24 Jun 2026 Nola-Reign Morgan · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 6 Delays in transferring patients between antenatal and HDU wards View source Failure to identify causes of transfer delays and take steps to avoid unnecessary delay recurring View source Insufficient training to enable obstetric and midwifery teams to identify the risk of chorioamnionitis and ensure adequate monitoring View source Lack of specific guidance for identifying and treating chorioamnionitis in pre-term mothers View source Lack of national antenatal guidance establishing when and in what circumstances fetal monitoring should be used, especially when chorioamnionitis is suspected View source Failure of local antenatal monitoring guidance to address chorioamnionitis, transfer times and consideration of continuous fetal monitoring View source See 3 more concerns
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Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Nola-Reign Morgan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Nola-Reign Morgan was born prematurely on 5 February 2024 after her mother developed suspected chorioamnionitis, and died three days later despite resuscitation and neonatal care. The report identified delays in transferring her mother to the labour ward and high dependency unit, a period without fetal monitoring, and gaps in national and local guidance and staff training on monitoring and managing suspected chorioamnionitis in pre-term pregnancies.
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 Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients between antenatal and HDU wards
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” 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 Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to identify causes of transfer delays and take steps to avoid unnecessary delay recurring
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” 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 Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Insufficient training to enable obstetric and midwifery teams to identify the risk of chorioamnionitis and ensure adequate monitoring
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” 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 Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of specific guidance for identifying and treating chorioamnionitis in pre-term mothers
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” 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 Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of national antenatal guidance establishing when and in what circumstances fetal monitoring should be used, especially when chorioamnionitis is suspected
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” 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 Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure of local antenatal monitoring guidance to address chorioamnionitis, transfer times and consideration of continuous fetal monitoring
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” Open source report
20 Apr 2016 Ronald Hamer · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Failure to provide timely ambulance responses to Amber 2 calls View source Failure to make timely follow-up calls to update, advise and reassess emergency callers View source Lack of clear planning and direction for maintaining and delivering ambulance services View source Failure to maintain ambulance service delivery during significant call volumes View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Ronald Hamer · 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
Ronald Hamer, an elderly man living independently at home, fell in his bathroom on 8 February 2016 and remained immobilised on the floor for over 13½ hours before being found. He was taken to hospital after a delayed ambulance response and died there on the morning of 10 February 2016. Concerns included the ambulance response time, the lack of timely follow-up contact with the family, and inadequate planning and direction during periods of very high call volumes.
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 Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely ambulance responses to Amber 2 calls
Wider context from the report “1) As against an internal Welsh Ambulance Services Trust response target time for an Amber 2 call of 20 minutes, an ambulance did not arrive at the scene for nearly 2 hours and 40 minutes . It was accepted in evidence on behalf of the Welsh Ambulance Services Trust that this response time was unacceptable and that the situation could happen again .
” 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 Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely follow-up calls to update, advise and reassess emergency callers
Wider context from the report “2) Cognisant of the delay in responding to the original call to the emergency services, good practice of the Welsh Ambulance Services Trust would have been to have made a phone call(s) to seek an update on the condition of the patient, to provide further advice and to ascertain whether it would have been appropriate to re-categorise the call . A call was not made to the family of the deceased (and this was disputed in evidence in any event) until just before 8:25pm, 1½ hours after the original call had been made .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of clear planning and direction for maintaining and delivering ambulance services
Wider context from the report “3) The evidence suggested that at or around the time of the first call being made to the Welsh Ambulance Services Trust at around 6:50pm on the 8th February 2016 there was an extremely high number of calls being polled. The evidence suggested that there was an absence of clear planning and direction as to the maintenance and delivery of the Trust's services and that in repeat circumstances of such significant polling the same circumstances as found at the inquest of Mr Hamer could repeat themselves .
” 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 Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain ambulance service delivery during significant call volumes
Wider context from the report “3) The evidence suggested that at or around the time of the first call being made to the Welsh Ambulance Services Trust at around 6:50pm on the 8th February 2016 there was an extremely high number of calls being polled . The evidence suggested that there was an absence of clear planning and direction as to the maintenance and delivery of the Trust's services and that in repeat circumstances of such significant polling the same circumstances as found at the inquest of Mr Hamer could repeat themselves .
” Open source report
Concerns raised 3 Lack of transfer handover information about high falls risk View source Failure to carry out falls risk assessments on readmission and after successive falls View source Insufficient staffing for required one-to-one nursing observation of patients at high risk of falls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Howell Glyndwr Fisher · 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
Howell Glyndwr Fisher fell at home, sustained a fractured hip, and later died in hospital on 9 December 2014 after developing an ischemic leg, pneumonia and other health problems. The concerns included at least five falls while he was assessed as being at high risk, insufficient staffing to provide required one-to-one nursing, and inadequate handover and falls-risk assessments between and within hospitals.
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 Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of transfer handover information about high falls risk
Wider context from the report “(2) There was no “handover material” at the point of transfer between the two hospitals detailing that he was at high risk of falls and further more on readmission to the Princess of Wales Hospital on the 20th November no falls risk assessment was carried out – indeed, after each successive fall in the Princess of Wales Hospital no formal assessment appears to have been undertaken. Throughout he remained at high risk of falls.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out falls risk assessments on readmission and after successive falls
Wider context from the report “(2) There was no “handover material” at the point of transfer between the two hospitals detailing that he was at high risk of falls and further more on readmission to the Princess of Wales Hospital on the 20th November no falls risk assessment was carried out – indeed, after each successive fall in the Princess of Wales Hospital no formal assessment appears to have been undertaken . Throughout he remained at high risk of falls.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing for required one-to-one nursing observation of patients at high risk of falls
Wider context from the report “(1) Within the space of a month the deceased had at least 5 falls whilst being deemed as high risk of falls. He was identified as requiring one to one nursing but there were many occasions when insufficient staff numbers meant that this could not be delivered.
” Open source report
Concerns raised 3 Unwitnessed patient falls View source Failure to prevent falls among patients identified as being at high risk of falling View source Failure to complete transfer documentation between wards View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Robert Henry Payne · 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 Henry Payne was admitted to hospital after falling at home and fracturing his left neck of femur. While in hospital, he experienced repeated falls, including one that dislocated the repaired hip and necessitated further surgery; the reported concerns included falls despite high-risk assessments and a ward transfer without an apparent transfer document, followed by a fall that was not witnessed. He later developed an infected surgical wound and died on 13 July 2014.
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 Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Unwitnessed patient falls
Wider context from the report “(1) Despite repeated falls risk assessments identifying the deceased as being at high risk of falling he fell on no less than four occasions whilst in hospital which necessitated further surgery as a direct consequence of the fall on the 20th May 2014.
(2) He was transferred between wards at 1am in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed .
” 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 Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent falls among patients identified as being at high risk of falling
Wider context from the report “(1) Despite repeated falls risk assessments identifying the deceased as being at high risk of falling he fell on no less than four occasions whilst in hospital which necessitated further surgery as a direct consequence of the fall on the 20th May 2014.
(2) He was transferred between wards at 1am in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed.
” 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 Healthcare Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to complete transfer documentation between wards
Wider context from the report “(1) Despite repeated falls risk assessments identifying the deceased as being at high risk of falling he fell on no less than four occasions whilst in hospital which necessitated further surgery as a direct consequence of the fall on the 20th May 2014.
(2) He was transferred between wards at 1am in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations