Concerns raised 3 Failure to review medical records during mental health risk assessments View source Over-reliance on referrer-provided information in mental health risk assessments View source Lack of investigation and scrutiny of available background information in mental health risk assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Trevor Anthony Evans · 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
Trevor Anthony Evans was struggling with his mental health and had contact with police, ambulance, mental health professionals and healthcare staff before taking his own life by hanging at home on 27 February 2020. The principal concerns were over-reliance on what he told a mental health nurse, failure to review medical records and insufficient investigation of available background information, resulting in concerns that mental health risk assessments could be incomplete or inadequate.
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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to review medical records during mental health risk assessments
Wider context from the report “In this case, I found that there was an over reliance on what Trevor told the nurse, a failure to review medical records and a lack of investigation or scrutiny into an abundance of background information that was available.
Notwithstanding the fact that I have been told that changes have been made by the Health Board to ensure that those undertaking assessments now look to obtain as much information as possible I also received evidence which indicates that assessors still harbour an attitude that it is the referrer job to provide all the relevant information and then those performing the risk assessment will simply assess the information.
For as long as that approach or culture continues I fear that mental health risk assessments in Pembrokeshire may be incomplete, perfunctory and inadequate. There needs to be a shift of onus to a more collaborative approach so that those undertaking the assessment explore what information is available to them and do not simply rely on the details provided by the referrer. It is essential that those undertaking the mental health assessments are aware of the need to obtain as much information as possible in order to complete a full and thorough assessment of the risk and that they are aware of how to and where to obtain the relevant information from.
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on referrer-provided information in mental health risk assessments
Wider context from the report “In this case, I found that there was an over reliance on what Trevor told the nurse , a failure to review medical records and a lack of investigation or scrutiny into an abundance of background information that was available.
Notwithstanding the fact that I have been told that changes have been made by the Health Board to ensure that those undertaking assessments now look to obtain as much information as possible I also received evidence which indicates that assessors still harbour an attitude that it is the referrer job to provide all the relevant information and then those performing the risk assessment will simply assess the information .
For as long as that approach or culture continues I fear that mental health risk assessments in Pembrokeshire may be incomplete, perfunctory and inadequate. There needs to be a shift of onus to a more collaborative approach so that those undertaking the assessment explore what information is available to them and do not simply rely on the details provided by the referrer . It is essential that those undertaking the mental health assessments are aware of the need to obtain as much information as possible in order to complete a full and thorough assessment of the risk and that they are aware of how to and where to obtain the relevant information from.
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of investigation and scrutiny of available background information in mental health risk assessments
Wider context from the report “In this case, I found that there was an over reliance on what Trevor told the nurse, a failure to review medical records and a lack of investigation or scrutiny into an abundance of background information that was available .
Notwithstanding the fact that I have been told that changes have been made by the Health Board to ensure that those undertaking assessments now look to obtain as much information as possible I also received evidence which indicates that assessors still harbour an attitude that it is the referrer job to provide all the relevant information and then those performing the risk assessment will simply assess the information.
For as long as that approach or culture continues I fear that mental health risk assessments in Pembrokeshire may be incomplete, perfunctory and inadequate. There needs to be a shift of onus to a more collaborative approach so that those undertaking the assessment explore what information is available to them and do not simply rely on the details provided by the referrer. It is essential that those undertaking the mental health assessments are aware of the need to obtain as much information as possible in order to complete a full and thorough assessment of the risk and that they are aware of how to and where to obtain the relevant information from.
” 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 Work with police colleagues to strengthen understanding and use of Pembrokeshire police handover processes so relevant information reaches assessing clinicians.
Verbatim wording from the response “3. Review of partnership information-sharing arrangements” Source location Response from Hywel Dda University Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue delivering WARRN training across mental health services on multi-source assessment, professional curiosity, collaborative risk management and safety planning.
Verbatim wording from the response “4. Workforce development through WARRN” Source location Response from Hywel Dda University Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen duty-practitioner expectations so urgent assessments include seeking necessary collateral information beyond analysing information presented.
Verbatim wording from the response “4. Strengthening the duty practitioner role” Source location Response from Hywel Dda University Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use comprehensive assessment and referral-support tools to prompt multi-source information gathering, collateral enquiries and documentation of information sources.
Verbatim wording from the response “1. Introduction of referral and assessment support tools” Source location Response from Hywel Dda University Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss historical-record review and collateral-information requirements in Adult Mental Health Services operational team meetings to reinforce consistent practice.
Verbatim wording from the response “2. Team discussions and practice reinforcement” Source location Response from Hywel Dda University Health Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a professional practice reminder requiring relevant practitioners to review electronic patient records before assessments and consider historical risks and safeguarding concerns.
Verbatim wording from the response “1. Reinforcement of expectations regarding historical information review” Source location Response from Hywel Dda University Health Board
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implemented, immediate and ongoing safety work collectively addresses the identified risk-assessment concerns.
Verbatim wording from the response “We believe the actions already implemented, the immediate actions undertaken following receipt of this report, and our ongoing participation in national safety and risk improvement work collectively address the issues identified and support the cultural shift towards collaborative, information-seeking, formulation-based assessment practice described by the Coroner.” Source location Response from Hywel Dda University Health Board
Open published response
27 Feb 2026 SUMMER RAE MANT · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Lack of standardised crash trolleys across hospital settings 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
SUMMER RAE MANT · 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
Summer Rae Mant, a four-year-old child with MIRAGE syndrome, developed severe infection and virus while an inpatient and suffered hypoxia and cardiac arrest during events on 17 and 18 March 2024. She later developed sudden multi-organ failure of uncertain cause and died at Ty Hafan on 21 September 2024. A substantive concern was a delay in obtaining adrenaline during resuscitation, associated with non-standardised crash trolleys and staff unfamiliarity with different hospital configurations.
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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised crash trolleys across hospital settings
Wider context from the report “During the resuscitation of Summer at Prince Charles Hospital in the theatre following intubation, there was a delay in obtaining adrenaline. The incident occurred at night and it involved a skeleton staff including some junior doctors, fairly new to the hospital.
The delay in finding adrenaline, was likely due to the fact that there is no standardised crash trolley , and junior doctors frequently rotate between hospitals and health boards and encounter different set-ups .
Paediatric crash trolleys are necessarily different to adult crash trolleys, but there was consensus in evidence that it would be safer if there was a single standardised version of each type across every hospital setting in which junior doctors rotate , to minimise confusion at a time critical moment.
” Open source report
Concerns raised 2 Lack of provision on the Accident & Emergency Record Card to record medication prescription and administration View source Failure of the Medication Record to record medication prescription times View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Susan Margaret Williams · 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
Susan Margaret Williams was admitted to hospital on 14 July 2019 with suspected sepsis and abdominal pain, later deteriorating and dying from cardiorespiratory failure due to lung fibrosis and cor pulmonale. The principal concerns were the lack of recorded medication prescription times, a potential delay in administering antibiotics, and the absence of equivalent medication timing records on the Accident & Emergency Record Card.
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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of provision on the Accident & Emergency Record Card to record medication prescription and administration
Wider context from the report “2. In the course of the evidence, it also became apparent that the Accident & Emergency Record Card (known as the “Cas Card”) has no similar provision to record medication prescription and administration within its content . This would have been a separate point of reference for this purpose.
Both of the documents referenced are understood to be used across the NHS in Wales and not confined to the Health Board in whose care Mrs Susan Margaret Williams was at the time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of the Medication Record to record medication prescription times
Wider context from the report “1. The Medication Record shows the time that the medications are administered, but not the time that they were prescribed. In this case the evidence showed that the antibiotics were administered later than the other medications and there was a conflict between the prescribing clinician and the nurse administering the medications as to whether all of the medications had been prescribed at the same time.
The concern in this case related to a potential delay in the administration of the antibiotic medication (considered to be a significant sepsis treatment), there being a period of some 90 minutes between the times entered on the Record for the administration of the analgesia and the anti-emetic.
I consider this to be a concern as the lack of a recorded time of prescription highlights the possibility that there is no immediate means of referencing whether a prescribed medication has been administered within a reasonable time of it being prescribed .
Although the factual findings in this inquest did not show a causative connection between the delays in the administration of the antibiotics, I consider this to be a concern that may result in a potential future death.
” 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 completion of an actual administration time on Emergency Department medication cards and prohibit recording “stat” for intravenous antibiotics.
Verbatim wording from the response “In the interim we will implement that the “time to be given” box on the Medication Card (Emergency Department) is always completed with an actual time. Practitioners will be directed not to write “stat”. The time written will be the time when the antibiotic was prescribed, as immediate administration will always be required with intravenous” Source location Response from Hywel Dda University Health Board
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Changes to the nationally approved Emergency Department medication chart must be considered by the national group, not unilaterally by the Health Board.
Verbatim wording from the response “The medication chart in the Emergency Department is a Wales NHS approved chart. Hywel Dda University Health Board is not able to unilaterally change the chart, although it can put forward proposals for variations to the national group. The Learned Coroner will appreciate that this takes quite some time, and we are aware that the issue has been raised with the National Authority directly in a separate, but linked PFD Report.” Source location Response from Hywel Dda University Health Board
Open published response
Concerns raised 4 Lack of a route back into the Mental Health Service after CRHT discharge View source Failure of communication and information sharing between Primary Mental Health Services and Tier 2 therapy providers View source Inappropriate communication of significant procedures View source Failure to monitor and execute significant actions or steps View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kieran Joseph Kevan CRIMMINS · 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
Kieran Joseph Kevan Crimmins took his own life after discharge from the Crisis and Home Treatment Team, in circumstances where the report found ongoing psychiatric monitoring and support would have been appropriate. The principal concerns were incomplete or inaccurately recorded actions, the way significant information was communicated to him, and apparent gaps in routes back into mental health services and communication between providers.
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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of a route back into the Mental Health Service after CRHT discharge
Wider context from the report “(3) I expressed concern that someone having been discharged from the CRHT, there appeared to be no route back into the Mental Health Service short of a re-referral to the CRHT itself via A & E for someone who remains vulnerable by reason of their mental state and who is receiving therapy as part of the discharge plan. This is in the context of someone who was receiving support from the Integrated Psychology Service (“IPTS”) and the Dyfed Drug and Alcohol Service (“DDAS”), both of whom were engaged in providing appropriate therapies.
My concern is that there appears to be an issue in relation to lines of communication and information sharing between Primary Mental Health Services and Tier 2 providers of therapy.
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of communication and information sharing between Primary Mental Health Services and Tier 2 therapy providers
Wider context from the report “(3) I expressed concern that someone having been discharged from the CRHT, there appeared to be no route back into the Mental Health Service short of a re-referral to the CRHT itself via A & E for someone who remains vulnerable by reason of their mental state and who is receiving therapy as part of the discharge plan. This is in the context of someone who was receiving support from the Integrated Psychology Service (“IPTS”) and the Dyfed Drug and Alcohol Service (“DDAS”), both of whom were engaged in providing appropriate therapies.
My concern is that there appears to be an issue in relation to lines of communication and information sharing between Primary Mental Health Services and Tier 2 providers of therapy.
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Inappropriate communication of significant procedures
Wider context from the report “(2) The evidence I heard from one witness described how she was asked to contact Kieran by telephone and to advise him of the fact that a Multi-agency Referral Form (“MARF”) was to be submitted. I considered this was an inappropriate means of communicating a significant procedure and which could potentially bear on his (or any other vulnerable person's) state of mind.
What was unclear is how the provision of this information and step to be taken will be approached in 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor and execute significant actions or steps
Wider context from the report “(1) I was told that the Crisis Recovery and Home Treatment Team ("CRHT") use the Care Partner records, a whiteboard and a manual diary to enter the various information and action points and that it is at the Multidisciplinary Team meetings that the actions or steps are discussed and progressed. They are either crossed out, if completed, or moved to the next date until they have been actioned. It was highlighted that in this particular case two actions were not completed either prior to Kieran’s discharge from the CRHT or shortly thereafter. In one of these, the entry had been crossed out, giving the impression that the matter had, in fact been dealt with when it had not. This indicated that there was an issue as to the monitoring and execution of such actions or steps.
This anomaly whereby a significant step may have been overlooked remains a concern.
” Open source report
10 Jun 2019 Glenys Button · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Lack of backup neurosurgical specialist capacity to field referrals View source Failure of the neurosurgical referral system to provide timely and reliable communication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Glenys Button · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Glenys Button, aged 78, died at Royal Glamorgan Hospital on 5 November 2018 after sustaining a head injury, including a basal skull fracture, pneumocephalus and brain bleed, following a likely accidental fall at home. The report raised concerns about delays, miscommunication, confusion and inadequate documentation in referrals to on-call neurosurgery, including uncertainty and changes over her potential transfer to Cardiff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of backup neurosurgical specialist capacity to field referrals
Wider context from the report “(1) There are a high number of referrals to the single rota’d on-call neurosurgical specialist registrar every day. The system for making and receiving the referrals is not fit for purpose, with inefficient delays, miscommunications and confusion occurring. The use of the UHW switchboard and bleeping the doctor is archaic, and does not utilise technology as it should. Further, if the on-call doctor is in surgery or dealing with an emergency, there is no back up doctor to field the referrals, which can often be time critical.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of the neurosurgical referral system to provide timely and reliable communication
Wider context from the report “(1) There are a high number of referrals to the single rota’d on-call neurosurgical specialist registrar every day. The system for making and receiving the referrals is not fit for purpose, with inefficient delays, miscommunications and confusion occurring. The use of the UHW switchboard and bleeping the doctor is archaic, and does not utilise technology as it should. Further, if the on-call doctor is in surgery or dealing with an emergency, there is no back up doctor to field the referrals, which can often be time critical.
” Open source report
Concerns raised 3 Failure to preserve handover records View source Failure to keep risk management strategies up to date in records View source Lack of an overarching risk management plan for treating and caring for patients 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
Emily Katherine Inglis · 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
Emily Katherine Inglis was found deceased in her bedroom at Prince Philip Hospital on 22 April 2016, with a plastic bag over her head; the cause of death was given as plastic bag asphyxia. The inquest identified concerns about the absence of an overarching risk management plan and deficiencies in record-keeping, including risk management strategies and handover records.
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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to preserve handover records
Wider context from the report “(2) The inquest further identified that there were deficiencies in record-keeping , both in terms of ensuring that risk management strategies remained up-to-date and in preserving handover records .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to keep risk management strategies up to date in records
Wider context from the report “(2) The inquest further identified that there were deficiencies in record-keeping , both in terms of ensuring that risk management strategies remained up-to-date and in preserving handover records.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of an overarching risk management plan for treating and caring for patients
Wider context from the report “(1) The inquest identified that there should have been an overarching risk management plan in place to assist medical professionals and staff in treating and caring for Emily.
” Open source report
Concerns raised 4 Inadequate content of police training on dealing with restraint View source Inadequate content and frequency of police training on the status and responsibilities of an Appropriate Adult View source Inadequate criteria for identifying the most appropriate place of safety View source Unclear responsibilities for transporting someone detained under Section 136 MHA 1983 View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Meirion 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
Meirion James was arrested for assaulting his mother and later became agitated at Haverfordwest Police station. During restraint, he was placed prone, stopped breathing and died from positional asphyxia. The report raised concerns about police restraint training, arrangements for people detained under Section 136 of the Mental Health Act, and training concerning Appropriate Adults.
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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Inadequate content of police training on dealing with restraint
Wider context from the report “(1) Whether the content of police training in dealing with restraint should be addressed
(2) Whether the criteria for identifying the most appropriate place of safety and the responsibilities for transporting someone who is detained under Section 136 MHA 1983 should be reviewed
(3) Whether the content and frequency of police training on the status and responsibilities of an Appropriate Adult under the Police & Criminal Evidence Act should be reviewed.
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Inadequate content and frequency of police training on the status and responsibilities of an Appropriate Adult
Wider context from the report “(1) Whether the content of police training in dealing with restraint should be addressed
(2) Whether the criteria for identifying the most appropriate place of safety and the responsibilities for transporting someone who is detained under Section 136 MHA 1983 should be reviewed
(3) Whether the content and frequency of police training on the status and responsibilities of an Appropriate Adult under the Police & Criminal Evidence Act should be reviewed .
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Inadequate criteria for identifying the most appropriate place of safety
Wider context from the report “(1) Whether the content of police training in dealing with restraint should be addressed
(2) Whether the criteria for identifying the most appropriate place of safety and the responsibilities for transporting someone who is detained under Section 136 MHA 1983 should be reviewed
(3) Whether the content and frequency of police training on the status and responsibilities of an Appropriate Adult under the Police & Criminal Evidence Act should be reviewed.
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibilities for transporting someone detained under Section 136 MHA 1983
Wider context from the report “(1) Whether the content of police training in dealing with restraint should be addressed
(2) Whether the criteria for identifying the most appropriate place of safety and the responsibilities for transporting someone who is detained under Section 136 MHA 1983 should be reviewed
(3) Whether the content and frequency of police training on the status and responsibilities of an Appropriate Adult under the Police & Criminal Evidence Act should be reviewed.
” Open source report
27 Jul 2017 Percy Jacks · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Reliance of GP prescribing on receipt of hospital scan-result notification View source Haphazard DVT management system View source Failure of the hospital-to-GP DVT result communication system View source Failure to reliably communicate medication and clinical plans from hospital to care home View source Lack of medication review for correct Rivaroxaban dosage and duration View source Fragile communication system between GP, hospital and care home View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Percy Jacks · 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
Percy Jacks died from a pulmonary embolus after being found unresponsive the morning following treatment for chest pain. The report identified failings in the management of his anticoagulation medication, including poor communication between the hospital, GP surgery and care home, and inadequate systems for ensuring the medication continued for the intended period.
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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Reliance of GP prescribing on receipt of hospital scan-result notification
Wider context from the report “(2) The system within the GP surgery for prescribing Rivaroxaban was poor and relied solely on receiving the notification of the results of the scan from the hospital . There was no facility to review the medication to ensure that the correct dosage for the correct period of time continued to be prescribed.
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Haphazard DVT management system
Wider context from the report “(3) The evidence revealed a view from one of the hospital doctors to the effect that DVT management should be undertaken within the hospital setting rather than by the GP’s to ensure that a comprehensive and failsafe system operated rather than the somewhat haphazard one revealed by the evidence .
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of the hospital-to-GP DVT result communication system
Wider context from the report “(1) The investigation revealed that the system for the Bronglais Hospital contacting the GP was poor. The result of the DVT scan which took place on 6 February was sent to the incorrect GP surgery and despite an explanation as to why that happened no satisfactory explanation could be found.
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably communicate medication and clinical plans from hospital to care home
Wider context from the report “(4) The evidence further revealed a practice of sending details of the medication and clinical plan back with the driver of the patient who had taken the patient back from hospital to the care home.
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of medication review for correct Rivaroxaban dosage and duration
Wider context from the report “(2) The system within the GP surgery for prescribing Rivaroxaban was poor and relied solely on receiving the notification of the results of the scan from the hospital. There was no facility to review the medication to ensure that the correct dosage for the correct period of time continued to be prescribed .
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Fragile communication system between GP, hospital and care home
Wider context from the report “(5) Overall the evidence revealed a very fragile system of communication between GP hospital and care home in circumstances in which the deceased had moved between three care homes in a short period of time.
” 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 streamlined DVT pathway directing suspected cases to radiology, initiating primary treatment before ultrasound, and ensuring positive and negative results receive appropriate follow-up.
Verbatim wording from the response “The process of managing potential DVT patients has been streamlined and a definite pathway introduced. All GP referrals which suspected DVTs are referred direct to the Hospital's Radiology Department as per the attached protocol. It is incumbent on the GPs to commence their primary prior to an ultrasound scan being undertaken. Following their scan, if the result is positive, the patient is referred back to the A & E Department where they are reviewed by the on-call Physicians. There is a pre-printed letter that is completed by the on-call physicians to the GP with recommendations and this is also copied to the Anticoagulation Clinic. If the result of the scan is negative, the patient is referred back to their GP for further evaluation.” Source location 2017-0329-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Welsh Clinical Portal access was considered sufficient for the GP to review the patient's A&E attendance outcome despite the discharge summary issue.
Verbatim wording from the response “All Primary and Secondary Care Doctors have access to the Welsh Clinical Portal. This allows them to access test, radiology and documentation for a patient wherever the patient receives cares in Wales, regardless of geographical or organisational boundaries. See attached printout from the NHS Wales Informatics Service website which provides further information. Mr Jacks' GP would have had access to this and would have been able to review the outcome of his attendance at the A & E Department at Bronglais General Hospital on 6 February 2017.” Source location 2017-0329-Response
Open published response
Concerns raised 3 Lack of a known mechanism to override liver function testing guidance when clinically appropriate View source Failure to ensure that consultant referrals are seen by consultants in the first instance View source Failure to undertake requested liver function tests when clinically required View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Cerith Wyn Pugh · 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
Cerith Wyn Pugh underwent surgery for bowel obstruction in March 2013, experienced a cardiac arrest and further surgery, and had subsequent hospital readmissions. He died on 20 May 2014 after developing bleeding from his ileostomy; the inquest recorded multi-organ failure, ischaemic bowel disease, and cholelithiasis with mechanical jaundice. Concerns included consultant referrals being handled initially by middle grade doctors and liver function tests being declined because testing had been conducted less than three days earlier, without evidence of a mechanism to override that guidance when clinically appropriate.
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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Lack of a known mechanism to override liver function testing guidance when clinically appropriate
Wider context from the report “That liver function tests were requested but the Health Board declined to undertake these for reasons of demand management on the basis that had been done some three days earlier. Expert evidence received at the inquest was highly critical of this practice. Whilst 72 hour testing is in accordance with guidance contained in guidance from the Association for Clinical Biochemistry and the Royal College of Pathologists both documents are clear that the guidance must be capable of being overridden if clinically appropriate . There was no evidence of any mechanism to override the guidance or, if such guidance existed, that it was known to staff .
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that consultant referrals are seen by consultants in the first instance
Wider context from the report “That referrals to consultants at Withybush General Hospital are routinely being dealt with by middle grade doctors and, if in the opinion of the middle grade doctor, the matter then needs a referral to a consultant only then is the matter passed to a consultant . All consultant referrals should be seen by consultants in the first instance . Expert evidence received at the inquest described this practice as not being best 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake requested liver function tests when clinically required
Wider context from the report “That liver function tests were requested but the Health Board declined to undertake these for reasons of demand management on the basis that had been done some three days earlier . Expert evidence received at the inquest was highly critical of this practice. Whilst 72 hour testing is in accordance with guidance contained in guidance from the Association for Clinical Biochemistry and the Royal College of Pathologists both documents are clear that the guidance must be capable of being overridden if clinically appropriate. There was no evidence of any mechanism to override the guidance or, if such guidance existed, that it was known to staff.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a process to provide specialist advice through an alternative on-site or cross-site specialist when a single-handed consultant is absent.
Verbatim wording from the response “Thank you for your report into the death of Cerith Wyn Pugh. As a result of your concerns we have issued your redacted report to the Hospital Directors (lead doctors) in each of the four acute hospitals and through them we have asked each consultant to review their practice and to ensure that consultant referrals are directly reviewed by the consultant or that the review involves proactive delegation where appropriate, and consultant supervision. Some of our services are led by a single handed consultant on a particular site and this does provide some challenges when this individual is on leave. We are actively looking at the process we need to put in place in these cases so that specialist advice can always be accessed either by an alternative consultant on site, or a similar specialist on a different site.” Source location 2016-0271-Response-by-University-health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ask consultants to review referral practice and ensure consultant review, appropriate delegation and supervision.
Verbatim wording from the response “Thank you for your report into the death of Cerith Wyn Pugh. As a result of your concerns we have issued your redacted report to the Hospital Directors (lead doctors) in each of the four acute hospitals and through them we have asked each consultant to review their practice and to ensure that consultant referrals are directly reviewed by the consultant or that the review involves proactive delegation where appropriate, and consultant supervision. Some of our services are led by a single handed consultant on a particular site and this does provide some challenges when this individual is on leave. We are actively looking at the process we need to put in place in these cases so that specialist advice can always be accessed either by an alternative consultant on site, or a similar specialist on a different site.” Source location 2016-0271-Response-by-University-health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind medical staff to undertake clinically justified tests and discuss provider-declined investigations with the ordering consultant.
Verbatim wording from the response “We have also reminded medical staff that where test requests are made on clinically justifiable grounds these should be undertaken regardless of guidance regarding repeating tests and in the event of an investigation being declined by a provider the matter must be discussed with the Consultant whose team has ordered the request.” Source location 2016-0271-Response-by-University-health-Board
Open published response
Concerns raised 7 Insufficient staff training in the section 136 procedure for police handovers View source Insufficient staff training to recognise absconding and respond after an absconding incident View source Insufficient staffing resources on the acute ward View source Insufficient staff training in powers of detention and their appropriate use View source Insufficient staff training in Personality Disorders View source Breakdown in information transition and passing between Child/Adolescent and Adult Mental Health Teams View source Failure of the ward door policy to prevent or promptly detect patient absconding View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Laura Hill · 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
Laura Hill, aged 21, was admitted to a psychiatric ward after a serious overdose and later absconded twice before being found hanging from a tree in a wooded area. The concerns identified included information-sharing failures, stretched staffing, training needs around police handovers, absconding, personality disorders and detention powers, and the ward door policy.
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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training in the section 136 procedure for police handovers
Wider context from the report “(3) There was a training need identified in relation to the section 136 procedure when patients are handed over by the Police .
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training to recognise absconding and respond after an absconding incident
Wider context from the report “(4) There was a training need identified in relation to what constitutes ‘absconding’ and what should be done by staff following an incident of absconding .
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing resources on the acute ward
Wider context from the report “(2) Staffing levels on the Ward need to be reviewed as it was felt that staffing resources were stretched at the relevant time (1 nurse and 3 support workers on a 16 bed acute ward ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training in powers of detention and their appropriate use
Wider context from the report “(7) There was a training need identified in relation to powers of detention and when those powers can and should be used .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training in Personality Disorders
Wider context from the report “(6) There was a training need identified in relation to Personality Disorders .
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Breakdown in information transition and passing between Child/Adolescent and Adult Mental Health Teams
Wider context from the report “(1) That there appears to be a breakdown in the transition and passing of information between the Child/Adolescent and the Adult Mental Health Teams .
” 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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure of the ward door policy to prevent or promptly detect patient absconding
Wider context from the report “(5) The door policy on the Ward needs to be reviewed as a patient was able to abscond without staff noticing .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase ward staffing to a minimum of four staff per shift, with flexible additional cover and escalation arrangements for increased need.
Verbatim wording from the response “Since the incident occurred, the ward has reviewed (May 2013) the shift pattern and now works on the basis of four staff as a minimum per shift, with an additional staff member on a flexible shift to cover the busier part of the day. This covers 10 nursing staff only. Additionally, the ward would have the manager and other disciplines providing input. Staffing levels have to be flexible and dependant upon patient acuity and complexity. This requires increasing staffing levels at short notice, particularly where one to one observations are required. There are systems in place on a twenty four hour basis to sanction increased staffing levels when they are required.” Source location 2015-0092-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Section 136 procedure training to nursing and medical staff through induction, follow-up training and continuing medical education.
Verbatim wording from the response “A multi-agency Section 136 Protocol was signed off in November 2014. This Protocol details partner responsibilities in relation to Section 136. There are clear guidelines to be followed and these include points of transition with associated documentation. Nursing staff on St Caradog Ward receive training in respect of their responsibilities as part of their induction. Further follow up training is thereafter provided directly to staff on the ward. Medical staff also receive training on induction as well as on-going through the Post Graduate Medical Training Forum. Medical staff have protected training on a weekly basis.” Source location 2015-0092-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enhance personality-disorder training through dialectical behavioural therapy, emotional coping skills and the Knowledge and Understanding Framework.
Verbatim wording from the response “Since the incident, there has been an enhancement of training in relation to personality disorder that has taken place within the Mental Health and Learning Disabilities Directorate. These include: Dialectical Behavioural Therapy, Emotional Coping Skills and Knowledge and Understanding Framework for Personality Disorders. The Health Board is committed to developing the use and range of psychological intervention and, in line with Welsh Government guidance, has a Committee dedicated to enhancing the delivery of psychological therapies across the whole service.” Source location 2015-0092-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain an up-to-date door-locking policy covering authorisation and recording requirements.
Verbatim wording from the response “St Caradog is an open adult admission ward. It is not a secure or locked ward. The ward has the option to lock its door, although this has to be done in line with guidance, as provided by the 1983 Mental Health Act – Code of Practice. An up to date policy is in place to guide staff in relation to the locking of doors on such units as well as the recording of these instances.” Source location 2015-0092-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate transition guidelines between child and adult mental health services.
Verbatim wording from the response “In January 2013, the Health Board provided transition guidelines in relation to Specialist Child and Adolescent Mental Health Services to Adult Mental Health and Learning Disability Services. The document was circulated across all the relevant teams and provides clear transition guidelines in line with best practice and government guidelines with regards to transitions between services. It is recognised that times of transition can pose potential risks if they are not robustly managed and the guidance enhances the safety of the transition process with clear steps for professionals to follow.” Source location 2015-0092-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide absconding-management guidance to relevant ward staff.
Verbatim wording from the response “Guidance in relation to the management of those patients who abscond from the in-patient ward has been provided to all relevant staff by the Head of Acute Care Services.” Source location 2015-0092-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide ongoing Mental Health Act and Mental Capacity Act training to update clinicians on detention powers.
Verbatim wording from the response “Registered clinical practitioners are aware of the powers of detention which are available to them. On-going Mental Health Act and Mental Capacity Act training (as detailed previously) ensure that clinicians are updated in relation to the application of powers of detention.” Source location 2015-0092-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ward’s current door-locking policy and continuous risk and observation assessments are relied on instead of further door-policy changes.
Verbatim wording from the response “5. The Door Policy on the ward needs to be reviewed as a patient was able to abscond without staff noticing.” Source location 2015-0092-Response-by-University-Health-Board
Open published response
Concerns raised 1 Failure to ensure staff in caring roles have current basic life support training View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Keith William Shelley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Keith William Shelley, who was wholly dependent on others following a brain injury at birth, consumed fairy liquid at a residential care home and quickly became ill. There was a significant delay in seeking and communicating advice, no timely contact with emergency services despite deterioration, and evidence that some care staff lacked current basic life-support training.
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 Hywel Dda University LHB; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff in caring roles have current basic life support training
Wider context from the report “That staff employed by the Health Board in caring roles should undertake basic first aid training and receive regular up-dates. There was information before the inquest that some staff at the residential unit had received no basic life support training and in relation to other staff members it was out-of-date .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a risk-based approach to determine which healthcare support staff require life-threatening-conditions training, including those working unsupervised.
Verbatim wording from the response “We will be taking a risk based approach to determine which staff will require this level of training, which will include if they will be working unsupervised i.e. without the direct support of trained clinical staff.” Source location 2014-0352-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evaluate training options for healthcare support staff focused on recognising and responding to life-threatening conditions.
Verbatim wording from the response “In terms of moving further forwards, we have also looked at other options which may be available for healthcare support staff, should this would be appropriate. We are evaluating options for training these staff groups to target “life threatening conditions”. We feel that a specifically targeted approach to life threatening conditions will provide the best type cover and will be more specific than a generalised first aid course. This course will include recognition & response to life threatening conditions i.e. heart attack, choking, serious bleeding including cardiac arrest and is recognised by The British Heart Foundation.” Source location 2014-0352-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train all residential-unit staff in Basic Life Support.
Verbatim wording from the response “Moving on to the second group of staff, our Healthcare Support Workers, who comprise the majority of the staff employed in this residential unit; they have not routinely been trained in Basic Life Support or “first aid”. Although if this had been requested and subject to capacity, this could be undertaken. This has been because the focus of the Simulation & Resuscitation Team has been to deliver training directly to all clinical staff annually within the Health Board. Risk assessments approved by the Health Board Resuscitation Committee have resulted in prioritising the training to high risk areas.” Source location 2014-0352-Response-by-University-Health-Board
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