Recipient

Senedd Cymru

First report 4 Mar 2015•Latest report 18 Feb 2025

Recipient record

Reports, concerns and published responses

Other public bodies · Devolved legislature. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 9
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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 Senedd Cymru linked to the concerns in each report. Select any concern, action or position to view the source wording.

18 Feb2025
Gwent
Concerns raised2
1. Failure to revise ambulance priority when a patient is deteriorating and in extremis
2. Inability of a patient who is alone to inform the ambulance service of deterioration
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

Jeffrey Martin Tyler · 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

Jeffrey Martin Tyler called emergency services with chest pains and difficulty breathing, but his condition deteriorated while he was alone at home. An ambulance arrived several hours later, and his death was confirmed by paramedics on 20 February 2024. The substantive concern was that, despite his deterioration and being alone and in extremis, the emergency call remained categorised as Amber 1, with a reported waiting time of between 5 and 7 hours.

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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Failure to revise ambulance priority when a patient is deteriorating and in extremis
Wider context from the report
“In evidence I found that the call handlers had been following the correct algorithm as dictated by the nationally adopted Medical Priority Dispatch System (MPDS), and that he was appropriately categorised as requiring an Amber 1 ambulance. However, it would also have been clear to any clinician that he was deteriorating and was in the process of having a cardiac event. Mr Tyler was on his own and could not inform the ambulance service if his condition deteriorated. Despite Mr Tyler being alone and being in extremis, the MPDS Code was maintained at Amber 1. The waiting time was between 5 and 7 hours. ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Inability of a patient who is alone to inform the ambulance service of deterioration
Wider context from the report
“In evidence I found that the call handlers had been following the correct algorithm as dictated by the nationally adopted Medical Priority Dispatch System (MPDS), and that he was appropriately categorised as requiring an Amber 1 ambulance. However, it would also have been clear to any clinician that he was deteriorating and was in the process of having a cardiac event. Mr Tyler was on his own and could not inform the ambulance service if his condition deteriorated. Despite Mr Tyler being alone and being in extremis, the MPDS Code was maintained at Amber 1. The waiting time was between 5 and 7 hours. ”
Open source report
17 May2017
North Wales (East and Central)
Concerns raised4
1. Delays in emergency department patient handover
2. Failure to maintain adequate emergency department staffing
3. Insufficient hospital bed capacity for admissions
1. Failure of hospital patient flow and delayed transfer of care processes
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

Lilly Baxandall · 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

Lilly Baxandall was found collapsed at home after an unwitnessed fall and was taken to hospital by ambulance. Her ambulance handover was delayed for almost four hours amid capacity issues, and a CT scan later showed a large acute subdural haematoma that could not be treated; she died on 5 September 2014. The report raised concerns about continuing ambulance and handover delays, bed shortages, patient flow and delayed transfers of care, placing patients’ lives at risk.

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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Delays in emergency department patient handover
Wider context from the report
“Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls". In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays. In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients". In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care. In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome. In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”. In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment” Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result. It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable. ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain adequate emergency department staffing
Wider context from the report
“Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls". In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays. In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients". In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care. In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome. In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”. In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment” Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result. It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable. ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Insufficient hospital bed capacity for admissions
Wider context from the report
“Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls". In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays. In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients". In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care. In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome. In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”. In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment” Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result. It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable. ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Failure of hospital patient flow and delayed transfer of care processes
Wider context from the report
“Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls". In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays. In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients". In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care. In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome. In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”. In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment” Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result. It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable. ”
Open source report
11 Sep2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised3
1. Unmonitored over-anticoagulation following omitted delegated INR testing
2. Non-uniform implementation of monitoring practices for delegated INR testing
3. Risk of unmonitored or unactioned failure to complete delegated INR testing
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

Mr Ronald Francis Bonfield · 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 Ronald Francis Bonfield sustained a head injury at home on 29 September 2014, was admitted to Prince Charles Hospital on 1 October, and died there on 2 October 2014. The inquest recorded that he was taking Warfarin, was over-anticoagulated, and that his INR levels were not being monitored as required. The substantive concerns related to inconsistent procedures for monitoring delegated INR testing and the risk of unmonitored over-anticoagulation.

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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Unmonitored over-anticoagulation following omitted delegated INR testing
Wider context from the report
“(3) Until such action is taken there remains a risk that a future death(s) could occur in similar circumstances to Mr Bonfield’s, where delegated INR testing has not been done leading to unmonitored over anti-coagulation ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Non-uniform implementation of monitoring practices for delegated INR testing
Wider context from the report
“(1) The practices and procedures implemented by the Practice 1, Keir Hardie Health Park, GP Surgery following Mr Bonfield’s death (with regard to monitoring the compliance of the Health Boards District Nurse Teams following delegation to undertake a patient’s INR testing) is not uniform and/or implemented across all of the Health Boards Level 4 Accredited GP practices. ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Risk of unmonitored or unactioned failure to complete delegated INR testing
Wider context from the report
“(2) The practices and procedures implemented by Practice 1, Keir Hardie Health Park Surgery act as a check and balance to reduce the risk of an unmonitored/unactioned failure on the part of the District Nurse service to undertake the task(testing the patients INR level) delegated to them by the GP practice concerned. ”
Open source report
4 Sep2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised4
1. Inadequate monitoring of INR levels
2. Inadequate communication about anticoagulation monitoring and potential therapy adjustment
3. Lack of certainty whether Warfarin was being taken
1. Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment
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

Mrs. Mary Patricia 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

Mrs. Mary Patricia James had a prosthetic heart valve requiring anticoagulation, but INR monitoring was inadequate and there was uncertainty about whether she was taking Warfarin. Concerns included failures in communication between the INR Unit, care home and GP, and that she was not admitted to hospital on 15 May 2015 despite concern about a possible ischaemic leg. The inquest concluded: “Ischaemic leg contributed to by inadequate Warfarin monitoring and dosing”.

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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Inadequate monitoring of INR levels
Wider context from the report
“(1) Inadequate monitoring of INR levels in a patient suffering from dementia; ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Inadequate communication about anticoagulation monitoring and potential therapy adjustment
Wider context from the report
“(3) Inadequate communication between the INR Unit, the Care Home and the GP regarding this patient’s anticoagulation monitoring and the potential need for therapy adjustment; ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Lack of certainty whether Warfarin was being taken
Wider context from the report
“(2) Lack of certainty whether Warfarin was being taken by the patient; ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment
Wider context from the report
“(4) That against this background and the Care Home’s concern about a possible ischaemic leg, Mrs. James was not admitted to hospital on the 15th May, 2015 when there may have been a window of opportunity to have adjusted the anticoagulation therapy. ”
Open source report
27 Jul2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised4
1. Insufficient staffing of Tissue Viability Nurses
2. Failure to maintain adequate repositioning charts
3. Failure to maintain adequate pressure ulcer documentation
1. Lack of integrated skin care across Health Boards and Primary healthcare services
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

Mr. Arthur Cook · 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. Arthur Cook had poor circulation and a chronic open wound that developed into an MRSA-infected category 4 pressure ulcer while he was resident at Four Seasons Healthcare Residential Home. He failed to respond to treatment and died. Concerns included insufficient tissue viability nursing capacity, inadequate pressure-ulcer documentation and repositioning charts, and a lack of integrated skin care across services.

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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staffing of Tissue Viability Nurses
Wider context from the report
“(1) Staffing levels of Tissue Viability Nurses within the Aneurin Bevan Health Board are low and to the extent that at times this service cannot be provided according to need; ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain adequate repositioning charts
Wider context from the report
“(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal. ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain adequate pressure ulcer documentation
Wider context from the report
“(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal. ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Lack of integrated skin care across Health Boards and Primary healthcare services
Wider context from the report
“(3) An apparent lack of integrated skin care within and between Health Boards and Primary healthcare services. ”
Open source report
9 Jul2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised4
1. Failure to advise the pharmacy of Warfarin withdrawal due to lack of INR safety testing
2. Failure to develop and maintain an anti-coagulation treatment register
3. Failure to use computer software to support prescription decisions
1. Failure to implement notification of failed attendance for INR testing
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

Mr. Alun Walters · 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. Alun Walters, who was prescribed Warfarin following receipt of a metallic heart valve, died after a gastro-intestinal haemorrhage in circumstances of suspected elevated Warfarin levels and failed INR monitoring. His prescriptions continued despite no INR tests after November 2013, and 51 prescriptions were provided without dosage assessment. Concerns included failures by the medical practice in monitoring, prescription systems and notifying the pharmacy that Warfarin had been withdrawn, while the pharmacy supplied Warfarin without a valid prescription.

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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Failure to advise the pharmacy of Warfarin withdrawal due to lack of INR safety testing
Wider context from the report
“The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Failure to develop and maintain an anti-coagulation treatment register
Wider context from the report
“The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Failure to use computer software to support prescription decisions
Wider context from the report
“The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Failure to implement notification of failed attendance for INR testing
Wider context from the report
“The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
Open source report
2 Jul2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Failure to ensure surgeons acknowledge having read applicable clinical guidelines
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

Mrs. Gail Prentice · 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

Mrs. Gail Prentice, aged 46, died after severe bleeding during an attempted percutaneous tracheostomy, caused by transection of the brachiocephalic artery. The report describes concerns about tracheostomy in altered neck anatomy following previous surgery, including the need for appropriate imaging and site selection, and about surgeons acknowledging relevant hospital and other guidelines.

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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure surgeons acknowledge having read applicable clinical guidelines
Wider context from the report
“(1) The requirement for surgeons to acknowledge having read the Health Board’s Hospital Guidelines and those of other bodies e.g. NICE Guidelines ”
Open source report
24 Apr2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised2
1. Unreliable booking system for community INR testing
2. Unreliable notification system for omissions by family or carers
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

Mrs. Hilda May Harris · 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

Mrs. Hilda May Harris, aged 86, suffered a cerebral infarction with an intracerebral haemorrhage on 04.01.15 after an additional INR test was not undertaken while she was taking Warfarin alongside medication for gout. The report identified unreliable systems for booking community INR tests and for notifying or acting on omissions.

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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Unreliable booking system for community INR testing
Wider context from the report
“(1) The current booking system for community INR testing is unreliable with scope for appointments not being transferred from one set of papers to another. (2) Where an omission occurs, the notification system (by the family or carers) also appears unreliable. ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Unreliable notification system for omissions by family or carers
Wider context from the report
“(1) The current booking system for community INR testing is unreliable with scope for appointments not being transferred from one set of papers to another. (2) Where an omission occurs, the notification system (by the family or carers) also appears unreliable. ”
Open source report
4 Mar2015
Powys, Bridgend & Glamorgan Valleys
Concerns raised2
1. Failure of paper records to accurately document Consultant patient review
2. Unavailability of Community medical records at hospital admission
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

Mr. Brian Francis · 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. Brian Francis was admitted to Princess of Wales Hospital on 5 September 2014 after several days of illness and was treated for presumed chest sepsis. He died of a pulmonary embolism the following day. Concerns included a failed process for recording Consultant attendance and the unavailability of Community medical records, which may have affected assessment and the commencement of anti-coagulation therapy.

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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Failure of paper records to accurately document Consultant patient review
Wider context from the report
“(1) The process of a Consultant’s attendance on patient being noted by a ‘tick in the box’ on a paper record failed. The box had been ticked when in fact the patient had not been reviewed by the Consultant. ”
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 Senedd Cymru; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of Community medical records at hospital admission
Wider context from the report
“(2) Had the Community medical records been available at the time of hospital admission the patient would most probably have been assessed differently and in all probability, anti-coagulation therapy commenced immediately or shortly thereafter. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised2

Failure to revise ambulance priority when a patient is deteriorating and in extremis

Inability of a patient who is alone to inform the ambulance service of deterioration

Concerns raised4

Delays in emergency department patient handover

Failure to maintain adequate emergency department staffing

Insufficient hospital bed capacity for admissions

Failure of hospital patient flow and delayed transfer of care processes

Concerns raised3

Unmonitored over-anticoagulation following omitted delegated INR testing

Non-uniform implementation of monitoring practices for delegated INR testing

Risk of unmonitored or unactioned failure to complete delegated INR testing

Concerns raised4

Inadequate monitoring of INR levels

Inadequate communication about anticoagulation monitoring and potential therapy adjustment

Lack of certainty whether Warfarin was being taken

Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment

Concerns raised4

Insufficient staffing of Tissue Viability Nurses

Failure to maintain adequate repositioning charts

Failure to maintain adequate pressure ulcer documentation

Lack of integrated skin care across Health Boards and Primary healthcare services

Concerns raised4

Failure to advise the pharmacy of Warfarin withdrawal due to lack of INR safety testing

Failure to develop and maintain an anti-coagulation treatment register

Failure to use computer software to support prescription decisions

Failure to implement notification of failed attendance for INR testing

Concerns raised1

Failure to ensure surgeons acknowledge having read applicable clinical guidelines

Concerns raised2

Unreliable booking system for community INR testing

Unreliable notification system for omissions by family or carers

Concerns raised2

Failure of paper records to accurately document Consultant patient review

Unavailability of Community medical records at hospital admission