 2016. The report raised concerns about the lack of a formal backup and transfer pathway for patients requiring PCI when capacity was unavailable at the relevant hospitals, including for unconscious STEMI patients.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of a bed management pathway
Wider context from the report
“3) As per the evidence of ████████ given at inquest, an agreed short term pathway needs to be put in place to access adult critical care beds outside Wales and a bed management pathway put in place. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of an agreed tertiary-services pathway for unconscious STEMI patients requiring PCI
Wider context from the report
“4) There is currently no agreed pathway for an unconscious STEMI patient requiring PCI in tertiary services as there is currently for conscious patients with STEMI. Although in the case of Dr Hassan transfer to another hospital for a rescue PCI was not clinically indicated, that may not necessarily be the case in the future, particularly in a patient who has had a short period of unconsciousness and a PCI is clinically indicated. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Insufficient capacity for admission to designated hospitals for PCI
Wider context from the report
“2) In such circumstances, a patient meeting the criteria for PCI is unable to undergo that procedure, increasing the risk of his/her death, until there is such capacity for that patient to be admitted to UHW or Morriston Hospitals for PCI. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of capacity for rescue PCI at designated hospitals
Wider context from the report
“5) In similar circumstances as pertained on the evening prior to / the morning of Dr Hassan's death such a patient (as described in 4)) may be deprived the opportunity of undergoing rescue PCI due to lack of capacity at either UHW in Cardiff or Morriston in Swansea. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of an agreed pathway to access adult critical care beds outside Wales
Wider context from the report
“3) As per the evidence of ████████ given at inquest, an agreed short term pathway needs to be put in place to access adult critical care beds outside Wales and a bed management pathway put in place. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of a formal backup plan for PCI when designated hospitals cannot accept a patient
Wider context from the report
“1) In the event that a patient at Prince Charles Hospital is deemed suitable for PCI there is currently no formal back up plan in place, to enable the PCI to proceed, should UHW in Cardiff or Morriston Hospital in Swansea be unable to accept that patient. ”
Open source report
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 further refine an interim specialist cardiology pathway with commissioning and provider organisations.

Verbatim wording from the response
“Further to the issuing of the Regulation 28 dated 26th August 2016, following the inquest into the sad death of Dr Imad Hassan (deceased on 18th April 2016). Cwm Taf University Health Board has been working with WHSSC (Welsh Health Specialised Services Committee) as the commissioner of specialist Cardiology services, and the Provider Units in Cardiff and Swansea to develop an interim solution pending the completion of a comprehensive pathway for this patient group in the summer of 2017.”

Source location
Hassan-Response
Page 1 · response
Published 5 September 2016
Open published response
11 Sep2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised3
1. Unmonitored over-anticoagulation following omitted delegated INR testing
2. Non-uniform implementation of monitoring practices for delegated INR testing
3. Risk of unmonitored or unactioned failure to complete delegated INR testing
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 Ronald Francis Bonfield · 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 Ronald Francis Bonfield sustained a head injury at home on 29 September 2014, was admitted to Prince Charles Hospital on 1 October, and died there on 2 October 2014. The inquest recorded that he was taking Warfarin, was over-anticoagulated, and that his INR levels were not being monitored as required. The substantive concerns related to inconsistent procedures for monitoring delegated INR testing and the risk of unmonitored over-anticoagulation.

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
Unmonitored over-anticoagulation following omitted delegated INR testing
Wider context from the report
“(3) Until such action is taken there remains a risk that a future death(s) could occur in similar circumstances to Mr Bonfield’s, where delegated INR testing has not been done leading to unmonitored over anti-coagulation ”
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
Non-uniform implementation of monitoring practices for delegated INR testing
Wider context from the report
“(1) The practices and procedures implemented by the Practice 1, Keir Hardie Health Park, GP Surgery following Mr Bonfield’s death (with regard to monitoring the compliance of the Health Boards District Nurse Teams following delegation to undertake a patient’s INR testing) is not uniform and/or implemented across all of the Health Boards Level 4 Accredited GP practices. ”
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 unmonitored or unactioned failure to complete delegated INR testing
Wider context from the report
“(2) The practices and procedures implemented by Practice 1, Keir Hardie Health Park Surgery act as a check and balance to reduce the risk of an unmonitored/unactioned failure on the part of the District Nurse service to undertake the task(testing the patients INR level) delegated to them by the GP practice concerned. ”
Open source report
4 Sep2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised4
1. Inadequate monitoring of INR levels
2. Inadequate communication about anticoagulation monitoring and potential therapy adjustment
3. Lack of certainty whether Warfarin was being taken
1. Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment
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

Mrs. Mary Patricia James · Prevention of Future Deaths report

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

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Inadequate monitoring of INR levels
Wider context from the report
“(1) Inadequate monitoring of INR levels in a patient suffering from dementia; ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Inadequate communication about anticoagulation monitoring and potential therapy adjustment
Wider context from the report
“(3) Inadequate communication between the INR Unit, the Care Home and the GP regarding this patient’s anticoagulation monitoring and the potential need for therapy adjustment; ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of certainty whether Warfarin was being taken
Wider context from the report
“(2) Lack of certainty whether Warfarin was being taken by the patient; ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment
Wider context from the report
“(4) That against this background and the Care Home’s concern about a possible ischaemic leg, Mrs. James was not admitted to hospital on the 15th May, 2015 when there may have been a window of opportunity to have adjusted the anticoagulation therapy. ”
Open source report
27 Jul2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised4
1. Insufficient staffing of Tissue Viability Nurses
2. Failure to maintain adequate repositioning charts
3. Failure to maintain adequate pressure ulcer documentation
1. Lack of integrated skin care across Health Boards and Primary healthcare services
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. Arthur Cook · Prevention of Future Deaths report

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

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staffing of Tissue Viability Nurses
Wider context from the report
“(1) Staffing levels of Tissue Viability Nurses within the Aneurin Bevan Health Board are low and to the extent that at times this service cannot be provided according to need; ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain adequate repositioning charts
Wider context from the report
“(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain adequate pressure ulcer documentation
Wider context from the report
“(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of integrated skin care across Health Boards and Primary healthcare services
Wider context from the report
“(3) An apparent lack of integrated skin care within and between Health Boards and Primary healthcare services. ”
Open source report
9 Jul2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised4
1. Failure to advise the pharmacy of Warfarin withdrawal due to lack of INR safety testing
2. Failure to develop and maintain an anti-coagulation treatment register
3. Failure to use computer software to support prescription decisions
1. Failure to implement notification of failed attendance for INR testing
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. Alun Walters · 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. Alun Walters, who was prescribed Warfarin following receipt of a metallic heart valve, died after a gastro-intestinal haemorrhage in circumstances of suspected elevated Warfarin levels and failed INR monitoring. His prescriptions continued despite no INR tests after November 2013, and 51 prescriptions were provided without dosage assessment. Concerns included failures by the medical practice in monitoring, prescription systems and notifying the pharmacy that Warfarin had been withdrawn, while the pharmacy supplied Warfarin without a valid prescription.

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 advise the pharmacy of Warfarin withdrawal due to lack of INR safety testing
Wider context from the report
“The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
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 develop and maintain an anti-coagulation treatment register
Wider context from the report
“The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
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 computer software to support prescription decisions
Wider context from the report
“The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
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 notification of failed attendance for INR testing
Wider context from the report
“The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
Open source report
2 Jul2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Failure to ensure surgeons acknowledge having read applicable clinical guidelines
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

Mrs. Gail Prentice · Prevention of Future Deaths report

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

Report summary

Mrs. Gail Prentice, aged 46, died after severe bleeding during an attempted percutaneous tracheostomy, caused by transection of the brachiocephalic artery. The report describes concerns about tracheostomy in altered neck anatomy following previous surgery, including the need for appropriate imaging and site selection, and about surgeons acknowledging relevant hospital and other guidelines.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure surgeons acknowledge having read applicable clinical guidelines
Wider context from the report
“(1) The requirement for surgeons to acknowledge having read the Health Board’s Hospital Guidelines and those of other bodies e.g. NICE Guidelines ”
Open source report
24 Apr2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised2
1. Unreliable booking system for community INR testing
2. Unreliable notification system for omissions by family or carers
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

Mrs. Hilda May Harris · Prevention of Future Deaths report

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

Report summary

Mrs. Hilda May Harris, aged 86, suffered a cerebral infarction with an intracerebral haemorrhage on 04.01.15 after an additional INR test was not undertaken while she was taking Warfarin alongside medication for gout. The report identified unreliable systems for booking community INR tests and for notifying or acting on omissions.

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
Unreliable booking system for community INR testing
Wider context from the report
“(1) The current booking system for community INR testing is unreliable with scope for appointments not being transferred from one set of papers to another. (2) Where an omission occurs, the notification system (by the family or carers) also appears unreliable. ”
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
Unreliable notification system for omissions by family or carers
Wider context from the report
“(1) The current booking system for community INR testing is unreliable with scope for appointments not being transferred from one set of papers to another. (2) Where an omission occurs, the notification system (by the family or carers) also appears unreliable. ”
Open source report
19 Feb2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised4
1. Failure to ensure crisis team responsibility for providing assistance
2. Failure to make clinical records of crisis team contact
3. Failure to undertake risk assessments specific to suicidal ideation
1. Lack of a formal communication mechanism between mental health out-patient and acute services
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review the Care Treatment Plan Policy and Procedures used in the outpatients department.
  Stated completed
2. Action
  Improve monitoring of recording systems and processes.
  Stated completed
3. Action
  Develop a procedure defining the role of the duty officer.
  Stated completed
AI-generated summary

Barrie 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

Barrie Lewis was found by his family hanging from a rope attached to a garage rafter on 31 August 2014. The inquest concluded that his death was suicide. Concerns included the absence of a specific risk assessment for suicidal ideation, poor communication between mental health services, no reliable system assigning responsibility for assistance, and a lack of clinical records of crisis-team contact.

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 ensure crisis team responsibility for providing assistance
Wider context from the report
“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A clinical review was undertaken of the contact the deceased had with the mental health services in the days prior to his death and it was apparent from that review, and from the evidence heard that: a) That no risk assessment was undertaken to detail risks specifically associated with the deceased’s suicidal ideation which, on the evidence, would have assisted the crisis team in assessing his risk of suicide or self harm. b) There was little formal mechanism for communication between the mental health out patients department and the acute services which he accessed in the days prior to his death. c) There was no reliable system to ensure that a member of the crisis team took responsibility for providing assistance to the deceased – simply leaving the deceased to make his own telephone call to the appropriate department. d) No clinical recordings were made of the contact the deceased had with the crisis team (Crisis Resolution Home Treatment team) following his contact with them. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to make clinical records of crisis team contact
Wider context from the report
“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A clinical review was undertaken of the contact the deceased had with the mental health services in the days prior to his death and it was apparent from that review, and from the evidence heard that: a) That no risk assessment was undertaken to detail risks specifically associated with the deceased’s suicidal ideation which, on the evidence, would have assisted the crisis team in assessing his risk of suicide or self harm. b) There was little formal mechanism for communication between the mental health out patients department and the acute services which he accessed in the days prior to his death. c) There was no reliable system to ensure that a member of the crisis team took responsibility for providing assistance to the deceased – simply leaving the deceased to make his own telephone call to the appropriate department. d) No clinical recordings were made of the contact the deceased had with the crisis team (Crisis Resolution Home Treatment team) following his contact with them. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake risk assessments specific to suicidal ideation
Wider context from the report
“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A clinical review was undertaken of the contact the deceased had with the mental health services in the days prior to his death and it was apparent from that review, and from the evidence heard that: a) That no risk assessment was undertaken to detail risks specifically associated with the deceased’s suicidal ideation which, on the evidence, would have assisted the crisis team in assessing his risk of suicide or self harm. b) There was little formal mechanism for communication between the mental health out patients department and the acute services which he accessed in the days prior to his death. c) There was no reliable system to ensure that a member of the crisis team took responsibility for providing assistance to the deceased – simply leaving the deceased to make his own telephone call to the appropriate department. d) No clinical recordings were made of the contact the deceased had with the crisis team (Crisis Resolution Home Treatment team) following his contact with them. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of a formal communication mechanism between mental health out-patient and acute services
Wider context from the report
“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A clinical review was undertaken of the contact the deceased had with the mental health services in the days prior to his death and it was apparent from that review, and from the evidence heard that: a) That no risk assessment was undertaken to detail risks specifically associated with the deceased’s suicidal ideation which, on the evidence, would have assisted the crisis team in assessing his risk of suicide or self harm. b) There was little formal mechanism for communication between the mental health out patients department and the acute services which he accessed in the days prior to his death. c) There was no reliable system to ensure that a member of the crisis team took responsibility for providing assistance to the deceased – simply leaving the deceased to make his own telephone call to the appropriate department. d) No clinical recordings were made of the contact the deceased had with the crisis team (Crisis Resolution Home Treatment team) following his contact with them. ”
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 the Care Treatment Plan Policy and Procedures used in the outpatients department.

Verbatim wording from the response
“2. Actions implemented”

Source location
2015-0065-Response-by-University-Health-Board
Page 1 · response
Published 19 February 2015
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
Improve monitoring of recording systems and processes.

Verbatim wording from the response
“2. Actions implemented”

Source location
2015-0065-Response-by-University-Health-Board
Page 1 · response
Published 19 February 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a procedure defining the role of the duty officer.

Verbatim wording from the response
“2. Actions implemented”

Source location
2015-0065-Response-by-University-Health-Board
Page 1 · response
Published 19 February 2015
Open published response
19 Dec2014
Powys, Bridgend and Glamorgan Valleys
Concerns raised3
1. Delays in Tissue Viability Nurse and wound care input
2. Insufficient Tissue Viability Nurse capacity to serve the regional hospitals
3. Specialist nurses not being based in the hospital for TVN and wound care input
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. Thomas Jenkins · 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. Thomas Jenkins developed pressure sores while receiving care after a cerebrovascular accident, including an infected chronic pressure sore on his right heel. He was readmitted to hospital and died of sepsis on 8 August 2014. The principal concern was inadequate and delayed tissue viability nursing and wound care input, attributed to specialist nurses not being based in the hospital and insufficient staffing across the region.

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 Tissue Viability Nurse and wound care input
Wider context from the report
“(1) Tissue Viability Nurse (TVN) input was requested at different times during the 7 month period whilst Mr. Jenkins was being nursed in YCR yet response was slow (as long as a week after a ward visit was requested). In fact the TVN did not assess the ulcer until 06.06.14 almost 2 months after its development and by which time the odour from the wound was described as ‘very offensive’. A bandage used was reported as the likely cause of a new ulcer forming - Datrix incident report 14.07.14. (2) The key concern is that of inadequate TVN and wound care input. The inadequate care in this instance was attributed to specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region. The service being overstretched. ”
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 Tissue Viability Nurse capacity to serve the regional hospitals
Wider context from the report
“(1) Tissue Viability Nurse (TVN) input was requested at different times during the 7 month period whilst Mr. Jenkins was being nursed in YCR yet response was slow (as long as a week after a ward visit was requested). In fact the TVN did not assess the ulcer until 06.06.14 almost 2 months after its development and by which time the odour from the wound was described as ‘very offensive’. A bandage used was reported as the likely cause of a new ulcer forming - Datrix incident report 14.07.14. (2) The key concern is that of inadequate TVN and wound care input. The inadequate care in this instance was attributed to specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region. The service being overstretched. ”
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
Specialist nurses not being based in the hospital for TVN and wound care input
Wider context from the report
“(1) Tissue Viability Nurse (TVN) input was requested at different times during the 7 month period whilst Mr. Jenkins was being nursed in YCR yet response was slow (as long as a week after a ward visit was requested). In fact the TVN did not assess the ulcer until 06.06.14 almost 2 months after its development and by which time the odour from the wound was described as ‘very offensive’. A bandage used was reported as the likely cause of a new ulcer forming - Datrix incident report 14.07.14. (2) The key concern is that of inadequate TVN and wound care input. The inadequate care in this instance was attributed to specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region. The service being overstretched. ”
Open source report
20 Nov2014
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Failure to maintain a current fall-risk assessment on admission
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

Martin Dilwyn McCabe · 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

Martin Dilwyn McCabe was admitted to hospital with gastrointestinal bleeding and later fell while being assisted out of bed, suffering an extensive bilateral subdural haemorrhage. The principal concern was that no new falls risk assessment was completed on admission, despite reported previous falls and night-time sedation, and staff relied on an assessment from three months earlier.

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 a current fall-risk assessment on admission
Wider context from the report
“(1) Upon his admission to ward 15 on the 11th September no risk assessment in relation to his risk of falling was carried out. Staff relied on a risk assessment which had previously been carried out 3 months before this admission and did not update it with relevant information such as a history of two falls whilst at home and also the use of night time sedation whilst on the ward. Both of these factors were accepted by the health board to be material factors in a risk assessment and which may well have had a bearing in the way in which staff dealt with him on the ward. ”
Open source report
11 Sep2014
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Lack of consistent post-surgical discharge advice on venous thromboembolism risks and concerning clinical signs
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

Nicholas James Megginson · 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

Nicholas James Megginson was found unresponsive at home on 22 May 2014 after fracturing his left ankle and undergoing surgery earlier that month. A post-mortem examination found that he died from a pulmonary embolism. The report raised concern that patients discharged after surgery were not consistently advised, orally or in writing, about venous thromboembolism risks and warning signs requiring urgent treatment.

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 consistent post-surgical discharge advice on venous thromboembolism risks and concerning clinical signs
Wider context from the report
“The evidence revealed that there was no consistent advice given to patients discharged post-surgery regarding the risks of venous thromboembolism either orally or in writing incorporating advice in relation to concerning clinical signs which may arise to indicate urgent medical treatment is required. ”
Open source report
6 Aug2014
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Failure to make neurological observations after falls and facial injury
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Implement compliance with neurological investigations following head injury.
  Stated in progress
AI-generated summary

Vivian Herbert HUNT · 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

Vivian Herbert HUNT, an 84-year-old patient on the Mental Health ward, fell in his hospital room on 3 April 2014 after a similar fall the previous day, sustained a facial injury, deteriorated, and later died from a brain bleed. The report raised concern that no neurological observations were made during specified periods after the falls and facial injury.

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 make neurological observations after falls and facial injury
Wider context from the report
“(1) Despite the fall he suffered on 2nd April and despite suffering a clear injury to his face in the fall on 3rd April 2014, no neurological observations were made of him between 5am on 3rd April and between 12:30 and 13:15pm that day. ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement compliance with neurological investigations following head injury.

Verbatim wording from the response
“2. Actions implemented”

Source location
2014-0363-Response-by-University-Health-Board
Page 1 · response
Published 6 August 2014
Open published response
9 Jul2014
Cardiff & the Vale of Glamorgan
Concerns raised12
1. Failure to monitor physiological trends over time
2. Failure to share and act promptly on nursing staff concerns
3. Failure to prioritise children’s cases appropriately for timely assessment
1. Reluctance to involve other hospital disciplines in paediatric care
2. Unclear guidance on pre-hospital antibiotics for suspected meningitis
3. Incomplete handovers between primary and secondary care providers
4. Difficulties in internal communication during evolving emergencies
5. Unavailability of consultant advice to registrars when needed
6. Exclusion of nursing colleagues from team debriefs
7. Failure to transfer patients to hospital by ambulance when required
8. Delays in treating raised intracranial pressure while awaiting diagnosis
9. Failure to retain meningitis as a differential diagnosis
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 George Smith · Prevention of Future Deaths report

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

Report summary

Thomas George Smith, aged 13, developed symptoms including headache, neck pain and vomiting before being admitted to hospital, where he later became unresponsive and died after suspected meningitis and raised intracranial pressure. The report identified concerns about delays in recognising and treating meningitis and raised intracranial pressure, communication and handover, responding to nursing concerns, monitoring physiological trends, and the transfer of the patient to hospital.

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 monitor physiological trends over time
Wider context from the report
“(1) The inquest revealed the importance of observing physiological trends in the patient’s condition, rather than observing readings on a “snap shot” basis. The Coroner considers that comprehensive time series data would have provided clinicians with a sounder platform for assessing Thomas. Can the Chief Executive confirm that this will be the practice at PCH? ”
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 share and act promptly on nursing staff concerns
Wider context from the report
“(2) The inquest revealed a somewhat fragmented approach to patient care, with nursing staff concerns not being acted on promptly by doctors. One expert highlighted the importance of a “whole team approach” where information could be freely shared and acted upon by nursing staff professionals. The Coroner suggests that this should be the correct approach. The Coroner noted with concern that at PCH nursing colleagues are not involved in a team debrief. The Coroner considers that they always should be involved. ”
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 prioritise children’s cases appropriately for timely assessment
Wider context from the report
“(2) The Coroner noted that it was only by chance that Thomas was seen more quickly than usual (because the case was “modified” and removed from the pool). Given the greater susceptibility of children to deteriorate in health the Coroner would like to see children’s cases be given a greater “weighting” so that they can be seen more quickly than adult cases if these can safely be delayed. ”
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 to involve other hospital disciplines in paediatric care
Wider context from the report
“(3) Similarly the expert commented that there appeared to be a reluctance on the paediatric ward to bring in other disciplines from the hospital where this might be ”
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
Unclear guidance on pre-hospital antibiotics for suspected meningitis
Wider context from the report
“The Coroner notes the guidance at page 61 of the June 2010 publication “Bacterial meningitis and meningococcal septicaemia” to the effect that “the available evidence does not allow any conclusion to be drawn about whether or not pre-hospital parenteral antibiotics affect mortality or morbidity”. This is however contradicted by the evidence heard at inquest from eminent experts ████████ who gave their empirical conclusions that the literature suggested that antibiotics should be given sooner rather than later in cases of meningitis. In the event of primary care doctors being involved in a remote location there might be a delay of some hours before transfer to secondary care. The Coroner also noted the Guidelines issued by the Scientific Advisory Committee of HPSF (Eire) which recommended that primary care providers administer antibiotics in cases of suspected meningitis (at page 17) “all GPs and advanced paramedics should have benzylpenicillin available when attending patients and should be ready to administer it without delay to patients with a systemic febrile illness and a petechial or purpuric rash”. The Coroner would recommend that the existing guidance is revisited. ”
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 handovers between primary and secondary care providers
Wider context from the report
“(1) No criticism is made of the actions of the Out of Hours Doctor ████████. The inquest however revealed the importance of full and accurate handover between primary and secondary care providers. Such handovers should record full observations and details of any medication already given (for instance painkillers may mask fever). Can the clinical director confirm OOH doctors observe this practice. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cwm Taf Morgannwg University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation
Difficulties in internal communication during evolving emergencies
Wider context from the report
“(4) The expert recommends a “stress testing of ward management” through a clinical scenario simulation of emergencies within ward areas. This could also test how to improve communication during times of evolving emergencies. Given the difficulties in internal communication as revealed by this inquest the Coroner suggests this would be a valuable exercise. ”
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 consultant advice to registrars when needed
Wider context from the report
“(6) There was a divergence of evidence at the hearing between ████████ and ████████ – with the former suggesting that at one point in the afternoon that he could not find ████████ while ████████ said he had been in his office all the time. While the resolution of this conflict was not necessary for the purposes of the inquest it does reveal a situation where (for whatever reason) a registrar was not able to obtain the advice of the consultant when he needed it. It appeared to the Coroner to be archaic for the Registrar to have to physically go looking for the Consultant on the ward – there must be modern telecommunication means to ensure that the consultant is always available for advice even if remotely. ”
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
Exclusion of nursing colleagues from team debriefs
Wider context from the report
“(2) The inquest revealed a somewhat fragmented approach to patient care, with nursing staff concerns not being acted on promptly by doctors. One expert highlighted the importance of a “whole team approach” where information could be freely shared and acted upon by nursing staff professionals. The Coroner suggests that this should be the correct approach. The Coroner noted with concern that at PCH nursing colleagues are not involved in a team debrief. The Coroner considers that they always should be involved. ”
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 transfer patients to hospital by ambulance when required
Wider context from the report
“(3) In this case Thomas was transferred to hospital by his mother. Although he suffered no ill effects from this the experts agreed that such a transfer should have been undertaken by ambulance. The Coroner suggests this should be the standard approach. ”
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 treating raised intracranial pressure while awaiting diagnosis
Wider context from the report
“(4) It appeared at the inquest if the clinicians had adopted an “exclusionary focus” to rule out meningitis rather than an “inclusionary focus” so as to be able to adopt a diagnosis of meningitis as a differential diagnosis. The Coroner considers that the inclusionary approach is appropriate where a patient presents with some of the signs of meningitis. It should be standard practice at PCH for raised Intracranial pressure to be treated without delay even if a diagnosis is awaited on the underlying condition. ”
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 retain meningitis as a differential diagnosis
Wider context from the report
“(4) It appeared at the inquest if the clinicians had adopted an “exclusionary focus” to rule out meningitis rather than an “inclusionary focus” so as to be able to adopt a diagnosis of meningitis as a differential diagnosis. The Coroner considers that the inclusionary approach is appropriate where a patient presents with some of the signs of meningitis. It should be standard practice at PCH for raised Intracranial pressure to be treated without delay even if a diagnosis is awaited on the underlying condition. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised9

Lack of effective tracking of items taken from and returned to patients

Lack of routine clinical monitoring of Hydroxychloroquine levels

Lack of active input from outside consultants into mental health unit patient care

Failure of liaison between dermatologists and other consultants about Hydroxychloroquine toxicity

Lack of awareness of Hydroxychloroquine toxic accumulation at recommended doses

Delays in rectifying obvious ligature points on mental health units

Incomplete description of the risk of combining Lamotrigine or similar drugs with Hydroxychloroquine

Lack of awareness among psychiatrists of Hydroxychloroquine mental and toxic side-effects

Failure to disseminate risk management policies clearly to frontline staff

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.2

Concerns raised3

Failure to appropriately escalate care in response to deteriorating NEWS scores

Failure to ensure surgical teams are aware of patients' history of deep vein thrombosis

Delays in clinical review of patients with deteriorating NEWS scores

Concerns raised4

Lack of clear guidance for nasogastric tube practice in the ITU setting

Failure to perform PH testing after nasogastric tube insertion

Failure to update and review the nasogastric insertion and positional confirmation guideline

Failure to follow the nasogastric tube insertion checklist

Concerns raised3

Failure to conduct scheduled neuro observations

Failure to accurately calculate NEWS scores and trigger required medical review

Failure to continue NEWS observations

Concerns raised6

Lack of a bed management pathway

Lack of an agreed tertiary-services pathway for unconscious STEMI patients requiring PCI

Insufficient capacity for admission to designated hospitals for PCI

Lack of capacity for rescue PCI at designated hospitals

Lack of an agreed pathway to access adult critical care beds outside Wales

Lack of a formal backup plan for PCI when designated hospitals cannot accept a patient

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.1

Concerns raised3

Unmonitored over-anticoagulation following omitted delegated INR testing

Non-uniform implementation of monitoring practices for delegated INR testing

Risk of unmonitored or unactioned failure to complete delegated INR testing

Actions described in response 2

Actions described in response 1