Health Education and Improvement Wales

Health and care · Special health authority

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First report 22 Dec 2022•Latest report 22 Dec 2022

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
3

Described in responses

Concerns and recipient responses

Statements from Health Education and Improvement Wales linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Gwent

    AI-generated summary

    Glenys Lillian Phipps · Prevention of Future Deaths report

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

    Report summary

    Glenys Lillian Phipps was admitted to hospital for investigations of abdominal pain and, while confused and living with dementia, fell twice after an inadequate assessment of her risk of falling and no personalised care plan. Her second fall caused a cerebral bleed, and she died from the head injury on 21 September 2020. The substantive concern was that newly qualified nurses may assume responsibility for patients before being trained in the multifactorial risk assessment process for falls.

    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 Health Education and Improvement Wales; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of MFRA training for nurses before assuming responsibility for patient care

    Wider context from the report

    “I heard that a key component of the policy to minimize the risk of falls is a thorough understanding of the multifactorial risk assessment process (MFRA) Whilst I was informed that all adult nurses were made aware of the risk of falls during their nurse training, they are not trained in the use of the MFRA. It is clear that newly qualified nurses rapidly assume responsibility for the care of a group of patients, often before they can undertake the MFRA training. The senior nurse who gave evidence and presented the internal investigation into the circumstances surrounding Mrs Phipps’ death, undertaken by Aneurin Bevan University Health Board, confirmed that it would be beneficial to the safety of patients if MFRA processes were taught to student nurses prior to qualification. ”
    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Pre-registration MFRA education and training is not appropriate because student nurses cannot be responsible for coordinating multifactorial care.

    Verbatim wording from the response

    “With reference to the MFRA, this is a nationally agreed programme delivered by all Health Boards and Trusts across Wales. The MFRA is an assessment with multiple components that aims to identify a person’s risk factors for falling. It should be performed by a healthcare professional with appropriate skills and experience and should be part of an individualised multifactorial intervention which may need to be coordinated across different professionals and settings; to ensure the patient receives the appropriate safe care.”

    Source location

    Response from Health Education and Improvement Wales
    Page 2 · response
    Published 4 January 2023

    Open published response
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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