NHS Wales Shared Services Partnership

Health and care · Health-system partnership

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First report 19 Dec 2014•Latest report 7 Aug 2018

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from NHS Wales Shared Services Partnership linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. South Wales Central

    AI-generated summary

    Mr. Steven John Welch · Prevention of Future Deaths report

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

    Report summary

    Mr. Steven John Welch was found at home on 26 December 2017 after a reported fall and head injury, and was later diagnosed with a subarachnoid haemorrhage, hydrocephalus and an aneurysm. His condition deteriorated during delays in assessment, neurosurgical admission and transfer of radiology images for specialist review; he was transferred to Southmead Hospital but died from a pulmonary embolism, with deep vein thrombosis and subarachnoid haemorrhage also recorded in the medical cause of death. The principal concerns included delayed emergency assessment and neurosurgical treatment, lack of interventionist radiology cover, and inadequate facilities for transferring radiological images to hospitals outside Wales.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Wales Shared Services Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of employed interventional radiologists to provide tertiary support

    Wider context from the report

    “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following: i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays; ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital; iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay; iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Wales Shared Services Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of software enabling electronic transfer of radiology for external review and consultation

    Wider context from the report

    “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following: i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays; ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital; iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay; iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Wales Shared Services Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide rapid A&E review for head injury patients with reducing or fluctuating Glasgow Coma Scores

    Wider context from the report

    “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following: i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays; ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital; iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay; iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Wales Shared Services Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in transferring patients to hospitals or specialist centres providing neurosurgical diagnosis and treatment

    Wider context from the report

    “At inquest, the errors in assessing the urgency of the need for medical assistance and the delay in providing that assistance were considered unlikely to have contributed to Steven Welch’s death. However, it was acknowledged that such errors could cause or contribute to the death of others where a subarachnoid haemorrhage had been sustained and for this reason, the Cwm Taf University Health Board is invited through this Regulation 28 to consider the following: i) Provision of rapid A&E review of a patient with a reported head injury and reducing or fluctuating Glasgow Coma Score even at times of public holidays; ii) Rapid transfer to a hospital or specialist centre providing neurosurgical diagnosis and treatment when such facilities are unavailable within the admitting hospital; iii) Failure by the Cardiff and Vale University Local Health Board to have any interventionist radiologists in employment at the time thereby failing to provide tertiary support to the RGH and necessitating its patients to be sent out of area to England for treatment with inevitable delay; iv) Failure by the Cwm Taf Health Board and Vale University Local Health Board to have computer software in place to enable electronic transfer of radiology to hospitals and specialist centres out of Wales for review and consultation. ”
    Open source report

  2. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Mr. Thomas Jenkins · Prevention of Future Deaths report

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

    Report summary

    Mr. Thomas Jenkins developed pressure sores while receiving care after a cerebrovascular accident, including an infected chronic pressure sore on his right heel. He was readmitted to hospital and died of sepsis on 8 August 2014. The principal concern was inadequate and delayed tissue viability nursing and wound care input, attributed to specialist nurses not being based in the hospital and insufficient staffing across the region.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Wales Shared Services Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in Tissue Viability Nurse and wound care input

    Wider context from the report

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

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Wales Shared Services Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient Tissue Viability Nurse capacity to serve the regional hospitals

    Wider context from the report

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

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Wales Shared Services Partnership; that does not assign responsibility.

    PFD Monitor interpretation

    Specialist nurses not being based in the hospital for TVN and wound care input

    Wider context from the report

    “(1) Tissue Viability Nurse (TVN) input was requested at different times during the 7 month period whilst Mr. Jenkins was being nursed in YCR yet response was slow (as long as a week after a ward visit was requested). In fact the TVN did not assess the ulcer until 06.06.14 almost 2 months after its development and by which time the odour from the wound was described as ‘very offensive’. A bandage used was reported as the likely cause of a new ulcer forming - Datrix incident report 14.07.14. (2) The key concern is that of inadequate TVN and wound care input. The inadequate care in this instance was attributed to specialist nurses not being based in the hospital and of insufficient TVNs to serve the several hospitals in the region. The service being overstretched. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026