Recipient

Recipient name withheld

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First report 7 Aug 2018•Latest report 7 Aug 2018

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Recipient name withheld 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 Recipient name withheld; 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 Recipient name withheld; 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 Recipient name withheld; 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 Recipient name withheld; 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
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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