27 Feb 2026 SUMMER RAE MANT · Prevention of Future Deaths report South Wales Central
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Concerns raised 1 Lack of standardised crash trolleys across hospital settings View source
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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
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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Powys Teaching Local Health Board; 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 3 Failure to follow up and action a recommended podiatry referral View source Failure to follow Tissue Viability Nurse dressing recommendations View source Lack of nursing staff knowledge about podiatry referral rationale and possible interventions View source
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Edward John FUNNELL · Prevention of Future Deaths report
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Report summary
Edward John Funnell died on 29 April 2023 at Ystradgynlais Community Hospital after developing a worsening pressure ulcer and an ischaemic left leg during hospital care, for which he received palliative care. The principal concerns were that a podiatry referral was not followed up, nursing staff lacked knowledge about podiatric interventions for pressure wounds and circulatory problems, and recommended wound dressings were not followed.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Powys Teaching Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up and action a recommended podiatry referral
Wider context from the report “a. There was a lack of appreciation of the need for the deceased to see a podiatrist as recommended by a Tissue Viability Nurse . The referral was not followed up or actioned .
” 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 Powys Teaching Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to follow Tissue Viability Nurse dressing recommendations
Wider context from the report “c. There was an identifiable lack of knowledge on the importance of following the recommendations of the Tissue Viability Nurse in respect of the type of dressings to be administered and the importance of ensuring such steps were followed as opposed to using an alternative and, on the evidence, an inappropriate dressing .
” 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 Powys Teaching Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of nursing staff knowledge about podiatry referral rationale and possible interventions
Wider context from the report “b. There was an identifiable lack of knowledge on the part of the nursing staff to understand the reason for referral to a podiatrist and the possible interventions a podiatrist could undertake in respect of pressure wound damage, particularly in patients with circulatory problems .
” 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 Provide additional Tissue Viability Nurse training on assessment, escalation, dressing management, and access to appropriate dressings, with attendance monitored through quality meetings.
Verbatim wording from the response “• Tissue Viability Specialist Nurse (TVN) to provide additional training to ward teams regarding the use and access to dressings.” Source location Response from Powys Teaching Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide ward-based and ward-leader education on the podiatrist’s role, scope, and service provision.
Verbatim wording from the response “• Lead podiatrist to attend all wards to ensure the teams are aware of the scope and breadth of the role of the podiatrist.” Source location Response from Powys Teaching Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the podiatry referral pathway and escalation framework to ensure urgent referrals receive a response within five working days.
Verbatim wording from the response “• The referral pathway to podiatry is being updated to ensure that urgent referrals are responded to within 5 working days, if this is not possible an escalation framework is in place to provide additional support.” Source location Response from Powys Teaching Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and widely disseminate the Tissue Viability referral process requiring prompt podiatry referral for foot ulceration.
Verbatim wording from the response “• The Tissue Viability team have updated their referral process (Appendix A) this has been shared widely with clinical teams, which underlines the requirement for foot ulceration to be referred to Podiatry without delay. (Implemented September 2025)” Source location Response from Powys Teaching Health Board
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1 Jun 2022 Samuel Joseph Gomm · Prevention of Future Deaths report South Wales Central
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Concerns raised 2 Failure of the WARRN assessment tool to prompt consideration and recording of advocacy referrals and capacity assessments View source Failure of the WARRN documentation to clearly and accessibly record fluctuating self-harm risk and reassessments View source
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AI-generated summary
Samuel Joseph Gomm · 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
Samuel Joseph Gomm, who had chronic mental ill health exacerbated by periods of alcohol abuse, died after deliberately self-inflicting lacerations to his neck at home on 3 June 2019. The principal concerns related to the WARRN risk-assessment tool: its format, accessibility and presentation could make fluctuating self-harm risks difficult for new or infrequent users to identify, potentially resulting in under-estimation of risk and sub-optimal mitigating measures.
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× 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 Powys Teaching Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the WARRN assessment tool to prompt consideration and recording of advocacy referrals and capacity assessments
Wider context from the report “(2) The evidence I received indicated that the WARRN assessment documentation/tool could be routinely accessed, updated & revised by the Integrated Team. It was a fluid document for the purpose of recording information as to the current assessment of risk(s) of self-harm & how that risk(s) was to be mitigated. Whilst I received evidence that in practice, such risk assessments were being undertaken with Sam, the WARRN documentation did not necessarily reflect that, nor was it optimally viewable in terms of clearly recording fluctuating presentations & any accompanying re-assessment of risk.
(3) It appeared to me that the format/layout of the WARRN tool, its accessibility, & in particular, its ability to provide a user with clear & easily viewable information as to how Sam’s risk of self-harm had fluctuated/altered/changed in the months preceding his death, could lead to important information/assessments being lost to a new/infrequent user. This, for example, might be a new care co-ordinator (as in Sam’s case), Crisis Team/Community Nurse, or clinician not previously involved with Sam.
(4) Given the variety of services involved in Sam’s care, this central document, addressing & recording fluctuating risk appeared to me to be a crucial document in the recording of current risk (eg emphasis). The ability of those charged with Sam’s care to view those fluctuations might be hampered by the current presentation of/access to such information. That could lead to an under-estimation of the current risk & sub-optimal mitigating measures being put in place.
(5) The WARRN assessment tool might also benefit from a greater degree of interaction between it & the user. For example, it was clear, on the evidence that Social Worker’s, Mental Health Nurses & Clinicians were all busy addressing the needs (& assessing risk) of a wide number & variety of patients. Prompting (my emphasis) the user to consider & record referrals for, for example, to advocacy services & for capacity assessments might optimise the benefits of the tool & reduce the risk of such opportunities being missed/un-recorded . Such then leading to the potential absence of key information for new/infrequent users when assessing risks of self-harm
” 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 Powys Teaching Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the WARRN documentation to clearly and accessibly record fluctuating self-harm risk and reassessments
Wider context from the report “(2) The evidence I received indicated that the WARRN assessment documentation/tool could be routinely accessed, updated & revised by the Integrated Team. It was a fluid document for the purpose of recording information as to the current assessment of risk(s) of self-harm & how that risk(s) was to be mitigated. Whilst I received evidence that in practice, such risk assessments were being undertaken with Sam, the WARRN documentation did not necessarily reflect that , nor was it optimally viewable in terms of clearly recording fluctuating presentations & any accompanying re-assessment of risk .
(3) It appeared to me that the format/layout of the WARRN tool, its accessibility, & in particular, its ability to provide a user with clear & easily viewable information as to how Sam’s risk of self-harm had fluctuated/altered/changed in the months preceding his death, could lead to important information/assessments being lost to a new/infrequent user . This, for example, might be a new care co-ordinator (as in Sam’s case), Crisis Team/Community Nurse, or clinician not previously involved with Sam.
(4) Given the variety of services involved in Sam’s care, this central document, addressing & recording fluctuating risk appeared to me to be a crucial document in the recording of current risk (eg emphasis). The ability of those charged with Sam’s care to view those fluctuations might be hampered by the current presentation of/access to such information. That could lead to an under-estimation of the current risk & sub-optimal mitigating measures being put in place.
(5) The WARRN assessment tool might also benefit from a greater degree of interaction between it & the user. For example, it was clear, on the evidence that Social Worker’s, Mental Health Nurses & Clinicians were all busy addressing the needs (& assessing risk) of a wide number & variety of patients. Prompting (my emphasis) the user to consider & record referrals for, for example, to advocacy services & for capacity assessments might optimise the benefits of the tool & reduce the risk of such opportunities being missed/un-recorded. Such then leading to the potential absence of key information for new/infrequent users when assessing risks of self-harm
” 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 Continue six-monthly Welsh Applied Risk Research Network record audits by Powys Teaching Health Board.
Verbatim wording from the response “22. In October 2021 and April 2022 Powys Teaching Health Board undertook an internal audit of Welsh Applied Risk Research Network documentation. Compliance with reviews and the quality of content was rated as good. Powys Teaching Health Board will continue to audit Service User records on a 6 monthly basis.” Source location Response from Powys County Council and Powys Teaching Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinstate advocacy clinics in community mental-health teams and inpatient units.
Verbatim wording from the response “36. The offer of advocacy is a legal requirement of both the Mental Health Measure (2010) and the Social Services Well Being Act, 2014. This is reflected in Care and Treatment Programme documentation, where staff are directed to offer advocacy and to confirm whether it is required. This is reported on through Powys County Council Business Insight programme and in Powys County Council audits. Advocacy clinics have been reinstated in CMHT’s and inpatient units following Covid19. These are advertised in patient access areas and can be booked directly with the advocate if preferred.” Source location Response from Powys County Council and Powys Teaching Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update WCCIS to record risk chronologies and significant self-harm events, supporting dynamic reassessment.
Verbatim wording from the response “16. This would include but is not limited to events such as, relationship breakdown, loss of care, increase in substance use, increase in contact with services, particularly out of hours. All significant self-harming events should be recorded on the document, this includes disclosure of thoughts of self harm. To support this WCCIS will be updated to include a Chronology of events to enable workers to keep a succinct and easily accessible record. This will allow staff to easily identify if there has been a recordable event, creating a clear timeline of presenting risks. This will alert practitioners to any changes or patterns of behaviour and enable better dynamic risk assessing.” Source location Response from Powys County Council and Powys Teaching Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve inpatient staff WCCIS access and training so staff can complete risk documentation without duplicate Word templates.
Verbatim wording from the response “2. As Powys Teaching Health Board inpatient staff are currently only able to read information stored on the Welsh Community Care Information System for case recordings, they have relied on a Welsh Applied Risk Research Network Word Document. This is then uploaded and attached to Welsh Community Care Information System by admin staff. It is accepted that this has led to a duplication of work and the risk of important information being lost. Having identified this, Powys Teaching Health Board are updating training and access arrangements for inpatient staff required to complete the Welsh Applied Risk Research Network document. This will ensure that all Welsh Applied Risk Research Network document will be recorded on the Welsh Community Care Information System and there will no longer be a need to use the Word Document template.” Source location Response from Powys County Council and Powys Teaching Health Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Welsh Applied Risk Research Network form cannot be altered because it must remain in its original evidence-based form.
Verbatim wording from the response “27. Work is currently in progress to ensure that the correct Welsh Applied Risk Research Network is available on the WCCIS system by the end of July 2022. This will enable all Community Staff to have access to the copyrighted version, stored in an easily accessible part of the database. This can be accessed by both Powys Teaching Health Board and Powys County Council. To enable the Welsh Applied Risk Research Network to maintain its evidence base it needs to remain in its original state and cannot be altered to provide additional prompts or data collection. The accompanying CTP documentation focuses on areas not directly included in Welsh Applied Risk Research Network. For example, capacity is” Source location Response from Powys County Council and Powys Teaching Health Board
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10 Jun 2019 Glenys Button · Prevention of Future Deaths report South Wales Central
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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.
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Powys Teaching Local Health Board; 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 Powys Teaching Local Health Board; 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
11 May 2016 Gillian Rose Taylor · Prevention of Future Deaths report South Wales Central
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Concerns raised 4 Increased risk of self-harm or suicide following adverse experiences of sectioning View source Lack of continuity of treatment View source Lack of an acute treatment facility for acute admission patients in Powys View source Lack of an acute treatment facility for acutely unwell patients in Powys View source See 1 more concern
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Gillian Rose Taylor · 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
Gillian Rose Taylor had a lengthy history of mental health issues and repeated suicide attempts. After being detained under the Mental Health Act and treated away from Powys because no acute bed was available locally, she remained under community mental health care until her death by hanging at home on 3 January 2016. The concerns included the lack of an acute treatment facility in Powys, resulting patient transfers, lack of continuity of treatment, and the possible adverse effect of this experience on her engagement with mental health professionals and risk of self-harm or suicide.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Powys Teaching Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Increased risk of self-harm or suicide following adverse experiences of sectioning
Wider context from the report “(3) The evidence showed that, on balance, it is likely that the experience of being sectioned in these circumstances had an adverse effect upon Mrs Taylor which fuelled an unwillingness, on her part, to engage with Mental Health professionals thereby increasing her risk of self harm/suicide .
” 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 Powys Teaching Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity of treatment
Wider context from the report “(2) As a consequence of 1 above there is often a lack of continuity of treatment which can be to the detriment of the patient concerned.
” 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 Powys Teaching Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of an acute treatment facility for acute admission patients in Powys
Wider context from the report “(4) It is believed that Powys Health Board is the only Health Board in the country that has no facility available to it for the treatment of acute admission patients in the position of Mrs Taylor.
” 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 Powys Teaching Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of an acute treatment facility for acutely unwell patients in Powys
Wider context from the report “(1) There is no acute facility in Powys for the treatment of acutely unwell patients , which the evidence showed, often leads to patients being moved the length and breadth of the country to an establishment where a bed can be found. The evidence also showed that the local acute unit at the Redwoord Centre in Shrewsbury had recently experienced a significant reduction in the number of acute beds available compounding and exacerbating the problem.
” 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 Explore every available in-county treatment option before arranging out-of-county admission.
Verbatim wording from the response “We acknowledge that when a North Powys patient is admitted out of area this can be disruptive for both patient and their family, and prior to admission out of county we seek to explore every in county treatment option first. We continue to commission inpatient provision in the Redwoods centre, however across the UK access to specialist beds is limited and unfortunately we share the same challenges in securing in patient beds close to home as many of our neighbouring Health Boards.” Source location 2016-0178-Response-by-Powys-Teaching-Health-Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue repatriating adult mental health services to direct delivery by Powys Teaching Health Board.
Verbatim wording from the response “In summary, having considered the matters you have raised, we have taken action as described below to put in place robust, high quality, safe services for our Powys population. As you will read, these actions are continuing reflecting the current work within Powys Teaching Local Health Board to repatriate adult mental health services.” Source location 2016-0178-Response-by-Powys-Teaching-Health-Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a fully functioning Crisis Resolution Home Treatment Team providing acute hospital-level care at home.
Verbatim wording from the response “A series of steps was taken. This involved establishing a fully functioning CRHTT which reduced the need for admissions out of county. Weekly discussions were put in place between Redwoods and local services to help get patients admitted to Redwoods when needed. Additional funding was allocated to the local service in Montgomeryshire, including for additional care co-ordination to help address out of county admissions. This was monitored on a weekly basis. The graphs attached at Appendix 1 (enclosed) show that the difficulties with admission significantly reduced for a sustained period. As the second graph indicates, acute admissions had been falling during October 2015 although they started to rise during November.” Source location 2016-0178-Response-by-Powys-Teaching-Health-Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Allocate additional funding for Montgomeryshire services, including additional care coordination to address out-of-county admissions.
Verbatim wording from the response “A series of steps was taken. This involved establishing a fully functioning CRHTT which reduced the need for admissions out of county. Weekly discussions were put in place between Redwoods and local services to help get patients admitted to Redwoods when needed. Additional funding was allocated to the local service in Montgomeryshire, including for additional care co-ordination to help address out of county admissions. This was monitored on a weekly basis. The graphs attached at Appendix 1 (enclosed) show that the difficulties with admission significantly reduced for a sustained period. As the second graph indicates, acute admissions had been falling during October 2015 although they started to rise during November.” Source location 2016-0178-Response-by-Powys-Teaching-Health-Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A hospital admission does not require changing the patient's statutory care coordinator under the applicable mental health care arrangements.
Verbatim wording from the response “As explained above additional funding was provided to strengthen care co-ordination. A Crisis Resolution Home Treatment Team was also implemented providing acute hospital level care at home with which Mrs Taylor engaged. Mrs Taylor would have had a statutory care co-ordinator and care and treatment plan under the Mental Health (Wales) Measure 2010. As set out in Paragraph 3.19 of the Code of Practice to Parts 2 and 3 of the Mental Health (Wales) Measure 2010 it is not necessary to change the care co-ordinator when a patient is admitted to hospital.” Source location 2016-0178-Response-by-Powys-Teaching-Health-Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Acute adult mental health provision already exists within Powys, contrary to the concern that no acute facility is available.
Verbatim wording from the response “It is important to clarify that there is acute adult mental health provision within Powys in addition to the services we commission from other providers close to our borders.” Source location 2016-0178-Response-by-Powys-Teaching-Health-Board
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations