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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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 Swansea Bay University 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 2 Delays in undertaking staging scans View source Delays in the diagnostic, staging and treatment phases of the Suspected Cancer Pathway View source
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Gareth Wynne Tatchell · Prevention of Future Deaths report
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Report summary
Gareth Wynne Tatchell died in hospital on 9 April 2024 from pneumonia, with squamous cell carcinoma contributing to his death. The report identified delays in diagnostic and staging scans and in providing treatment, with the inquest concluding that the delay more than minimally contributed to his death. It also raised concern that ongoing delays in staging scans were affecting survivability and prognoses by making treatable cancers irreversible.
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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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Delays in undertaking staging scans
Wider context from the report “2. Part of the delays resolve around the time taken to undertake staging scans for the purpose of the diagnostic and staging phase.
3. Two Associate Medical Directors have communicated that delays in undertaking staging scans are ongoing and are having an impact on survivability rates and prognoses by making treatable cancers irreversible.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Delays in the diagnostic, staging and treatment phases of the Suspected Cancer Pathway
Wider context from the report “1. There was a delay in both the diagnostic and staging phase and treatment phase contrary to the timescales in the Suspected Cancer Pathway.
” Open source report
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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 specialty action plans addressing cancer pathway non-compliance.
Verbatim wording from the response “• Action plans for each specialty are in place targeted at addressing areas of non-compliance.” Source location Response from Bwrdd Lechyd Prifsgol Bae Abertawe
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PFD Monitor interpretation Provide additional histopathology support to improve turnaround times.
Verbatim wording from the response “• Additional support has been provided to histopathology to facilitate improvement in the turnaround times, but this is still an area of considerable challenge for the Health Board.” Source location Response from Bwrdd Lechyd Prifsgol Bae Abertawe
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor individual cancer patients through weekly or fortnightly specialty review meetings.
Verbatim wording from the response “• Monitoring at an individual patient level is in place with weekly or fortnightly review meetings depending on the specialty.” Source location Response from Bwrdd Lechyd Prifsgol Bae Abertawe
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Escalate unbooked staging scans after five days through direct contact with referring radiology or tracking teams.
Verbatim wording from the response “Although we do not directly manage elements of the pathway that occur outside SBUHB, we have oversight and liaise closely with the parent Health Board to expedite tests if needed. For example, if a scan has not been booked by Day 5 after a diagnostic referral has been made, the cancer tracking team in SBUHB will reach out either directly to the radiology department of the referring Health Board or contact the local tracking team to escalate on behalf of the patient.” Source location Response from Bwrdd Lechyd Prifsgol Bae Abertawe
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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 Track cancer patients across the pathway, including referrals to regional specialist services.
Verbatim wording from the response “We have processes in place that enable us to track all cancer patients’ progress through the pathway. This includes patients who have been referred to regional specialist services in SBUHB from other Health Boards. While we act as the centre for delivery of the specialist care for these patients, diagnostic testing and staging are conducted within their ‘home’ Health Board, as was the case with Mr. Tatchell, who was a resident of Cwm Taf Morgannwg University Health Board (CTMUHB).” Source location Response from Bwrdd Lechyd Prifsgol Bae Abertawe
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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 Review head and neck cancer pathway performance against key indicators.
Verbatim wording from the response “Recent review of the head & neck single cancer pathway, for patient seen between May 2034 and May 2025 (sample n=50) has confirmed positive compliance against key indicators:” Source location Response from Bwrdd Lechyd Prifsgol Bae Abertawe
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PFD Monitor interpretation Continue advertising and re-advertising to recruit specialist head and neck radiology staff.
Verbatim wording from the response “Radiology provision to the Head and Neck service is not as robust as the Health Board would like it to be. We have several highly committed clinicians who deliver this specialist service as part of their roles, including three at consultant level and one at Specialty (SAS) Doctor level. We have worked hard to recruit additional staff and there is a continuous process of advertising and re-advertising in place to actively seek suitable applicants. Locum cover was in place until May 2025. We advertised for a replacement, anticipating the locum’s departure, and interviewed two candidates - but were not able to appoint.” Source location Response from Bwrdd Lechyd Prifsgol Bae Abertawe
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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 12-month locum radiology cover for the head and neck service from October 2025.
Verbatim wording from the response “Another round of advertisement has been completed, and we have now secured locum cover for 12 months commencing in October 2025. You can be assured that we are making every effort to recruit in a timely way, recognising that there is a challenge across the UK of recruiting into these highly specialised posts.” Source location Response from Bwrdd Lechyd Prifsgol Bae Abertawe
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Track cancer pathway compliance against stage-specific targets and report performance monthly by specialty.
Verbatim wording from the response “• There are explicit targets for each stage of the cancer pathway: first appointment (10 working days) and Decision to Treat (DTT) by Day 31, DTT to First Definitive Treatment in 32 days. This information is collected for each specialty and reported monthly.” Source location Response from Bwrdd Lechyd Prifsgol Bae Abertawe
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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 Diagnostic testing and staging for patients from other Health Boards are delivered by their home Health Board, not Swansea Bay University Health Board.
Verbatim wording from the response “We have processes in place that enable us to track all cancer patients’ progress through the pathway. This includes patients who have been referred to regional specialist services in SBUHB from other Health Boards. While we act as the centre for delivery of the specialist care for these patients, diagnostic testing and staging are conducted within their ‘home’ Health Board, as was the case with Mr. Tatchell, who was a resident of Cwm Taf Morgannwg University Health Board (CTMUHB).” Source location Response from Bwrdd Lechyd Prifsgol Bae Abertawe
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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 Swansea Bay University Health Board does not directly manage diagnostic and staging pathway elements occurring outside its area.
Verbatim wording from the response “Although we do not directly manage elements of the pathway that occur outside SBUHB, we have oversight and liaise closely with the parent Health Board to expedite tests if needed. For example, if a scan has not been booked by Day 5 after a diagnostic referral has been made, the cancer tracking team in SBUHB will reach out either directly to the radiology department of the referring Health Board or contact the local tracking team to escalate on behalf of the patient.” Source location Response from Bwrdd Lechyd Prifsgol Bae Abertawe
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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 National shortages and recruitment difficulties constrain the Health Board’s ability to provide robust specialist head and neck radiology services.
Verbatim wording from the response “Radiology is a national shortage specialty that can be a challenge for recruitment, this is further compounded when recruiting sub-speciality interest.” Source location Response from Bwrdd Lechyd Prifsgol Bae Abertawe
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Concerns raised 2 Failure to involve community care co-ordinators and professionals in multidisciplinary discharge decisions View source Failure to identify and learn critical lessons from the death View source
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AI-generated summary
Jean Pike · 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
Jean Pike, who had suicidal thoughts and intended to hang herself, was left unattended for between 20 and 45 minutes in her supported living accommodation and was then found suspended and declared deceased on 18 May 2022. The concerns included hospital discharge decisions made without multidisciplinary consultation with community professionals, inadequate consideration of risks, and an inadequate safety plan before Jean was left unattended.
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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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to involve community care co-ordinators and professionals in multidisciplinary discharge decisions
Wider context from the report “I am concerned that Jean was discharged from Ward F of Neath Port Talbot Hospital on two occasions shortly before her death by a consultant psychiatrist and that prior to the decision to discharge on both occasions there was no multi-disciplinary meeting between the consultant on Ward F and the professionals directly involved in caring for Jean in the community about Jean’s mental health and the risks she posed to herself in the community . This was in circumstances where the consultant knew before the decisions to discharge that these professionals, which included Jean’s care co-ordinator, were clearly stating that they were extremely concerned about Jean’s mental health and that they did not consider that they could keep Jean safe in the community and that they thought that Jean would hang herself in the community – which is in fact what happened in this case. I am particularly concerned by the evidence I heard from Jean’s care co-ordinator that care co-ordinators are rarely if ever consulted by consultant psychiatrists in Ward F of Neath Port Talbot Hospital before a decision is made to discharge a patient/person under secondary mental health care . This issue was not identified by Swansea Bay University Health Board (“SUBHB”) in their internal investigation into Jean’s death. This investigation found that “there is evidence of regular and effective communication between support staff, community staff and hospital staff”.
The above finding of SUBHB’s internal investigation raises a concern that critical lessons have not being identified and learnt by SUBHB from Jean’s death about the importance of multi-disciplinary decision making in clinical care and risk management and the importance of including care co-ordinators and professionals in the community before a decision is taken to discharge a patient from Ward F . This creates a continuing risk to life as it may lead to risk being ignored or not properly considered by Ward F. I am also concerned that if there is a lack of clarity or a reluctance in Ward F at the consultant level to engage with care co-ordinators and professionals in the community (and before decisions are made to discharge) there is a risk that the concerns of the professionals managing a patient/person under secondary care will not be adequately considered in the decisions made by Ward F clinicians . This also creates a continuing risk to life as it may lead to risk being ignored or not properly considered by Ward F.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and learn critical lessons from the death
Wider context from the report “I am concerned that Jean was discharged from Ward F of Neath Port Talbot Hospital on two occasions shortly before her death by a consultant psychiatrist and that prior to the decision to discharge on both occasions there was no multi-disciplinary meeting between the consultant on Ward F and the professionals directly involved in caring for Jean in the community about Jean’s mental health and the risks she posed to herself in the community. This was in circumstances where the consultant knew before the decisions to discharge that these professionals, which included Jean’s care co-ordinator, were clearly stating that they were extremely concerned about Jean’s mental health and that they did not consider that they could keep Jean safe in the community and that they thought that Jean would hang herself in the community – which is in fact what happened in this case. I am particularly concerned by the evidence I heard from Jean’s care co-ordinator that care co-ordinators are rarely if ever consulted by consultant psychiatrists in Ward F of Neath Port Talbot Hospital before a decision is made to discharge a patient/person under secondary mental health care. This issue was not identified by Swansea Bay University Health Board (“SUBHB”) in their internal investigation into Jean’s death. This investigation found that “there is evidence of regular and effective communication between support staff, community staff and hospital staff”.
The above finding of SUBHB’s internal investigation raises a concern that critical lessons have not being identified and learnt by SUBHB from Jean’s death about the importance of multi-disciplinary decision making in clinical care and risk management and the importance of including care co-ordinators and professionals in the community before a decision is taken to discharge a patient from Ward F . This creates a continuing risk to life as it may lead to risk being ignored or not properly considered by Ward F. I am also concerned that if there is a lack of clarity or a reluctance in Ward F at the consultant level to engage with care co-ordinators and professionals in the community (and before decisions are made to discharge) there is a risk that the concerns of the professionals managing a patient/person under secondary care will not be adequately considered in the decisions made by Ward F clinicians. This also creates a continuing risk to life as it may lead to risk being ignored or not properly considered by Ward F.
” 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 Embed recommendations from the commissioned review of Serious Incident Group functions and processes.
Verbatim wording from the response “In relation to the Serious Incident Review Process, the MH&LD team is continually working towards improving this and in August 2024 a review was commissioned by the MH&LD Nurse Director, requesting that Professor Jason Davies: (RDIAL Hub Director and Consultant Forensic and Clinical Psychologist).” Source location Response from Swansea Bay University 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 Use a revised pre-discharge checklist requiring communication and collaboration with care coordinators, families, carers and relevant agencies, with weekly clinical-record audits.
Verbatim wording from the response “There are going to be times where patients are appropriate for discharge in circumstances outside of the above meetings; such as a short admission, in this situation and for planned discharged, the utilisation of a discharge checklist ensures that there is effective communication and collaboration with all parties. The purpose of the Pre-discharge checklist is to provide an overview of the necessary actions required in preparation for a patient discharge. The checklist includes the required stakeholders who need to attend, such as family/carer or advocacy, care coordinator, care providers and any other agencies involved. Other aspects of the checklist include social circumstances, occupational therapy needs, safeguarding, follow up from the Crisis resolution and home treatment team, and take-home medication requirements.” Source location Response from Swansea Bay University Health Board
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement regular investigator-team meetings to reflect on review methods, identify learning themes and consider report feedback.
Verbatim wording from the response “As with the change in process for strategy meetings, the Service Group are in a transition period regards the investigation methodology and will be monitoring and reviewing the process. To support this the team are implementing regular team meetings to reflect on the review process, identify themes in the learning and reflect on feedback on the reports.” Source location Response from Swansea Bay University 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 Train Serious Incident Investigators in effective review techniques and cascade process-mapping training to the mental health investigation team.
Verbatim wording from the response “In line with the above review, further training has been provided to the Serious Incident Investigators within MH&LD Service Group. The Health Board Serious Incident Investigators received training from Consequence UK, an organisation which provides training on techniques and processes to increase the effectiveness of Serious Incident reviews. Following this, training on process mapping in particular, was cascaded to the MH&LD Serious Incident investigator team (October 2024) in line with this. This way of reviewing, aids the investigator to break down policy and procedures into step-by-step guidance, which in turn can be used by the investigator to map and measure the care provided. This allows the incident investigators to make more accurate analysis of the clinical input against the specified clinical processes and guidance.” Source location Response from Swansea Bay University 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 Cascade the discharge-planning correspondence through ward, team-manager and consultant forums.
Verbatim wording from the response “This formal correspondence will also be cascaded through the relevant forums throughout May 2025, such as Ward/Team manager meetings and consultant forums.” Source location Response from Swansea Bay University 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 Hold weekly discharge planning meetings attended by inpatient and community team representatives to discuss and prioritise discharge plans.
Verbatim wording from the response “Within the adult Mental Health services, a weekly discharge planning meeting is held, where all inpatients progress and discharge plans are discussed and prioritised. Attendees at this meeting are representatives from each of the inpatient and community teams. The purpose of this meeting is for information sharing, working collaboratively to inform effective patient flow and discharge planning through the service.” Source location Response from Swansea Bay University Health Board
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a clinical audit of adult inpatient discharges against national transition guidance and present its findings.
Verbatim wording from the response “Discharge planning has been a focus of a current clinical audit that is being undertaken by the Quality Improvement and Practice Development teams. This audit is looking at Discharges from the Adult Inpatient Wards against the guidance identified in NG53 Transition between inpatient Mental Health Settings and Community or Care home settings. This audit commenced in March 2025 and the findings are planned to be presented in July 2025.” Source location Response from Swansea Bay University Health Board
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly multidisciplinary ward meetings with community mental health services and other agencies to support collaborative discharge decisions.
Verbatim wording from the response “Discharge processes within the adult mental health wards have been reviewed over the last three years and Terms of Reference were developed for the Multi-Disciplinary Team (MDT) Ward meetings in April 2022. The MDT meeting is held on a weekly basis, with the focus being to work collaboratively with colleagues in the Community Mental Health Services and other agencies/providers to provide holistic and patient centred care. The Terms of Reference for the MDT meetings and review process sets out the purpose and expectation of all parties within this process; including collaboration with care coordinators, families, and other agencies. Prior to each MDT meeting, a communication is sent to all Integrated team managers for CMHTs (this includes the Local Authority and Health manager), informing them of the MDT meeting agenda.” Source location Response from Swansea Bay University 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 Issue formal correspondence reaffirming compliance with discharge-planning policy, the pre-discharge checklist and patient information requirements.
Verbatim wording from the response “In addition to these, the Medical Director and Nurse Director for MH&LD have issued formal correspondence to all clinical areas and teams, reaffirming adherence to Section 3.4: Discharge and Discharge Planning of the Acute Adult Mental Health Inpatient Wards Operational Policy and the Pre-Discharge Planning Checklist and the patient/relative receives the “Moving on” information leaflet.” Source location Response from Swansea Bay University 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 Implement a two-stage Serious Incident Review approval and learning process, including senior clinical scrutiny and a forum to share learning and assign improvement actions.
Verbatim wording from the response “A further change has been implemented in the development of a two-stage process for sign off and approval of the learning and findings identified in Serious Incident Reviews. The initial stage is for a focused group of senior clinicians to scrutinise and critique the outcome report to ensure that it meets the scope, terms of reference and areas of review as commissioned within” Source location Response from Swansea Bay University Health Board
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Concerns raised 2 Failure to provide concurrent mental health assessment and support to individuals with addiction View source Lack of guidance for managing individuals with co-occurring addiction and mental health diagnoses and liaising with third-sector addiction agencies View source
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AI-generated summary
Amy Marie Padley · 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
Amy Marie Padley suffered from alcohol addiction, depression and emotionally unstable personality disorder, and was found deceased at home on 8 July 2022 after taking her own life by suspension. The concerns included missed opportunities to refer her for community mental health assessment, insufficient guidance on managing co-occurring addiction and mental health conditions, and a reluctance to provide mental health support alongside addiction services.
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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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide concurrent mental health assessment and support to individuals with addiction
Wider context from the report “I am concerned about the evidence I heard in this inquest that when an individual is suffering from alcohol or drug addiction alongside a mental health diagnosis, which in this case was EUPD and depression, that the focus of SUBHB is normally to advise that individual to address their addiction before they can access mental health services . I heard that addiction services do not fall within the remit of SUBHB and are provided by third-sector agencies. I heard that individuals who have a mental health diagnosis may self-medicate to manage symptoms of a mental health deterioration and that increased use of alcohol/drugs can increase the risk of self-harm to such individuals which may prove fatal. I am concerned that there is no guidance to staff within SUBHB on how to manage individuals with addiction and a mental health diagnosis and how SUBHB staff should liaise with and work alongside third-sector agencies in respect of an individual suffering from addiction. I am also concerned that there appears to be a reluctance within SUBHB to offer mental health support alongside suggesting that an individual access addiction services . I am concerned that this may mean that individuals in mental health crisis and suffering from addiction may not be getting the mental health assessment and support that they require alongside seeking to overcome their addiction and as such there is continuing risk to life.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for managing individuals with co-occurring addiction and mental health diagnoses and liaising with third-sector addiction agencies
Wider context from the report “I am concerned about the evidence I heard in this inquest that when an individual is suffering from alcohol or drug addiction alongside a mental health diagnosis, which in this case was EUPD and depression, that the focus of SUBHB is normally to advise that individual to address their addiction before they can access mental health services. I heard that addiction services do not fall within the remit of SUBHB and are provided by third-sector agencies. I heard that individuals who have a mental health diagnosis may self-medicate to manage symptoms of a mental health deterioration and that increased use of alcohol/drugs can increase the risk of self-harm to such individuals which may prove fatal. I am concerned that there is no guidance to staff within SUBHB on how to manage individuals with addiction and a mental health diagnosis and how SUBHB staff should liaise with and work alongside third-sector agencies in respect of an individual suffering from addiction . I am also concerned that there appears to be a reluctance within SUBHB to offer mental health support alongside suggesting that an individual access addiction services. I am concerned that this may mean that individuals in mental health crisis and suffering from addiction may not be getting the mental health assessment and support that they require alongside seeking to overcome their addiction and as such there is continuing risk to life.
” Open source report
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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 Start local Operational Co-occurring Strategy meetings to review current practice, identify service gaps and promote integrated mental-health and substance-use care.
Verbatim wording from the response “To progress the Co-occurring and Mental Health Strategy (2023–2026), SBUHB recognises the need to instigate local Operational Co-occurring Strategy meetings and re-engage with the Regional Area Planning Board for Substance Use and Partnership Board to explore further support following the receiving of the West Glamorgan Drug Commission Report. These meetings, starting in May 2025, will be critical in reviewing current practices, identifying gaps, and driving forward a more integrated and responsive approach to care. Key areas for action include reviewing and aligning mental health and substance use services to ensure individuals do not fall through the gaps while seeking treatment for either need, particularly during periods of crisis. The development of the SOP and Care pathway will achieve this.” Source location Response from SWANSEA BAY UNIVERSITY 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 Employ two co-occurring link workers to bridge community mental health and drug and alcohol services.
Verbatim wording from the response “The SBUHB CDAT service is staffed by qualified Mental Health Nurses and Consultant Psychiatrist who have specialist roles in the management of substance misuse patients. Since Spring 2024, SBUHB has employed two co-occurring (mental health and substance misuse) link workers, experienced mental health nurses covering the Swansea Bay footprint. They provide support to individuals with both mental health issues and substance use challenges. These link workers work specifically bridge the gap between the Community Mental Health Teams (CMHTs) and Community Drug and Alcohol Teams (CDATs) ensuring a more seamless, collaborative approach to care. They work as members of the multi-disciplinary team, with their role centred on promoting joined up working, actively participating in assessments, ongoing screening, care planning, and treatment delivery.” Source location Response from SWANSEA BAY UNIVERSITY 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 Develop an Operational Co-occurring Group and a standard operating procedure and care pathway for managing patients with co-occurring addiction and mental-health diagnoses.
Verbatim wording from the response “An Operational Co-occurring Group is currently being developed between Mental Health and CDAT services to implement clear working guidance on joint working processes. This group will commence in May 2025 and will be co-chaired by the Directorate Managers for both the Adult Mental Health Directorate and the CDAT Directorate. The objectives for this group are to develop a Standard Operating Procedure for managing individuals with both addiction and a mental health diagnosis, ways of strengthening this support, including developing further guidance for staff to help them navigate these complex cases and provide clear direction on how to liaise with third-sector organisations effectively. This will be completed by October 2025.” Source location Response from SWANSEA BAY UNIVERSITY 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 Employ an additional substance-misuse nurse in Liaison Psychiatry to support joint assessments and identify mental-health needs among patients with substance-use issues.
Verbatim wording from the response “In Liaison Psychiatry an additional Substance Misuse nurse was employed starting on 12th November 2023. This role has the additional responsibility in working with the mental health nurses in Liaison Psychiatry to highlight the mental health needs of patients with substance misuse issues. The additional Substance Misuse nurse has increased the opportunity for joint assessments with mental health nurses, aiming to provide a comprehensive care package for the individuals and improving awareness of the needs of this patient group within the service.” Source location Response from SWANSEA BAY UNIVERSITY 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 co-occurring training for liaison psychiatry, mental health and substance-use clinicians on dual diagnosis, trauma-informed practice and collaborative care.
Verbatim wording from the response “Between October 2024 and March 2025, SBUHB held co-occurring training for clinicians working in Liaison Psychiatry along with both mental health and substance use services in the community and in the wards, with the aim of building knowledge, skills and helping staff understand the complexities of dual diagnosis and equipping them to respond effectively. This two-day training focused on enhancing trauma-informed practice, promoting a deeper understanding of how mental health challenges and addiction are often rooted in past experiences and unmet needs. Through interactive sessions, reflective exercises, and real-life case examples, clinicians explored the impact of trauma, the evolving concepts of addiction and mental health, and the importance of relationship-based working.” Source location Response from SWANSEA BAY UNIVERSITY HEALTH BOARD
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Concerns raised 2 Delays in responding to Amber 1 emergency calls View source Unavailability of ambulances due to prolonged waits to offload patients at hospitals View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Peter Parker · 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
Peter Parker sustained a laceration to his right wrist from broken glass at home and called an ambulance, but the call disconnected and assistance arrived approximately 9½ hours later, after he had died. The principal concern was that the ambulance response exceeded the expected survival time for the injury, with delays attributed to ambulances waiting to hand over patients at emergency departments.
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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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Delays in responding to Amber 1 emergency calls
Wider context from the report “During the course of the inquest the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance. The longest wait at the Emergency Department by an ambulance on the evening in question was 11-12 hours, which is the equivalent of a whole 12 hour shift where that ambulance was not responding to calls. The inquest heard evidence that when the MPDS system was introduced in 2015 it was envisaged that an Amber 1 priority call would be responded to in 20 minutes from the time of the call and that a person with a transected radial artery could expect to survive 30-45 minutes. Given that it was not feasible for Peter to transport himself to hospital, and Peter had not contacted his family for their assistance.
I am concerned that the response time in this case was beyond the expected survivability of such an injury. The Amber 1 priority rating was by itself not incorrect but was inappropriate in the context of the time taken to respond to such priorities on the evening in question. I am further concerned that the reason for the delay was due to ambulances waiting to offload patients at hospitals, in accordance with the ambulance’s duty of care, and therefore not responding to emergency calls as is their purpose.
1. There was a significant delay in getting an ambulance to Peter which resulted in him dying from his injuries before assistance arrived. The time for survival of such injuries was 30-45 minutes, however the time taken to respond was in excess of 9 hours. Whilst there is no specific target for Amber 1 calls it was envisaged that when the system was introduced such calls would be responded to in 20 minutes.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of ambulances due to prolonged waits to offload patients at hospitals
Wider context from the report “During the course of the inquest the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance. The longest wait at the Emergency Department by an ambulance on the evening in question was 11-12 hours, which is the equivalent of a whole 12 hour shift where that ambulance was not responding to calls. The inquest heard evidence that when the MPDS system was introduced in 2015 it was envisaged that an Amber 1 priority call would be responded to in 20 minutes from the time of the call and that a person with a transected radial artery could expect to survive 30-45 minutes. Given that it was not feasible for Peter to transport himself to hospital, and Peter had not contacted his family for their assistance.
I am concerned that the response time in this case was beyond the expected survivability of such an injury. The Amber 1 priority rating was by itself not incorrect but was inappropriate in the context of the time taken to respond to such priorities on the evening in question. I am further concerned that the reason for the delay was due to ambulances waiting to offload patients at hospitals, in accordance with the ambulance’s duty of care, and therefore not responding to emergency calls as is their purpose.
1. There was a significant delay in getting an ambulance to Peter which resulted in him dying from his injuries before assistance arrived. The time for survival of such injuries was 30-45 minutes, however the time taken to respond was in excess of 9 hours. Whilst there is no specific target for Amber 1 calls it was envisaged that when the system was introduced such calls would be responded to in 20 minutes.
” 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 Assess, document and notify site management of decisions to decline Amber1 ambulance-release requests.
Verbatim wording from the response “Step 3 – Should an immediate release direction be declined by the ED staff, WAST will act in accordance with the WAST Resource Deployment SOP and record and escalate the refusal to the Operational Delivery Unit. If a Health Board does decline an immediate release direction, they will be required to provide the reasons for this and the name or identifying detail (e.g., employee number) of the declining staff member.” Source location Response from SWANSEA BAY UNIVERSITY HEALTH BOARD
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Action all Red ambulance-release requests and facilitate prompt release of identified emergency resources.
Verbatim wording from the response “Step 1 – WAST will contact ED staff via the “red phone” and direct an immediate release of an ambulance delayed outside the ED when no other appropriate resource is available to respond to a Red or Amber1 patient and/or when the resource has an extended travel time and nearer appropriate resources could attend that patient. The direction made by WAST will share the incident priority, patient age and chief complaint, identify the number of resources that are required to be released and the callsigns of the resources to be released (those that are immediately able to respond to the incident).” Source location Response from SWANSEA BAY UNIVERSITY HEALTH BOARD
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor ambulance handover delays and lost hours daily using established performance measures.
Verbatim wording from the response “The Health Board actively monitors ambulance handover performance against the following two performance measures, on a daily basis:” Source location Response from SWANSEA BAY UNIVERSITY HEALTH BOARD
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out a targeted programme to redesign urgent and emergency care access, services, staffing and infrastructure to reduce patient harm and service failure.
Verbatim wording from the response “The Health Board has commenced a programme of targeted intervention in conjunction with the National Strategy for Right Care, Right Place, First Time: Six Goals for Urgent & Emergency Care, supported by Welsh Government, to address risks associated with urgent and emergency patient pathways, including the ability to release emergency response vehicles, following arrival at Morriston Hospital. The aim of this programme of work is to critically review and redesign across community access, service delivery, staffing models and infrastructure in order to reduce risk of patient harm and service failure.” Source location Response from SWANSEA BAY UNIVERSITY HEALTH BOARD
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amber1 ambulance release requests may be declined where accepting additional patients creates a significant or severe clinical safety risk.
Verbatim wording from the response “I can confirm that all Red release requests are actioned by the Health Board. Amber1 release requests are managed on a case-by-case basis and the Health Board may have to decline requests when there is a significant/severe clinical safety risk to the Emergency” Source location Response from SWANSEA BAY UNIVERSITY HEALTH BOARD
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ambulance handover delays were solely caused by insufficient hospital capacity, including safe space, clinical support and staffing.
Verbatim wording from the response “The reason for handover delays is solely related to a lack of capacity to bring the conveyed patient into the hospital; both in terms of safe physical space including access to essential clinical support and staffing to take care of the patient. All patient’s waiting on the back of ambulances will have been clinically assessed and all opportunities explored as to how best to deliver a safe, timely, clinical management plan. The Emergency Department at Morriston Hospital routinely functions with additional patients across its template including within the acute resuscitation area, with “Major” patients overflowing into the “Minors” area and “Minors” patients sitting in the “Waiting Room”.” Source location Response from SWANSEA BAY UNIVERSITY HEALTH BOARD
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Determining WAST clinical priorities and resource allocation is outside the Health Board’s role.
Verbatim wording from the response “At any point in time (24/7), the Health Board and specifically the Hospital Management Team at Morriston Hospital is aware of the number of open calls being managed by WAST, the clinical priority assigned to each of these calls, by WAST, and a very general comment on clinical presentation; universally referred to as the “stack”. The extent of information available, at this point is very limited and the Health Board has no role in determining clinical priority and resource allocation.” Source location Response from SWANSEA BAY UNIVERSITY HEALTH BOARD
Open published response
Concerns raised 7 Failure to conduct timely and sufficiently wide patient safety investigations View source Failure to conduct robust, transparent and timely formal complaint investigations View source Insufficient staff training in risk assessment on Ward F View source Requirement for consent before assertive outreach to mentally unwell people in the community View source Failure to gather sufficient collateral information for MHA 83 assessments View source Failure to record s.12 doctors’ assessment outcomes when patients are not admitted View source Unavailability of relevant medical records to s.12 doctors before MHA 83 assessments View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Provide bespoke WARRN risk-assessment training to inpatient clinical staff and maintain training compliance above 90%, with monthly performance monitoring.
Stated completedThe respondent said that this action was complete when they made their response on 9 May 2024. View source
Action
Monitor Assertive Outreach Team activity monthly, including rejected referrals, reasons, rationale, review, and resulting actions.
Stated completedThe respondent said that this action was complete when they made their response on 9 May 2024. View source
Action
Commission a governance review of serious-incident-review arrangements within the Mental Health and Learning Disabilities Service Group.
Stated completedThe respondent said that this action was complete when they made their response on 9 May 2024. View source
Action
Provide all SBUHB-employed Section 12 doctors with read access to WCCIS for Mental Health Act assessments.
Stated plannedThe respondent said that this action was planned when they made their response on 9 May 2024. View source
Action
Review clinical-review processes with involved clinicians within seven working days to support complaint investigations and reflection on care.
Stated completedThe respondent said that this action was complete when they made their response on 9 May 2024. View source
Action
Remind AMHPs and Section 12 doctors to discuss patient history and collateral information before Mental Health Act assessments.
Stated plannedThe respondent said that this action was planned when they made their response on 9 May 2024. View source
Action
Conduct quarterly reviews of serious-incident investigations and complaints to ensure coordinated, timely progression under the relevant processes.
Stated plannedThe respondent said that this action was planned when they made their response on 9 May 2024. View source
Action
Review the governance report recommendations and prepare an implementation plan for the serious-incident investigative process.
Stated plannedThe respondent said that this action was planned when they made their response on 9 May 2024. View source
Action
Review the standard operating protocol for coordinating complaints and patient-safety incidents and identifying shared learning.
Stated completedThe respondent said that this action was complete when they made their response on 9 May 2024. View source
Action
Review, ratify, and recirculate the combined Assertive Outreach operational policy, including referral and eligibility arrangements.
Stated completedThe respondent said that this action was complete when they made their response on 9 May 2024. View source See 7 more actions
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AI-generated summary
Nicholas Kim Harrison · 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
Nicholas Kim Harrison died on 9 April 2022 from injuries sustained when he was seriously assaulted by his son at the family home on 12 March 2022. The report identifies concerns about failures in mental health assessment, information-sharing, community engagement, patient risk assessment, Ward F security and staff training, and the scope and timeliness of investigations and complaints handling.
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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct timely and sufficiently wide patient safety investigations
Wider context from the report “I am concerned that if there is a reluctance within SBUHB to conduct robust, transparent and timely investigations into complaints in line with the formal complaints process and if there is a reluctance within SBUHB to ensure that a formal patient safety investigation following a death and / or patient safety incident is conducted in a timely manner and is sufficiently wide in scope, including reflecting on and incorporating the concerns from the affected family member , then SBUHB will not learn lessons from patient safety incidents and that this creates a risk that deaths will continue to occur.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct robust, transparent and timely formal complaint investigations
Wider context from the report “I am concerned that if there is a reluctance within SBUHB to conduct robust, transparent and timely investigations into complaints in line with the formal complaints process and if there is a reluctance within SBUHB to ensure that a formal patient safety investigation following a death and / or patient safety incident is conducted in a timely manner and is sufficiently wide in scope, including reflecting on and incorporating the concerns from the affected family member, then SBUHB will not learn lessons from patient safety incidents and that this creates a risk that deaths will continue to occur.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training in risk assessment on Ward F
Wider context from the report “I heard evidence that Ward F of Neath and Port Talbot hospital is being used as the Single Point of Admission (‘SPOA’) for all adults requiring hospital admission in the locality for assessment of their mental illness. I heard that Ward F is a 21 bedded unit and that the move to using just Ward F as the SPOA (as opposed to three units which had been the practice) was brought in during the Covid-19 pandemic to manage the spread of the Covid-19 virus but that this change had been under consideration in SBUHB prior to the Covid-19 pandemic. I heard that this has resulted in a significantly increased level of acuity on Ward F with a significant increase in pressure on staff, a higher turnover of mentally unwell patients, and an increased pressure on staff from, for example, the need to prepare paperwork for the Mental Health Review Tribunal for Wales in a short period of time after admission. During the inquest I heard evidence (and SBUHB accepted) that the risk assessment conducted on ████████ during his time in Ward F was not adequate and that there was no assessment of ████████ risk of absconding. I found that the pressure on staff in Ward F due to its use as the SPOA impacted on ████████ care whilst he was on Ward F. I heard evidence from SBUHB that at the time there was insufficient training on risk assessments in Ward F . I heard from SBUHB that the current target is to ensure that 75% of staff on Ward F are trained in risk assessment by the end of 2024. I am concerned that only having 75% of staff trained in assessing risk means that risks may not be adequately assessed in respect of all patients on Ward F which raises a concern that risk to self and / or others and / or the risk of absconding will not be properly identified thus creating a risk that other deaths will occur. This is particularly so given the increased rates of acuity in the patients on Ward F due to it being used as the SPOA.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Requirement for consent before assertive outreach to mentally unwell people in the community
Wider context from the report “I am concerned that if consent is required before a mentally unwell person in the community is able to receive assertive outreach then there may be a gap in the mental health services within SBUHB that creates a risk that mentally unwell people will remain in the community without access to mental health services in circumstances where they may pose a risk to their own life or the lives of others. This is because whilst they may need access to mental health services, they may be too unwell to consent to that access. I am concerned that if there is such a systemic deficiency within SBUHB in relation to how to engage mentally unwell people in the community then this creates a risk that deaths will continue to occur.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to gather sufficient collateral information for MHA 83 assessments
Wider context from the report “I am concerned that an inadequate understanding within the CCOS AMPH service of the duty to gather sufficient collateral information in the context of any assessment under the MHA 83 and / or inadequate systems being employed within CCOS in relation to this issue creates a risk that information may not be captured and / or may be lost in relation to mentally unwell individuals in the community where they may pose a risk to their own lives and / or the lives of others and that this creates a risk that other deaths will occur.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to record s.12 doctors’ assessment outcomes when patients are not admitted
Wider context from the report “It is a mandatory requirement of the MHACOP Wales that a medical examination by a doctor of a patient in a formal assessment under the MHA 83 where they are considering admission to hospital must involve consideration by that doctor of all available relevant clinical information. I heard evidence in the inquest that doctors approved under s.12 MHA 83, and used by SBUHB to conduct assessments under the MHA 83, only have access to a patient’s medical records if they are employed by SBUHB. I heard that SBUHB rely heavily on s.12 doctors who are not directly employed by them and / or are locum doctors. I also heard that there is no system within SBUHB to ensure s.12 doctors are required to record the outcome of their assessment when there is a decision not to admit a patient to hospital . I heard evidence that there is no single digital record system / platform for Mental Health Services and associated access for practitioners across Wales. I am concerned that there is a system in place (or a lack of a system) in SBUHB and more widely across the NHS in Wales which is placing s.12 doctors at risk of acting contrary to the MHACOP Wales where they are unable to view a patient’s medical records prior to an assessment under the MHA 83. I am concerned that this creates a risk that assessments may be flawed and / or may not detect that a person requires admission to hospital in circumstances where that patient may pose a risk to their own life and / or to the lives of others and that this creates a risk that other deaths will occur. In addition, if a s.12 doctor is unable to record their assessment in a patient’s medical records there is a risk that important information may not be documented which may be relevant to an understanding of the risk a patient may pose to themselves or others thus creating a risk that other deaths will occur.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of relevant medical records to s.12 doctors before MHA 83 assessments
Wider context from the report “It is a mandatory requirement of the MHACOP Wales that a medical examination by a doctor of a patient in a formal assessment under the MHA 83 where they are considering admission to hospital must involve consideration by that doctor of all available relevant clinical information. I heard evidence in the inquest that doctors approved under s.12 MHA 83, and used by SBUHB to conduct assessments under the MHA 83, only have access to a patient’s medical records if they are employed by SBUHB. I heard that SBUHB rely heavily on s.12 doctors who are not directly employed by them and / or are locum doctors. I also heard that there is no system within SBUHB to ensure s.12 doctors are required to record the outcome of their assessment when there is a decision not to admit a patient to hospital. I heard evidence that there is no single digital record system / platform for Mental Health Services and associated access for practitioners across Wales. I am concerned that there is a system in place (or a lack of a system) in SBUHB and more widely across the NHS in Wales which is placing s.12 doctors at risk of acting contrary to the MHACOP Wales where they are unable to view a patient’s medical records prior to an assessment under the MHA 83 . I am concerned that this creates a risk that assessments may be flawed and / or may not detect that a person requires admission to hospital in circumstances where that patient may pose a risk to their own life and / or to the lives of others and that this creates a risk that other deaths will occur. In addition, if a s.12 doctor is unable to record their assessment in a patient’s medical records there is a risk that important information may not be documented which may be relevant to an understanding of the risk a patient may pose to themselves or others thus creating a risk that other deaths will occur.
” 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 bespoke WARRN risk-assessment training to inpatient clinical staff and maintain training compliance above 90%, with monthly performance monitoring.
Verbatim wording from the response “Swansea Bay University Health Board Response
The Mental Health and Learning Disability Service Group Learning and Development Team have in place a program of training and monitoring for WARRN training, which will ensure that the training levels are above 90% for staff working in the area. Since the inquest additional and bespoke training has been provided for clinical staff on Ward F and across the other 2 adult Mental Health inpatient wards. This was provided on 20th and 21st May 2024 and again on 4th and 5th June 2024. Following these additional dates, the current compliance for WARRN training for registered nursing staff on Ward F is 94% and the overall percentage for Clinical staff on Ward F is 96% (this includes psychology, Occupational Therapy and Psychiatry). It would not be possible to achieve 100% compliance due to staff absence (e.g. maternity leave) and staff turnover.” Source location Response from Swansea Bay University Health Board 2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor Assertive Outreach Team activity monthly, including rejected referrals, reasons, rationale, review, and resulting actions.
Verbatim wording from the response “Swansea Bay University Health Board Response
The core role of the Assertive Outreach Team (AOT) is to work with patients who are difficult to engage or demonstrate poor compliance with care & treatment plans. Referral to the AOT is not dependant on the patient giving consent to such referral. A monthly monitoring system is now in place to scrutinise the activity of the AOT. This includes recording the reason for any individual referral not being accepted by the team, the rationale for declining and a review and any actions in regards to this decision making. This will allow for more oversight; and a deeper understanding of any referrals not being accepted as part of our quality assurance process.” Source location Response from Swansea Bay University Health Board 2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission a governance review of serious-incident-review arrangements within the Mental Health and Learning Disabilities Service Group.
Verbatim wording from the response “Review Commissioning and Purpose
As a commitment to ensure our internal processes remain robust, open to scrutiny, and are responsive, we commissioned a review by the Director of the Research, Development, Innovation, Improvement and Learning Hub of the governance in respect of the service’s serious incident reviews.” Source location Response from Swansea Bay University Health Board 2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide all SBUHB-employed Section 12 doctors with read access to WCCIS for Mental Health Act assessments.
Verbatim wording from the response “Regarding access to WCCIS for MHA Assessments, all S12 Drs employed by SBUHB will be given read access to WCCIS to enable them to access information pertaining to the patient being assessed under the MHA 83. AMHPs also have full access to WCCIS. Both organisations (SBUHB/CCOS) committed to reminding both the AMHP and the S12 Drs to discuss patient history and any collateral information prior to the assessment taking place who recognise the importance of an all Wales digital solution. The Health Board, in the letter sent on 3rd April 2024, (referenced on page of this letter) covered this important area.” Source location Response from Swansea Bay University Health Board 2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review clinical-review processes with involved clinicians within seven working days to support complaint investigations and reflection on care.
Verbatim wording from the response “Although the external report findings had been shared with the Clinician referred to in the concern identified by the Coroner, the Health Board accepts it should have been shared with the Clinician involved in a more timely manner. The Health Board has reflected and reviewed its processes which are currently used in clinical reviews, obtained to support the investigation of complaints, with the Clinicians involved within 7 working days. This will enable further discussions to take place and reflection undertaken in the care provided.” Source location Response from Swansea Bay University Health Board 2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind AMHPs and Section 12 doctors to discuss patient history and collateral information before Mental Health Act assessments.
Verbatim wording from the response “Regarding access to WCCIS for MHA Assessments, all S12 Drs employed by SBUHB will be given read access to WCCIS to enable them to access information pertaining to the patient being assessed under the MHA 83. AMHPs also have full access to WCCIS. Both organisations (SBUHB/CCOS) committed to reminding both the AMHP and the S12 Drs to discuss patient history and any collateral information prior to the assessment taking place who recognise the importance of an all Wales digital solution. The Health Board, in the letter sent on 3rd April 2024, (referenced on page of this letter) covered this important area.” Source location Response from Swansea Bay University Health Board 2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct quarterly reviews of serious-incident investigations and complaints to ensure coordinated, timely progression under the relevant processes.
Verbatim wording from the response “The Health Board is committed to ensuring a co-ordinated approach when an incident being investigated and when a concern is received by the Health Board. The Health Board’s approach is to investigate once and to investigate well in accordance with the Regulations and the Duty of Candour Statutory Guidance. Going forward the Head of Concerns Assurance will carry out a quarterly review of SI investigations and complaints to ensure that a coordinated approach is being delivered and investigations are being progressed in line with process.” Source location Response from Swansea Bay University Health Board 2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the governance report recommendations and prepare an implementation plan for the serious-incident investigative process.
Verbatim wording from the response “The report provided a summary of the current processes established through this review and provided a number of recommendations which the Service Group Directors are set to review in July 2024 and prepare an implementation plan. One area of the Report focuses on the Investigative process and recommendations around:-” Source location Response from Swansea Bay University Health Board 2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the standard operating protocol for coordinating complaints and patient-safety incidents and identifying shared learning.
Verbatim wording from the response “The Health Board has reviewed the Standard Operating Protocol document which outlines the process of managing a complaint which has already been identified as an incident which ensures that incidents and complaints are managed together or individually within a timely manner ensuring that a full investigation is undertaken, and shared learning identified. If a complaint is received which raises issues that are not being considered within the incident process then a complaint will be opened and investigated fully. If a complaint raises the same concerns as the scope of the incident, then the complaint will be investigated as part of the incident process and will be fully addressed within the incident report. For assurance, please find attached the SOP document.” Source location Response from Swansea Bay University Health Board 2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review, ratify, and recirculate the combined Assertive Outreach operational policy, including referral and eligibility arrangements.
Verbatim wording from the response “The AOT Operational policy was reviewed earlier this year and ratified in March 2024. This review included the amalgamation of the policies for both the Neath Port Talbot and Swansea AOT. The role, function and purpose of the AOT is clearly set out within the policy, including the process of referral and eligibility criteria. This has been recirculated to all referring clinicians and the wider teams.” Source location Response from Swansea Bay University Health Board 2
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Achieving 100% risk-assessment training compliance is not possible because of staff absence and turnover.
Verbatim wording from the response “Swansea Bay University Health Board Response
The Mental Health and Learning Disability Service Group Learning and Development Team have in place a program of training and monitoring for WARRN training, which will ensure that the training levels are above 90% for staff working in the area. Since the inquest additional and bespoke training has been provided for clinical staff on Ward F and across the other 2 adult Mental Health inpatient wards. This was provided on 20th and 21st May 2024 and again on 4th and 5th June 2024. Following these additional dates, the current compliance for WARRN training for registered nursing staff on Ward F is 94% and the overall percentage for Clinical staff on Ward F is 96% (this includes psychology, Occupational Therapy and Psychiatry). It would not be possible to achieve 100% compliance due to staff absence (e.g. maternity leave) and staff turnover.” Source location Response from Swansea Bay University Health Board 2
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assertive Outreach Team referrals do not depend on patients consenting to referral.
Verbatim wording from the response “Swansea Bay University Health Board Response
The core role of the Assertive Outreach Team (AOT) is to work with patients who are difficult to engage or demonstrate poor compliance with care & treatment plans. Referral to the AOT is not dependant on the patient giving consent to such referral. A monthly monitoring system is now in place to scrutinise the activity of the AOT. This includes recording the reason for any individual referral not being accepted by the team, the rationale for declining and a review and any actions in regards to this decision making. This will allow for more oversight; and a deeper understanding of any referrals not being accepted as part of our quality assurance process.” Source location Response from Swansea Bay University Health Board 2
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The concern relates to City and County of Swansea’s AMHP service, not the Health Board’s actions.
Verbatim wording from the response “Whilst this concern relates to the actions of City and County of Swansea (CCOS) and not Swansea Bay University Health Board (SBUHB), the two organisations are working closely together, to ensure that all learning is identified to improve patient safety. A formal meeting has been held between the Service and Head of Adult Services and Tackling Poverty from CCOS, to identify specific actions.” Source location Response from Swansea Bay University Health Board 2
Open published response
21 Mar 2024 Alan Richard Miles Davies · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 13 Failure to provide staff with clear information about food and fluid refusal duration and warning signs View source Insufficient consideration of alternative specialist placement View source Failure to provide rest breaks during prolonged night shifts View source Failure to communicate relevant clinical information before transfer View source Insufficient GP capacity to meet demand at HMP Cardiff View source Failure to provide agency staff with sufficient information for informed reception support View source Failure to accompany transfers with Caswell Clinic staff View source Failure to provide clear and understandable discharge information and assessment View source Insufficient assessment of whether needs are too complex for HMP Cardiff View source Failure of healthcare staff to challenge senior staff withdrawal from healthcare assistance View source Failure to devise and implement a clear plan for assessing capacity to refuse food or fluid View source Failure to devise and implement a clear plan for engagement with medical services and assessment of condition View source Lack of a food and fluid refusal policy View source See 10 more concerns
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
Alan Richard Miles Davies · 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
Alan Richard Miles Davies was transferred to HMP Cardiff after 16 days of refusing food and was found collapsed in his cell 10 days later; he later died in hospital. The reported concerns included inadequate communication and handover of information, insufficient care planning and observation, the absence of a food and fluid refusal policy, inadequate staffing, and missed opportunities to escalate his care.
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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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide staff with clear information about food and fluid refusal duration and warning signs
Wider context from the report “(11) The Nurse, Health care assistant and Custodial manager responsible for Mr Davies on the night of his collapse were not provided with clear information regarding the duration of his fluid and food refusal or the warning signs to consider in the context of the known risk of sudden collapse
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient consideration of alternative specialist placement
Wider context from the report “(5) Mr Davies was transferred to HMP Cardiff with the intention that he be transferred again within a short time to HMP Parc. Insufficient consideration was given as to whether Mr Davies’ needs were better met at an alternative specialist institution .
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide rest breaks during prolonged night shifts
Wider context from the report “(10) The Nurse and Health care assistant responsible for Mr Davies on the night of his collapse were working an 11.5 hour night shift without rest breaks , which they identified as being overly fatiguing
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant clinical information before transfer
Wider context from the report “(1) There was limited communication between the Caswell clinic and HMP Cardiff following the s 117 meeting until Mr Davies’ discharge . In particular, information that Mr Davies had commenced food refusal following the s 117 meeting and that it had not been possible to assess him physically prior to transfer was not clearly communicated to HMP Cardiff before the transfer occurred
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient GP capacity to meet demand at HMP Cardiff
Wider context from the report “(9) The number of GPs working in HMP Cardiff was insufficient to meet the demands upon them .
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide agency staff with sufficient information for informed reception support
Wider context from the report “(3) Mr Davies was transferred to prison without being accompanied by a member of Caswell Clinic staff. Agency staff did not have sufficient information to be able to assist prison reception staff in an informed manner
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to accompany transfers with Caswell Clinic staff
Wider context from the report “(3) Mr Davies was transferred to prison without being accompanied by a member of Caswell Clinic staff . Agency staff did not have sufficient information to be able to assist prison reception staff in an informed manner
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear and understandable discharge information and assessment
Wider context from the report “(2) Discharge information and assessment was not provided to HMP Cardiff in a clear and easily understandable format to manage the known risks associated with the transfer of Mr Davies to prison
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient assessment of whether needs are too complex for HMP Cardiff
Wider context from the report “(4) Insufficient consideration was given to whether Mr Davies’ needs were too complex to be met by HMP Cardiff .
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare staff to challenge senior staff withdrawal from healthcare assistance
Wider context from the report “(12) The Health care assistant caring for Mr Davies overnight overheard more senior prison staff stating that they would not return to assist Mr Davies in healthcare , and felt unable to challenge this .
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to devise and implement a clear plan for assessing capacity to refuse food or fluid
Wider context from the report “(7) No clear plan for the assessment of Mr Davies’ capacity to refuse food or fluid was devised or implemented at HMP Cardiff
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to devise and implement a clear plan for engagement with medical services and assessment of condition
Wider context from the report “(6) No clear plan to promote Mr Davies’ engagement with prison medical services, or the assessment of his mental or physical condition was devised or implemented at HMP Cardiff
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a food and fluid refusal policy
Wider context from the report “(8) No food and fluid refusal policy was in place to guide healthcare staff .
” Open source report
13 Mar 2024 Jacob Michael Nicholas BILLINGTON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Failure to record prisoners’ GP and CMHT details in an easily accessible format View source Failure to establish effective information sharing for prison discharge coordination View source Lack of cross-agency provisions and guidance for release planning of high-risk prisoners with mental health difficulties View source Unclear responsibilities and case remit for the prison discharge coordinator role View source Failure to coordinate interagency release management and share critical information View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jacob Michael Nicholas BILLINGTON · 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
Jacob Michael Nicholas Billington was unlawfully killed when he was stabbed in the neck during a night out in Birmingham on 6 September 2020. The concerns included inadequate coordination and information-sharing between agencies during the release of a high-risk prisoner with serious mental health difficulties, and a lack of clear cross-agency guidance and understanding of responsibilities.
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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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to record prisoners’ GP and CMHT details in an easily accessible format
Wider context from the report “2. Sysmone Details of the perpetrators GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. I was informed that this change in information management and presentation within Sysmone is unique to HMP Swansea and is not the practice in other prisons. I am concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to establish effective information sharing for prison discharge coordination
Wider context from the report “4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-agency provisions and guidance for release planning of high-risk prisoners with mental health difficulties
Wider context from the report “3. Cross agency guidance regarding release of high risk prisoners with mental health difficulties at their sentence end date. There are no provisions available nor any cross agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibilities and case remit for the prison discharge coordinator role
Wider context from the report “4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate interagency release management and share critical information
Wider context from the report “1. Management of release and lack of interagency working. The management of the perpetrators release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include the resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning any are not traced and treated assertively in the community.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use weekly discharge information, prison NOMIS access and a Governor Grade officer at Single Point of Access meetings to verify release dates.
Verbatim wording from the response “• On a weekly basis the MHIR Team are sent the discharge information of prisoners from the Offender Management Unit (OMU). We don’t request travel warrant information as the travel warrant is only issued on the day of travel. We also now have access to the prison NOMIS system which we didn’t previously (training for use is being rolled out to the whole team with 50% already achieved). This system is updated by the Resettlement Team and OMU regarding release dates. These layered approaches help to avoid the risk of the team not being aware of relevant information” Source location Response from Swansea Bay University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct multidisciplinary pre-discharge reviews and formal pre-release planning meetings four to six weeks before known release dates.
Verbatim wording from the response “Discharge to Community” Source location Response from Swansea Bay University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Highlight patients’ general-practitioner, community-team, care-coordinator and MHIR-worker details on the HMP Swansea SystemOne front screen.
Verbatim wording from the response “Details of the perpetrators GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. You were informed that this change in information management and presentation within SystemOne is unique to HMP Swansea and is not the practice in other prisons. You were concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information.” Source location Response from Swansea Bay University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold formal admission handovers and pre-release meetings with transferring mental-health teams or prisons and relevant agencies.
Verbatim wording from the response “• Formal hand over of care is received from the transferring Community Mental Health Team (CMHT) or previous prison via a formal meeting” Source location Response from Swansea Bay University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide documented discharge summaries and comprehensive handovers to primary care, general practitioners, patients and, with consent, probation officers.
Verbatim wording from the response “A Formal discharge meeting is also held between the MHIR and Primary Care Teams when patients / prisoners within the prison setting are being discharged from secondary care services (MHIR) back to primary care services within the prison. This meeting includes a full” Source location Response from Swansea Bay University Health Board
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Liaison with MAPPA is the Offender Management Unit’s responsibility, while the Responsible Authority must notify Health and arrange relevant meetings.
Verbatim wording from the response “In respect of MAPPA, Swansea Bay University Health Board undertake the role of a ‘Duty to Cooperate Agency’ with Probation, HMP and the Police as the Responsible Authority – it is the Responsible Authority’s responsibility to inform Health if a MAPPA eligible individual is scheduled for discharge and ensure we are invited to relevant meetings to coordinate release / discharge management. The MHIR Team liaise directly with the prison based Offender Management Unit and not directly with MAPPA. Liaison with MAPPA is the responsibility of the Offender Management Unit.” Source location Response from Swansea Bay University Health Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Health Board lacks jurisdiction or power over the cross-agency actions required for release planning at sentence end.
Verbatim wording from the response “There are no provisions available nor any cross agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community.” Source location Response from Swansea Bay University Health Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A unified prison interagency IT system cannot be implemented because the Health Board lacks the necessary power.
Verbatim wording from the response “Swansea University Health Board recognise that there is not a shared database for interagency working in place across England and Wales prison establishments to enable the transfer and access to key information by agencies coordinating the discharge of high risk individuals.” Source location Response from Swansea Bay University Health Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Health Board lacks power to take action regarding the West Midlands MAPPA prison discharge coordinator concern.
Verbatim wording from the response “West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.” Source location Response from Swansea Bay University Health Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Changes to SystemOne across prison estates cannot be implemented because the Health Board lacks relevant system control.
Verbatim wording from the response “Details of the perpetrators GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. You were informed that this change in information management and presentation within SystemOne is unique to HMP Swansea and is not the practice in other prisons. You were concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information.” Source location Response from Swansea Bay University Health Board
Open published response
Concerns raised 2 Delays in offloading patients into hospital View source Delays in getting ambulances to vulnerable patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jean Thomas · 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
Jean Thomas fell at home and remained on the floor for approximately 14 hours while waiting for an ambulance, during which a sacral pressure sore began to develop. The sore was exacerbated by a further delay in offloading her from the ambulance and by delays in obtaining an appropriate anti-pressure sore mattress; it later became infected, and she died at Morriston Hospital. The report raises concerns about pressure sores developing or worsening when vulnerable patients experience delays in ambulance response and hospital offloading.
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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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Delays in offloading patients into hospital
Wider context from the report “During the course of the inquest it was apparent that the pressure sore was caused by the long lie at home waiting for an ambulance, and then the sore would have been exacerbated by a further long wait in the back of the ambulance waiting to be offloaded into hospital. Issues regarding the treatment of the pressure sore was recognised by the Health Board, consisting of a delay in obtaining an appropriate anti pressure sore mattress and a lack of pressure sore assessment documentation and the issues regarding treatment have been addressed by way of appropriate learning outcomes and action plans.
I am concerned that where vulnerable patients are left waiting for an ambulance then pressure sores can develop due to a long lie. I am further concerned that these sores can be exacerbated in cases where there is a delay in offloading patients into hospital where they can then be nursed on an appropriate anti-pressure sore mattress. Whilst I am aware that the issues raised above occur nationally and are not restricted to the areas that the Welsh Ambulance Service NHS Trust and Swansea Bay University Health Board cover, in my opinion there is a risk that future deaths will occur unless action is taken.
1. There was a significant delay in getting an ambulance to Jean which resulted in a pressure sore forming due to long lie. That pressure sore was exacerbated by a further long wait to be offloaded into hospital . The time taken to offload was in excess of 16 hours, when the target offloading time is 15 minutes ,
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Delays in getting ambulances to vulnerable patients
Wider context from the report “During the course of the inquest it was apparent that the pressure sore was caused by the long lie at home waiting for an ambulance, and then the sore would have been exacerbated by a further long wait in the back of the ambulance waiting to be offloaded into hospital. Issues regarding the treatment of the pressure sore was recognised by the Health Board, consisting of a delay in obtaining an appropriate anti pressure sore mattress and a lack of pressure sore assessment documentation and the issues regarding treatment have been addressed by way of appropriate learning outcomes and action plans.
I am concerned that where vulnerable patients are left waiting for an ambulance then pressure sores can develop due to a long lie . I am further concerned that these sores can be exacerbated in cases where there is a delay in offloading patients into hospital where they can then be nursed on an appropriate anti-pressure sore mattress. Whilst I am aware that the issues raised above occur nationally and are not restricted to the areas that the Welsh Ambulance Service NHS Trust and Swansea Bay University Health Board cover, in my opinion there is a risk that future deaths will occur unless action is taken.
1. There was a significant delay in getting an ambulance to Jean which resulted in a pressure sore forming due to long lie . That pressure sore was exacerbated by a further long wait to be offloaded into hospital. The time taken to offload was in excess of 16 hours, when the target offloading time is 15 minutes,
” 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 Apply a zero-tolerance threshold to ambulance off-load delays exceeding 10 hours as part of improving handover times.
Verbatim wording from the response “In November 2023, a “zero” tolerance to ambulance off-load delays, in excess of 10 hours, was introduced, at Morriston Hospital. The introduction of this tolerance is part of a reduction trajectory to improving handover times and achieving the 15-minute target. However, despite improvements in this area, continued pressures on the unscheduled care system has resulted in delays over 10 hours still being experienced by patients.” Source location Response from Swansea Bay University 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 Work with the Welsh Ambulance Service to develop use of pressure-relieving equipment during ambulance transport and delayed handover situations.
Verbatim wording from the response “There is ongoing work in conjunction with the Welsh Ambulance Service to address how pressure relieving equipment can be used on ambulances, both in transit and in situations where patients are unable to be handed over from the ambulance crew to the Emergency Department Team. The Health Board has proactively shared with the Welsh Ambulance Service comprehensive risk assessment documentation relating to the use of pressure relieving mattresses which are able to be used on ambulance trolleys since 2021 (and subsequently in 2023 and 2024). Independent audit outcomes from two Ambulance Trusts in NHS England, who have adopted the use of pressure relieving equipment in ambulance vehicles (using Swansea Bay’s risk assessment) have shown a significant reduction in healthcare acquired pressure injuries of up to 30%.” Source location Response from Swansea Bay University Health Board
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use of pressure-relieving ambulance equipment depends on the Welsh Ambulance Service accepting the Health Board’s existing offer of equipment.
Verbatim wording from the response “There is ongoing work in conjunction with the Welsh Ambulance Service to address how pressure relieving equipment can be used on ambulances, both in transit and in situations where patients are unable to be handed over from the ambulance crew to the Emergency Department Team. The Health Board has proactively shared with the Welsh Ambulance Service comprehensive risk assessment documentation relating to the use of pressure relieving mattresses which are able to be used on ambulance trolleys since 2021 (and subsequently in 2023 and 2024). Independent audit outcomes from two Ambulance Trusts in NHS England, who have adopted the use of pressure relieving equipment in ambulance vehicles (using Swansea Bay’s risk assessment) have shown a significant reduction in healthcare acquired pressure injuries of up to 30%.” Source location Response from Swansea Bay University Health Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation REACT assessments largely prevent significant harm during delayed ambulance handovers by identifying patient risks and enabling immediate treatment or prevention.
Verbatim wording from the response “The majority of delayed ambulance handover events do not result in a significant harm to a patient. This is largely due to the REACT risk assessment described above. In the rare case when a patient does incur a significant harm, a Duty of Candour process is triggered; notified to the patient and/or family and a full investigation undertaken with the outcome provided in line with “Putting Things Right” (2011) Regulations.” Source location Response from Swansea Bay University Health Board
Open published response
Concerns raised 5 Failure to account for respiratory compromise when administering laxatives View source Failure to closely monitor laxative treatment to ensure safe dosages View source Risk of further respiratory-function loss from abdominal distension View source Difficulty obtaining an accurate clinical picture from patients with learning disabilities View source Failure to maintain consistent records of laxative administration View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Shane Luke West · 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
Shane Luke West was pronounced dead on 17 August 2018 at Morriston Hospital after multi-organ failure caused by cardiorespiratory arrest associated with abdominal distention from chronic constipation and fluid build-up from laxative treatment. The principal concerns were inconsistent records of laxative administration, difficulty assessing his condition due to his learning disability, and whether the risks of further abdominal distention and respiratory compromise were sufficiently appreciated when administering laxatives.
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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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to account for respiratory compromise when administering laxatives
Wider context from the report “I am concerned that in cases involving patients with learning disabilities (who commonly suffer from chronic constipation) the management of laxative treatment was not monitored closely enough to ensure a safe dosage of laxatives.
1. There was a contradiction between the nursing notes and the prescription charts as to the amount of laxatives administered on the 15th and 16th of August 2018.
2. Shane was known to hide his physical condition on questioning due to his learning disabilities and saying what he thought people wanted to hear. As such it was difficult for staff to get a true picture of Shane's condition.
3. Shane had ongoing respiratory compromise due to his abdominal distension pressing against his diaphragm therefore further distention posed a risk of further loss of respiratory function.
4. It was not clear whether medical professionals appreciated this risk and whether the administering of the laxatives ought to be staggered to allow Shane to receive the prescribed dose but not to the extent of overloading his already distended abdomen with fluid
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to closely monitor laxative treatment to ensure safe dosages
Wider context from the report “I am concerned that in cases involving patients with learning disabilities (who commonly suffer from chronic constipation) the management of laxative treatment was not monitored closely enough to ensure a safe dosage of laxatives .
1. There was a contradiction between the nursing notes and the prescription charts as to the amount of laxatives administered on the 15th and 16th of August 2018.
2. Shane was known to hide his physical condition on questioning due to his learning disabilities and saying what he thought people wanted to hear. As such it was difficult for staff to get a true picture of Shane's condition.
3. Shane had ongoing respiratory compromise due to his abdominal distension pressing against his diaphragm therefore further distention posed a risk of further loss of respiratory function.
4. It was not clear whether medical professionals appreciated this risk and whether the administering of the laxatives ought to be staggered to allow Shane to receive the prescribed dose but not to the extent of overloading his already distended abdomen with fluid
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Risk of further respiratory-function loss from abdominal distension
Wider context from the report “I am concerned that in cases involving patients with learning disabilities (who commonly suffer from chronic constipation) the management of laxative treatment was not monitored closely enough to ensure a safe dosage of laxatives.
1. There was a contradiction between the nursing notes and the prescription charts as to the amount of laxatives administered on the 15th and 16th of August 2018.
2. Shane was known to hide his physical condition on questioning due to his learning disabilities and saying what he thought people wanted to hear. As such it was difficult for staff to get a true picture of Shane's condition.
3. Shane had ongoing respiratory compromise due to his abdominal distension pressing against his diaphragm therefore further distention posed a risk of further loss of respiratory function .
4. It was not clear whether medical professionals appreciated this risk and whether the administering of the laxatives ought to be staggered to allow Shane to receive the prescribed dose but not to the extent of overloading his already distended abdomen with fluid
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Difficulty obtaining an accurate clinical picture from patients with learning disabilities
Wider context from the report “I am concerned that in cases involving patients with learning disabilities (who commonly suffer from chronic constipation) the management of laxative treatment was not monitored closely enough to ensure a safe dosage of laxatives.
1. There was a contradiction between the nursing notes and the prescription charts as to the amount of laxatives administered on the 15th and 16th of August 2018.
2. Shane was known to hide his physical condition on questioning due to his learning disabilities and saying what he thought people wanted to hear. As such it was difficult for staff to get a true picture of Shane's condition .
3. Shane had ongoing respiratory compromise due to his abdominal distension pressing against his diaphragm therefore further distention posed a risk of further loss of respiratory function.
4. It was not clear whether medical professionals appreciated this risk and whether the administering of the laxatives ought to be staggered to allow Shane to receive the prescribed dose but not to the extent of overloading his already distended abdomen with fluid
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain consistent records of laxative administration
Wider context from the report “I am concerned that in cases involving patients with learning disabilities (who commonly suffer from chronic constipation) the management of laxative treatment was not monitored closely enough to ensure a safe dosage of laxatives.
1. There was a contradiction between the nursing notes and the prescription charts as to the amount of laxatives administered on the 15th and 16th of August 2018.
2. Shane was known to hide his physical condition on questioning due to his learning disabilities and saying what he thought people wanted to hear. As such it was difficult for staff to get a true picture of Shane's condition.
3. Shane had ongoing respiratory compromise due to his abdominal distension pressing against his diaphragm therefore further distention posed a risk of further loss of respiratory function.
4. It was not clear whether medical professionals appreciated this risk and whether the administering of the laxatives ought to be staggered to allow Shane to receive the prescribed dose but not to the extent of overloading his already distended abdomen with fluid
” 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 Remind medication prescribers to select, dispense and administer medicines correctly under NICE and BNF guidance, reinforcing safe maximum-dose awareness and pharmacist dosage scrutiny.
Verbatim wording from the response “Action 3.1: All staff that prescribe medications are to be reminded that the correct drug needs to be selected, dispensed, and administered in line with National Institute for Health & Care Excellence (NICE) and British National Formulary (BNF) Guidelines.” Source location Response from Swansea Bay University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Hospital Electronic Prescribing and Administration of Medicines system at Morriston Hospital.
Verbatim wording from the response “Action 1.2: Swansea Bay University Health Board is currently implementing a Hospital Electronic Prescribing and Administration of Medicines (HEPMA) system.” Source location Response from Swansea Bay University Health Board
Open published response
Concerns raised 2 Lack of care-coordinator oversight for complex cases outside secondary mental health services View source Lack of integrated electronic access to medical and treatment records between treating teams View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samuel Alexander Morgan · 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 Alexander Morgan, who was suffering from alcohol addiction and had diagnoses of ADHD and social anxiety, was found deceased at his parents’ house on 9 May 2019 after tying a ligature around his neck. The principal concern was that addiction and mental health services could not electronically access each other’s records, meaning important information about suicide risk and patient safety might be lost or insufficiently understood between treating teams.
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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of care-coordinator oversight for complex cases outside secondary mental health services
Wider context from the report “I am concerned that in cases where an individual is receiving treatment from alcohol and drug addiction services and treatment from the primary community mental health team that neither team is able to access the other teams records electronically. The lack of integrated electronic records between treating team means that important information regarding patient safety is not easily accessible between treating teams. Treating teams are reliant on referral letters which are necessarily limited and not always sufficient to capture all the detailed information available to a referring team. This is particularly concerning where there is dual diagnosis - such as substance misuse and mental health - given these are often complex cases. This is particularly the case where complex cases have not been referred into secondary mental health services and so do not have access to a care-coordinator who can oversee and understand the views of the various professionals treating and assisting an individual .
I am concerned that the lack of such an integrated electronic system of medical and treatment records inhibits the effective sharing of information regarding patient safety and so increases the risk that information of significance regarding a risk to life will be lost between agencies and not sufficiently understood between all those managing risk.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of integrated electronic access to medical and treatment records between treating teams
Wider context from the report “I am concerned that in cases where an individual is receiving treatment from alcohol and drug addiction services and treatment from the primary community mental health team that neither team is able to access the other teams records electronically . The lack of integrated electronic records between treating team means that important information regarding patient safety is not easily accessible between treating teams . Treating teams are reliant on referral letters which are necessarily limited and not always sufficient to capture all the detailed information available to a referring team. This is particularly concerning where there is dual diagnosis - such as substance misuse and mental health - given these are often complex cases. This is particularly the case where complex cases have not been referred into secondary mental health services and so do not have access to a care-coordinator who can oversee and understand the views of the various professionals treating and assisting an individual.
I am concerned that the lack of such an integrated electronic system of medical and treatment records inhibits the effective sharing of information regarding patient safety and so increases the risk that information of significance regarding a risk to life will be lost between agencies and not sufficiently understood between all those managing risk.
” 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 Enable two-way WCCIS information sharing between Swansea community mental health and drug and alcohol teams.
Verbatim wording from the response “1. For Swansea based teams there is opportunity to share information between community mental health teams and drug and alcohol services via WCCIS which will allow 2 way sharing of all information in the WCCIS system relating to episodes of care both within community mental health services and drug and alcohol services. The technical changes to enable this will be completed within 10 working days and it is intended that this will be implemented week commencing 7th August 2023.” Source location Response from Swansea Bay University Health Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further WCCIS rollout is on hold pending Welsh Government approval of National Programme Team recommendations.
Verbatim wording from the response “The solution to this is intended to be the implementation of the Welsh Community Care Information System, (WCCIS) which is a national IT programme aimed at enabling the safe sharing of information between health and social care. This has been partially rolled out within the Health Board as part of the implementation of the solution within Swansea Local Authority. Further roll out within the Health Board is currently on hold pending the approval by Welsh Government of recommendations made within a Ministerial Advice Paper presented by the National Programme Team. The situation is complicated by the fact that only one of our Local Authority partners has chosen to implement WCCIS. The current deployment of the solution within SB UHB is managed by Swansea Local Authority who” Source location Response from Swansea Bay University Health Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Local Authority must request and implement any amendments to WCCIS system functionality.
Verbatim wording from the response “The solution to this is intended to be the implementation of the Welsh Community Care Information System, (WCCIS) which is a national IT programme aimed at enabling the safe sharing of information between health and social care. This has been partially rolled out within the Health Board as part of the implementation of the solution within Swansea Local Authority. Further roll out within the Health Board is currently on hold pending the approval by Welsh Government of recommendations made within a Ministerial Advice Paper presented by the National Programme Team. The situation is complicated by the fact that only one of our Local Authority partners has chosen to implement WCCIS. The current deployment of the solution within SB UHB is managed by Swansea Local Authority who” Source location Response from Swansea Bay University Health Board
Open published response
Concerns raised 3 Lack of regular access to ACCT training for bank nurses View source Failure to apply ACCT opening criteria to information indicating current self-harm or suicide risk View source Inadequate frequency and currency of ACCT training for prison officers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Khalid Abiaz · 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
Khalid Abiaz, a prisoner at HMP Swansea, died in the early hours of 13 September 2016 after being found suspended by a ligature. The report identified concerns that an ACCT was not opened despite suicide warning markers and relevant historical information, and that prison and bank nursing staff may not have received sufficiently frequent or up-to-date ACCT training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of regular access to ACCT training for bank nurses
Wider context from the report “2. I heard evidence from the nurse who saw Khalid on reception. This person is an experienced mental health nurse who is now a charge nurse on bank. The nurse told me that he still does at times work through the bank as a mental health nurse in HMP Swansea. At the time of Khalid’s death the Nurse was the mental health nurse working on reception and he completed the first reception health screen for Khalid and he did not open an ACCT. It was unclear what documents the nurse had seen on reception for Khalid but he did not ask prison staff if he could see any documents. The Nurse gave evidence that even if he had known that there was a suicide warning marker on Khalid’s prison escort record this would not have been enough combined with what Khalid said to him to open an ACCT, he relies on Khalid’s presentation. Khalid had been assessed by a consultant psychiatrist as a significant risk to himself a matter of weeks before he was seen by the Nurse in reception. HMP Swansea prison staff and the Nurse were not aware of this information but even if the Nurse had known this information his evidence was that this would not necessarily have been enough for him to open an ACCT, he would consider presentation. The revised ACCT version 6 and accompanying policy guidance set out above makes clear that an ACCT must be opened by any member of staff who receives information that indicates a prisoner may be currently at risk of self-harm or suicide and that this information may come from a prison escort. The answers of the Nurse raise a concern around the level and adequacy of the training on ACCT. The Nurse stated that he has reflected on his practice but that he still places emphasis on what the prisoner says and how they present when considering whether to open an ACCT. I heard evidence that bank nurses were supervised in the prison but that training on ACCT remained the responsibility of HMP Swansea . I am concerned that bank nurse may not receive access to ACCT training including at the required regularity and I am concerned that unless this happens there remains a risk of similar deaths occurring in the future in HMP Swansea
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to apply ACCT opening criteria to information indicating current self-harm or suicide risk
Wider context from the report “2. I heard evidence from the nurse who saw Khalid on reception. This person is an experienced mental health nurse who is now a charge nurse on bank. The nurse told me that he still does at times work through the bank as a mental health nurse in HMP Swansea. At the time of Khalid’s death the Nurse was the mental health nurse working on reception and he completed the first reception health screen for Khalid and he did not open an ACCT. It was unclear what documents the nurse had seen on reception for Khalid but he did not ask prison staff if he could see any documents. The Nurse gave evidence that even if he had known that there was a suicide warning marker on Khalid’s prison escort record this would not have been enough combined with what Khalid said to him to open an ACCT, he relies on Khalid’s presentation. Khalid had been assessed by a consultant psychiatrist as a significant risk to himself a matter of weeks before he was seen by the Nurse in reception. HMP Swansea prison staff and the Nurse were not aware of this information but even if the Nurse had known this information his evidence was that this would not necessarily have been enough for him to open an ACCT, he would consider presentation. The revised ACCT version 6 and accompanying policy guidance set out above makes clear that an ACCT must be opened by any member of staff who receives information that indicates a prisoner may be currently at risk of self-harm or suicide and that this information may come from a prison escort. The answers of the Nurse raise a concern around the level and adequacy of the training on ACCT. The Nurse stated that he has reflected on his practice but that he still places emphasis on what the prisoner says and how they present when considering whether to open an ACCT. I heard evidence that bank nurses were supervised in the prison but that training on ACCT remained the responsibility of HMP Swansea. I am concerned that bank nurse may not receive access to ACCT training including at the required regularity and I am concerned that unless this happens there remains a risk of similar deaths occurring in the future in HMP Swansea
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate frequency and currency of ACCT training for prison officers
Wider context from the report “1. I heard evidence that following a review in 2015 changes to the ACCT document and process were piloted in 10 establishments in 2019 and this included HMP Swansea. As a result a revised ACCT version 6 and accompanying policy guidance was issued. This revised guidance makes clear that an ACCT must be opened by any member of staff who receives information that indicates a prisoner may be currently at risk of self-harm or suicide and that this information may come from a prison escort. However, this requirement is not new. It was clear in my view from the HMP Swansea Suicide and Prevention Policy that was in place at the time of Khalid’s death that a warning marker for suicide on a prison escort record (‘PER’) should result in the opening of an ACCT. The prison officer who saw Khalid first in reception gave evidence that he was an experienced prison officer with over 20 years-experience of working in prisons including 18 years at HMP Swansea. At the time when Khalid came into custody he was an ACCT assessor and remains in this role. He saw Khalid’s PER which stated that Khalid had recently made threats to kill himself and was alleging mental health issues and he saw the NOEMIS transfer report which contained reference to historic ACCTs that Khalid had been in custody and an act of cutting and ligaturing by Khalid 9 months before in December 2015. He did not open an ACCT but referred the nurse who also did not open an ACCT. In his evidence the Prison Officer stated that if a prisoner came into custody now in 2022 with a warning on his PER stating that he has recently made threats to kill himself then this would not be enough to trigger the opening of an ACCT. This view is inconsistent with the mandatory revised ACCT policy guidance that I have set out above. This indicates that the system for training on ACCT in HMP Swansea is inadequate. The Prison Officer could not recall whether his ACCT training was up to date. His training records show that he was ACCT trained in 2005, 2008, 2011 and 2014 and I am told there was training on the new ACCT document that is not recorded in the training records and a further up-skilling session with staff date not specified. I did hear that training was difficult during the Covid 19 pandemic in HMP Swansea, however, ACCT training is required to be carried out with much more frequency than the training provided to the officer on reception and staff should understand that warning markers that require an ACCT to be opened. I am concerned that unless prison officers are provided with frequent ACCT training which is kept up to date then there remains a risk of similar deaths occurring in the future in HMP Swansea.
” 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 Make ACCT training mandatory in induction for new prison Health Board staff and provide refresher access.
Verbatim wording from the response “Furthermore, Health Staff will be rostered to attend the ACCT Awareness training as a matter of priority. Updates on training numbers will be provided by the Health Care lead on a monthly basis via the Quality and Safety forum. Training will be a part of the mandatory induction for new Prison Health Board staff, and refresher training will be accessible to staff also, as and when the prison release dates.” Source location Response from Swansea Bay University Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Secure ACCT training places for medical staff as national training dates are released.
Verbatim wording from the response “To date, 8 prison health staff have undergone the version 6 ACCT training with 22 staff members remaining. The Health Board are also negotiating securing places for the medical staff on the training. This remains very much on our radar and as the national ACCT training dates are released, securing places will be a priority for the Health Board for those individuals who work in this setting.” Source location Response from Swansea Bay University Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reserve two places in each ACCT training session for Health Board staff.
Verbatim wording from the response “Although the response from the Prison will address the majority of the points you raise in respect of the adequacy of ACCT training, the Health Board has been working closely with the Prison and we are able to confirm that two slots per ACCT training session will be ring fenced going forward for Health Board staff.” Source location Response from Swansea Bay University Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise and roster Health Board staff to attend ACCT Awareness training.
Verbatim wording from the response “Furthermore, Health Staff will be rostered to attend the ACCT Awareness training as a matter of priority. Updates on training numbers will be provided by the Health Care lead on a monthly basis via the Quality and Safety forum. Training will be a part of the mandatory induction for new Prison Health Board staff, and refresher training will be accessible to staff also, as and when the prison release dates.” Source location Response from Swansea Bay University Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide ACCT version 6 training to eight prison health staff.
Verbatim wording from the response “To date, 8 prison health staff have undergone the version 6 ACCT training with 22 staff members remaining. The Health Board are also negotiating securing places for the medical staff on the training. This remains very much on our radar and as the national ACCT training dates are released, securing places will be a priority for the Health Board for those individuals who work in this setting.” Source location Response from Swansea Bay University Hospital
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for ACCT training adequacy rests with the prison and will be addressed in the prison’s response.
Verbatim wording from the response “The report highlights your concern around the level and adequacy of the training on ACCT, which falls under the remit of the prison and thus will be addressed separately in the prisons response, but also concerns in respect of a bank nurse employed by SBUHB having access to the ACCT training.” Source location Response from Swansea Bay University Hospital
Open published response
Concerns raised 1 Failure to provide consistent nasogastric supplementary feeding when oral intake is insufficient View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Catherine Jane Best · 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
Catherine Jane Best was pronounced dead on 23 June 2012 at Morriston Hospital after an anoxic brain injury caused by a cardiac arrest associated with malnourishment and sepsis. The report raised concerns that nasogastric feeding was removed despite poor oral intake and was not consistently reinstated, resulting in inadequate nutritional supplementation. The inquest concluded that there had been a failure to invoke nasogastric feeding sooner when oral intake was insufficient, although it could not be determined whether this would have prevented the cardiac arrest.
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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistent nasogastric supplementary feeding when oral intake is insufficient
Wider context from the report “During the course of the inquest it was apparent that the deceased was a complex and challenging patient and her appetite was poor. Although there were attempts to get her to eat, and alternatives offered, her calorific input remained poor. Up until the 17th of May Catherine was fed using a combination of nasogastric feeding and oral intake. After that date regular NG feeding was removed despite poor oral intake. There were instances where NG feeding were re-introduced after that date but it was not consistent and there was no explanation for the removal of regular NG feeding on the 17th of May at a time when her oral intake was not sufficient to provide the required nutrition.
Whilst encouraging Catherine to obtain her calories from oral intake was appropriate there was a regular pattern of her refusing her meals or eating less than the portions provided. There was a lack of documentary evidence verifying options and encouragement although assurances that this was being done was provided by way of oral evidence. I am concerned however that in cases involving difficult or challenging patients they may not be given adequate nourishment if the oral offering is refused or partly taken. This could result in situations where a patient's ability to recover is reduced due to insufficient nourishment. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.
1. There was an inadequate regime of supplemented feeding by way of nasogastric tube meaning that Kate was not receiving a consistent amount of calories per day to increase the chances of fighting infection. Kate was a challenging patient and it could not be guaranteed that Kate would always take her meals thus ensuring that her calorie intake was obtained orally.
” 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 Deliver nutrition and enteral or parenteral nutrition training to F1 and F2 medical staff as ongoing professional development.
Verbatim wording from the response “The Nutrition and Dietetic Service deliver training sessions on nutrition and enteral/parenteral nutrition for F1 and F2 medical staff as part of their ongoing professional development.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue developing the high-nutritional-risk care plan with colleagues to support areas experiencing staff shortages.
Verbatim wording from the response “The Nutrition and Dietetic service are continuing to work with colleagues to develop this care plan to support areas of staff shortage.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a high-nutritional-risk care plan for periods of low staffing or staff redeployment.
Verbatim wording from the response “During the COVID 19 pandemic a Care Plan for the Management of High Nutritional Risk was implemented to support areas in the event of low staffing levels or staff redeployment.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver nutrition-risk, nutritional-care-pathway and enteral-feeding training through New Registrant and Nurse Induction programmes.
Verbatim wording from the response “The Nutrition and Dietetic Service delivers training on the identification of nutritional risk, nutritional care pathways and enteral tube feeding as part of the New Registrant and Nurse Induction programmes.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update eating-disorder nutritional-management and enteral-feeding guidance to reflect MARSIPAN recommendations and review it every three years.
Verbatim wording from the response “Additional SBUHB Guidance on the Nutritional Management of Patients with Eating Disorders during acute admissions and a Standard Enteral Feeding Regime for patients with Eating Disorders were published in June 2012. This guidance has been updated to reflect changes in the recommendations of the ‘MARSIPAN working group² and is reviewed every 3 years.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Apply Clinical Standards for Inpatient Nutritional Support, including consideration of enteral nutrition when oral intake is insufficient.
Verbatim wording from the response “The Clinical Standards for Inpatient Nutritional Support have been adopted by the Health Board since 2017. They include reference to consideration of enteral nutrition for patients who are unable to meet their nutritional requirements orally. An audit of compliance to the standards is undertaken every 2 years by the Nutrition and Dietetic Service with the next planned audit in autumn 2021. The results and Action Plan for improvement are agreed with the Nutrition and Dietetic Service Clinical Governance meetings.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt the All-Wales inpatient nutrition risk screening tool and provide supporting training and e-learning, with compliance monitored through the Steering Committee.
Verbatim wording from the response “In 2019, the “All Wales in Patient Nutrition Risk Screening Tool” was adopted within SBUHB following the Welsh Health Circular (2019) 026. The tool includes additional guidance on referral to Nutrition and Dietetic Services, including for those who require enteral tube feeding or where clinical judgment indicates that there are additional nutritional concerns. The implementation of the All Wales Tool was supported by additional training sessions provided by the Nutrition & Dietetic Service and the launch of an e-learning module. Compliance with the e-learning module will be monitored through the Nutrition and Hydration Steering Committee.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Screen every admitted patient for nutritional risk using the All-Wales tool and monitor intake through Food and Fluid Charts.
Verbatim wording from the response “The All-Wales Hospital Nutrition Care Pathway Protocol was adopted within the predecessor organisations of SBUHB in 2008. As part of this pathway, the Adult Nutrition Risk Screening Tool (WAASP) was used for the identification of nutritional risk. This tool is used for every patient on admission to ensure the early identification and intervention for patients at risk or presenting with malnutrition or dehydration. The pathway also mandated the use of All Wales Food and Fluid Charts which monitor patient's oral food and fluid intake to identify those patients at risk of malnutrition and to aid referral to specialist teams such as dietetics or speech and language therapists to identify poor intakes.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update refeeding-syndrome and out-of-hours enteral-feeding guidance to reflect national recommendations and clinical practice.
Verbatim wording from the response “The Swansea Bay University Health Board Guidance on the Management of Refeeding Syndrome and the Standard Out of Hours Enteral Feeding Regime have been reviewed three yearly since they were published in 2011.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with inpatient nutritional-support standards every two years and agree improvement actions through clinical governance meetings.
Verbatim wording from the response “The Clinical Standards for Inpatient Nutritional Support have been adopted by the Health Board since 2017. They include reference to consideration of enteral nutrition for patients who are unable to meet their nutritional requirements orally. An audit of compliance to the standards is undertaken every 2 years by the Nutrition and Dietetic Service with the next planned audit in autumn 2021. The results and Action Plan for improvement are agreed with the Nutrition and Dietetic Service Clinical Governance meetings.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the NG-tube insertion and management policy to include clinical decision-making guidance and deliver competency-based implementation training.
Verbatim wording from the response “The Health Board policy on the Insertion and Management of NG Feeding Tubes was updated in 2018 and includes reference to the clinical decision making process to support NG tube feeding.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
Open published response
Concerns raised 3 Lack of documentation of discrepancies between clinicians’ accounts View source Lack of an overnight consultant authorisation pathway for next-day CT scans View source Failure to perform indicated CT head scans View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Pamela Moran · 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
Pamela Moran died at Morriston Hospital on 17 March 2017 after falling at Tonna Hospital and suffering fractures and a head injury. She developed an acute on chronic intracranial bleed, and the report identified three missed opportunities for a CT head scan, along with inadequate documentation and a system that relied on junior doctors to hand over requests for scans.
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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation of discrepancies between clinicians’ accounts
Wider context from the report “During the course of the inquest a report from Dr ████████ instructed as an independent expert in this case, found 3 missed opportunities for the CT head scan to be performed. Dr ████████ conclusion noted at paragraph 6.5.6 that:
“Regional neurosurgical services keep a record of the cases referred to them and discuss all cases at a handover meeting so that if the advice given is to carry out certain investigations or initiate a line of management and then ring back the second doctor giving advice has access to the earlier information. The discrepancy between D████████ account and Dr ████████ account of the conversation on the evening of 14 March 2017 about Mrs Moran unfortunately cannot be clarified by the use of structured documentation generated by either or both parties. Dr ████████ states that he was not given Mrs Moran’s name and has relied on his memory about anticoagulation and a previous CSH not being mentioned.
The local system does not seem to facilitate an overnight consultant authorising a next day CT scan but relies on the junior doctors to hand over the task of requesting the scan again, possibly twice - firstly from the evening to the night shift doctors and then the night shift doctor to a third, different morning shift doctor. There may be other radiology services that have developed formal systems which the Health Board could adopt.”
1. There were 3 missed opportunities for a CT scan to be undertaken in this case, which may have prevented the deceased’s death, or at the very least improved her prospects of survival.
2. There appeared to be no documentation relating to the discrepancy between the accounts of Drs ████████████████ in respect of their conversation on the 14th of March 2017.
3. There does not appear to be a facility for an overnight consultant to authorise a next day CT scan, and relies on a junior doctor to hand over the task at the end of their shift.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of an overnight consultant authorisation pathway for next-day CT scans
Wider context from the report “During the course of the inquest a report from Dr ████████ instructed as an independent expert in this case, found 3 missed opportunities for the CT head scan to be performed. Dr ████████ conclusion noted at paragraph 6.5.6 that:
“Regional neurosurgical services keep a record of the cases referred to them and discuss all cases at a handover meeting so that if the advice given is to carry out certain investigations or initiate a line of management and then ring back the second doctor giving advice has access to the earlier information. The discrepancy between D████████ account and Dr ████████ account of the conversation on the evening of 14 March 2017 about Mrs Moran unfortunately cannot be clarified by the use of structured documentation generated by either or both parties. Dr ████████ states that he was not given Mrs Moran’s name and has relied on his memory about anticoagulation and a previous CSH not being mentioned.
The local system does not seem to facilitate an overnight consultant authorising a next day CT scan but relies on the junior doctors to hand over the task of requesting the scan again, possibly twice - firstly from the evening to the night shift doctors and then the night shift doctor to a third, different morning shift doctor. There may be other radiology services that have developed formal systems which the Health Board could adopt.”
1. There were 3 missed opportunities for a CT scan to be undertaken in this case, which may have prevented the deceased’s death, or at the very least improved her prospects of survival.
2. There appeared to be no documentation relating to the discrepancy between the accounts of Drs ████████████████ in respect of their conversation on the 14th of March 2017.
3. There does not appear to be a facility for an overnight consultant to authorise a next day CT scan, and relies on a junior doctor to hand over the task at the end of their shift.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to perform indicated CT head scans
Wider context from the report “During the course of the inquest a report from Dr ████████ instructed as an independent expert in this case, found 3 missed opportunities for the CT head scan to be performed . Dr ████████ conclusion noted at paragraph 6.5.6 that:
“Regional neurosurgical services keep a record of the cases referred to them and discuss all cases at a handover meeting so that if the advice given is to carry out certain investigations or initiate a line of management and then ring back the second doctor giving advice has access to the earlier information. The discrepancy between D████████ account and Dr ████████ account of the conversation on the evening of 14 March 2017 about Mrs Moran unfortunately cannot be clarified by the use of structured documentation generated by either or both parties. Dr ████████ states that he was not given Mrs Moran’s name and has relied on his memory about anticoagulation and a previous CSH not being mentioned.
The local system does not seem to facilitate an overnight consultant authorising a next day CT scan but relies on the junior doctors to hand over the task of requesting the scan again, possibly twice - firstly from the evening to the night shift doctors and then the night shift doctor to a third, different morning shift doctor. There may be other radiology services that have developed formal systems which the Health Board could adopt.”
1. There were 3 missed opportunities for a CT scan to be undertaken in this case , which may have prevented the deceased’s death, or at the very least improved her prospects of survival.
2. There appeared to be no documentation relating to the discrepancy between the accounts of Drs ████████████████ in respect of their conversation on the 14th of March 2017.
3. There does not appear to be a facility for an overnight consultant to authorise a next day CT scan, and relies on a junior doctor to hand over the task at the end of their shift.
” Open source report
Concerns raised 2 Failure to provide gateway assessors with full access to relevant review and concern notes View source Failure to make patients’ treatment wishes and concerns available for gateway assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jane Diane Livingston · 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
Jane Diane Livingston was receiving treatment for anxiety and depression and died by suicide after being found hanging in a multi-storey car park on Trawler Road, Swansea. The report identified concern that gateway assessors did not have access to her earlier review and stated concerns, potentially leading to an assessment and treatment plan based on incomplete information.
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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide gateway assessors with full access to relevant review and concern notes
Wider context from the report “During the course of the inquest it was apparent that the deceased’s wishes for hospital treatment and the reasons behind the same were not available to the gateway assessors on the 14th of December 2018. In this case the deceased underwent further assessments therefore the effects of this situation were reduced. I am concerned however that in other cases this could result in situations where a patient’s own concerns are not addressed or taken into consideration when conducting an assessment that could lead to an assessment based on incomplete information and result in another patient taking their own life.
1. The gateway assessors did not have full access to the notes relating to the review and subsequent concerns that triggered the gateway assessment. This may result in the assessors not obtaining the full picture when assessing a patient and making a treatment plan based on incomplete information .
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to make patients’ treatment wishes and concerns available for gateway assessment
Wider context from the report “During the course of the inquest it was apparent that the deceased’s wishes for hospital treatment and the reasons behind the same were not available to the gateway assessors on the 14th of December 2018. In this case the deceased underwent further assessments therefore the effects of this situation were reduced. I am concerned however that in other cases this could result in situations where a patient’s own concerns are not addressed or taken into consideration when conducting an assessment that could lead to an assessment based on incomplete information and result in another patient taking their own life.
1. The gateway assessors did not have full access to the notes relating to the review and subsequent concerns that triggered the gateway assessment. This may result in the assessors not obtaining the full picture when assessing a patient and making a treatment plan based on incomplete information.
” Open source report
10 Jun 2019 Glenys Button · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Lack of backup neurosurgical specialist capacity to field referrals View source Failure of the neurosurgical referral system to provide timely and reliable communication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Glenys Button · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Glenys Button, aged 78, died at Royal Glamorgan Hospital on 5 November 2018 after sustaining a head injury, including a basal skull fracture, pneumocephalus and brain bleed, following a likely accidental fall at home. The report raised concerns about delays, miscommunication, confusion and inadequate documentation in referrals to on-call neurosurgery, including uncertainty and changes over her potential transfer to Cardiff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swansea Bay University 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 Swansea Bay University 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
26 Feb 2019 Mr Keith Heatley · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Lack of policy or procedure for reviewing and assessing voluntarily admitted patients before home leave View source Failure to provide defined and sufficient guidance for hospital staff and patients on home leave View source Insufficient procedures for liaising with family and CPN to assess preparedness and support before patient leave View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Keith Heatley · 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 Keith Heatley was admitted voluntarily to hospital on 1 May 2018 and transferred to Ward 14, later leaving the family home during home leave on 18 May and being found in the water; the medical cause of death was drowning and the inquest reached an open conclusion. Concerns included the absence in Wales of a policy for reviewing and assessing voluntarily admitted patients before home leave, insufficient guidance for staff, and insufficient procedures for liaising with the family and community psychiatric nurse about preparedness and support.
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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of policy or procedure for reviewing and assessing voluntarily admitted patients before home leave
Wider context from the report “(1) The evidence of a Consultant Psychiatrist who was a Clinical Advisor to a Significant Incident Review stated that there was a policy in England for reviewing and assessing patients who are voluntarily admitted to hospitals before they go on home leave. There is no such policy or procedure in Wales.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide defined and sufficient guidance for hospital staff and patients on home leave
Wider context from the report “(2) As a result of there being no policy in Wales, hospital doctors and Nursing staff are reliant on ‘best practice’ however this concept is not defined nor does it provide a sufficient level of guidance for patients and staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient procedures for liaising with family and CPN to assess preparedness and support before patient leave
Wider context from the report “(3) There were no insufficient procedures in place for hospital staff to liaise with the patient’s family and CPN when leave is considered to examine the preparedness of the family and whether there were systems of support in place.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a policy addressing leave arrangements for informal patients in compliance with Welsh legislation.
Verbatim wording from the response “Furthermore, the Health Board is taking advice on the policies in place in England in terms of ensuring the Welsh legislation is complied with, Mental Health Measure 2012, which is not applicable in England. Consideration will also be given to balancing the fact that they are voluntary patients and we cannot deprive these patients of their liberties. Once the Health Board has developed a policy then it will be shared on an all Wales basis to ensure learning from this case is shared across NHS Wales.” Source location 2019-0478-Response-from-Swansea-Bay-Health-Board-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a checklist requiring multidisciplinary staff, the Community Mental Health Team and family to review and express views before informal patients take ward leave.
Verbatim wording from the response “The Regulation 28 Report related to the fact that there was no policy or procedure in place in Wales to review and assess informal patients prior to them going on leave from the Ward. The Health Board accepts that Mr Heatley’s leave should have been managed better and has implemented a checklist to ensure multi-disciplinary team members including the Community Mental Health Team and the patient’s family are aware and able to express their views on the leave, prior to the patient going on leave away from the Ward.” Source location 2019-0478-Response-from-Swansea-Bay-Health-Board-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Voluntary patients’ liberty rights constrain the Health Board’s ability to restrict their leave while developing a compliant policy.
Verbatim wording from the response “Furthermore, the Health Board is taking advice on the policies in place in England in terms of ensuring the Welsh legislation is complied with, Mental Health Measure 2012, which is not applicable in England. Consideration will also be given to balancing the fact that they are voluntary patients and we cannot deprive these patients of their liberties. Once the Health Board has developed a policy then it will be shared on an all Wales basis to ensure learning from this case is shared across NHS Wales.” Source location 2019-0478-Response-from-Swansea-Bay-Health-Board-Redacted
Open published response
Concerns raised 3 Unsuitability of Nomad trays for dispensing medication to some patients View source Failure to record care plan reviews and their outcomes View source Failure to document consideration of recent suicide attempts during care plan review View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Christopher John Llewellyn Roberts · 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
Christopher John Llewellyn Roberts was pronounced dead at his home on 19 October 2015 after an overdose involving prescribed opiate medication. He was receiving treatment for mental illness, and his medication use was described as chaotic. The report raised concerns that a care plan review was not recorded, including whether a recent overdose attempt had been considered, and that nomad trays may be unsuitable for some patients.
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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Unsuitability of Nomad trays for dispensing medication to some patients
Wider context from the report “2. Nomad trays may be unsuitable in dispensing medication to some patients , which may deprive them of the benefits in taking that medication .
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to record care plan reviews and their outcomes
Wider context from the report “1. The care plan review was not recorded which would not allow another person reviewing the file to ascertain that a care plan review had taken place and what the outcome of that review was . It was also the case that a lack of documentation would not demonstrate whether CMHT had considered the matter of the attempt on his own life by the deceased in the weeks leading up to that review, when considering whether to amend or retain the care plan in place at the time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to document consideration of recent suicide attempts during care plan review
Wider context from the report “1. The care plan review was not recorded which would not allow another person reviewing the file to ascertain that a care plan review had taken place and what the outcome of that review was. It was also the case that a lack of documentation would not demonstrate whether CMHT had considered the matter of the attempt on his own life by the deceased in the weeks leading up to that review , when considering whether to amend or retain the care plan in place at the time .
” Open source report
26 Sep 2017 Hedley Greenland · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 8 Failure to flush indwelling catheters when required View source Failure to use the Catheter Care Bundle View source Lack of training in male catheterisation View source Lack of understanding, knowledge and training in long-term indwelling catheter management View source Failure to provide written handover to incoming nursing teams View source Failure to recognise and escalate absent urine output View source Failure to actively monitor urine output View source Failure to use fluid balance charts to monitor fluid intake and urine output View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Hedley Greenland · 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
Hedley Greenland, who was residing in a nursing home and had prostate cancer requiring permanent catheterisation, became acutely unwell on 17 December 2016 and died in hospital on 20 December 2016. The inquest concluded that he died from the effects of a urine infection in circumstances where fluid input and catheter output were not adequately monitored for over nine hours. Concerns included the absence of fluid balance monitoring and written handover, inadequate catheter-care training and knowledge, and the absence of evidence that the Catheter Care Bundle was being used.
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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to flush indwelling catheters when required
Wider context from the report “(1) A fluid balance chart should have been used by nursing staff to monitor fluid intake and urine output. There was no evidence that one had been thus rendering it impossible to measure urine output which might have indicated a blockage and/or infection. It was apparent during the course of the evidence that the nurse in charge of Mr Greenland's care did not consider actively monitoring his urine output, neither did she consider flushing the catheter . There was no written handover, as the evidence showed is normally the practice, to the incoming nursing team the following morning. There was no clear evidence that the lack of urine output had been noted by the night shift with a view to escalating his care. The evidence revealed that there was no urine output for at least 9 hours but probably substantially more than that.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to use the Catheter Care Bundle
Wider context from the report “(3) There was no evidence in the medical/nursing notes that the "Catheter Care Bundle" was being used.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of training in male catheterisation
Wider context from the report “(2) The qualified nurse on duty overnight 16th/17th December was not trained in male catheterisation .
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding, knowledge and training in long-term indwelling catheter management
Wider context from the report “(4) The evidence given by two nurses involved in Mr Greenland's care revealed a clear lack of understanding, knowledge and training as to how to manage a long term indwelling catheter .
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide written handover to incoming nursing teams
Wider context from the report “(1) A fluid balance chart should have been used by nursing staff to monitor fluid intake and urine output. There was no evidence that one had been thus rendering it impossible to measure urine output which might have indicated a blockage and/or infection. It was apparent during the course of the evidence that the nurse in charge of Mr Greenland's care did not consider actively monitoring his urine output, neither did she consider flushing the catheter. There was no written handover, as the evidence showed is normally the practice, to the incoming nursing team the following morning. There was no clear evidence that the lack of urine output had been noted by the night shift with a view to escalating his care. The evidence revealed that there was no urine output for at least 9 hours but probably substantially more than that.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and escalate absent urine output
Wider context from the report “(1) A fluid balance chart should have been used by nursing staff to monitor fluid intake and urine output. There was no evidence that one had been thus rendering it impossible to measure urine output which might have indicated a blockage and/or infection. It was apparent during the course of the evidence that the nurse in charge of Mr Greenland's care did not consider actively monitoring his urine output, neither did she consider flushing the catheter. There was no written handover, as the evidence showed is normally the practice, to the incoming nursing team the following morning. There was no clear evidence that the lack of urine output had been noted by the night shift with a view to escalating his care. The evidence revealed that there was no urine output for at least 9 hours but probably substantially more than that.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to actively monitor urine output
Wider context from the report “(1) A fluid balance chart should have been used by nursing staff to monitor fluid intake and urine output. There was no evidence that one had been thus rendering it impossible to measure urine output which might have indicated a blockage and/or infection. It was apparent during the course of the evidence that the nurse in charge of Mr Greenland's care did not consider actively monitoring his urine output , neither did she consider flushing the catheter. There was no written handover, as the evidence showed is normally the practice, to the incoming nursing team the following morning. There was no clear evidence that the lack of urine output had been noted by the night shift with a view to escalating his care. The evidence revealed that there was no urine output for at least 9 hours but probably substantially more than that.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to use fluid balance charts to monitor fluid intake and urine output
Wider context from the report “(1) A fluid balance chart should have been used by nursing staff to monitor fluid intake and urine output. There was no evidence that one had been thus rendering it impossible to measure urine output which might have indicated a blockage and/or infection. It was apparent during the course of the evidence that the nurse in charge of Mr Greenland's care did not consider actively monitoring his urine output, neither did she consider flushing the catheter. There was no written handover, as the evidence showed is normally the practice, to the incoming nursing team the following morning. There was no clear evidence that the lack of urine output had been noted by the night shift with a view to escalating his care. The evidence revealed that there was no urine output for at least 9 hours but probably substantially more than that.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a central electronic booking and attendance diary for community catheterisation training.
Verbatim wording from the response “Since this incident a review has been undertaken. The Health Board have now implemented a booking and attendance system at community training which is to be recorded using an electronic central booking diary. This will ensure that accurate records are maintained of those who have attended training. It will also highlight areas where staff have not attended training.” Source location 2017-0235-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share catheter bundles and urinary-catheter passports with the Long Term Care Team for dissemination to nursing and care-home staff.
Verbatim wording from the response “Good practice documentation will be shared with the Long Term Care Team on the 31st October 2017 when the Community Continence Service and Long Term Care Team meet. This will include catheter bundles, patient urinary catheter passport for dissemination to Nursing/Care home staff. The care home sector are not currently using the above documentation in totality as the catheter passport is a new document which was recently introduced to the hospital & community setting and will now be extended to care homes.” Source location 2017-0235-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assign community catheterisation training to the Community Continence Service and secondary-care training to secondary care.
Verbatim wording from the response “Furthermore, where training for catheterisation was shared previously between all Continence Assessors, the Community Continence Service will now take responsibility for training community staff and secondary care will train staff in the secondary care setting.” Source location 2017-0235-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train Health Board nursing-home assessors in urinary-catheter management and documentation, enabling practice measurement against agreed standards.
Verbatim wording from the response “The Health Board’s Nursing home assessors will receive training from the Community Continence Service regarding the management of urinary catheters including documentation. This will provide an opportunity for Health Board Nursing Home assessors to share good practice and to measure practice within the Care home setting against agreed standards of practice.” Source location 2017-0235-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share catheterisation training dates with the Long Term Care Team to monitor attendance by care home and identify non-participating homes for closer monitoring.
Verbatim wording from the response “Training dates for catheterisation have been shared with Long Term Care Team to ensure the Health Board are able to monitor attendance from each care home. The Long Term Care Team work in partnership with Local Authority to monitor standards within the care home setting, part of this process is to review each care homes training register. Care homes that are not participating in training will be identified and monitored closely to improve compliance.” Source location 2017-0235-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Care-home staff are not obliged to attend training, and attendance depends on providers releasing staff.
Verbatim wording from the response “The Health Board also offers this training to registered nurses within the nursing home setting, however they are not obliged to attend. The Health Board encourages providers to nominate staff to attend the various training sessions offered, unfortunately the Health Board is reliant on the provider being able to release staff to attend.” Source location 2017-0235-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Because of the region’s large care-home workforce, only general continence training can be offered to all staff.
Verbatim wording from the response “Long Term Care Team will explore the feasibility of setting up a network of ‘Continence Champions’ where additional training could be provided by the Community Continence Service to cascade in all homes. Due to the large number of care home staff in the region the Health Board can offer a general level of continence training to care home staff, however, Continence Champions will be provided with a more intense programme of training to ensure they can support and advise their colleagues. Additionally, a continence e-learning link will be shared with Long Term care team for dissemination to Nursing/Care home staff.” Source location 2017-0235-Response
Open published response
9 Aug 2017 Dennis George Redmore · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Lack of management oversight to ensure required observations are carried out View source Failure to carry out neurological observations at the required frequency View source Failure to record observations View source Delay in acting on abnormal NEWS observations View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dennis George Redmore · 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
Dennis George Redmore was admitted to hospital with a blocked catheter and presumed urinary tract infection while receiving palliative treatment for lymphoma. After an unwitnessed fall in hospital on 6 March 2017, he deteriorated, was found to have a subdural haematoma, and died later the following evening. The report identified gaps in neurological observations, delayed response to abnormal observations, and inadequate management to ensure checks were completed; it did not establish that these failures caused or contributed to his death.
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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of management oversight to ensure required observations are carried out
Wider context from the report “(1) There where clear failures to monitor the deceased neurologically with gaps of several hours between observations. He should have been monitored every 30 minutes but was in fact, according to the evidence monitored at 20:15, 21:00, 22:00, 23:00, 01:00, 04:00, 07:30 and 08:50.
“NEWS” observations were carried out and one was carried out at 06:20 on the morning of the 7th March which revealed an elevation in blood pressure and pulse. That was not acted upon for approximately another hour. The evidence suggested that the observations may have undertaken but not recorded.
The clear concern is that observations were not carried out in accordance with local and national guidance. There was no clear evidence in this case that the lack of observations had in fact caused or contributed to the death of Mr Redmore but this must give rise to a concern for the welfare of others.
No appropriate management of the nurse responsible for the observations was in place to ensure the checks were carried out.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out neurological observations at the required frequency
Wider context from the report “(1) There where clear failures to monitor the deceased neurologically with gaps of several hours between observations. He should have been monitored every 30 minutes but was in fact, according to the evidence monitored at 20:15, 21:00, 22:00, 23:00, 01:00, 04:00, 07:30 and 08:50.
“NEWS” observations were carried out and one was carried out at 06:20 on the morning of the 7th March which revealed an elevation in blood pressure and pulse. That was not acted upon for approximately another hour. The evidence suggested that the observations may have undertaken but not recorded.
The clear concern is that observations were not carried out in accordance with local and national guidance. There was no clear evidence in this case that the lack of observations had in fact caused or contributed to the death of Mr Redmore but this must give rise to a concern for the welfare of others.
No appropriate management of the nurse responsible for the observations was in place to ensure the checks were carried out.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to record observations
Wider context from the report “(1) There where clear failures to monitor the deceased neurologically with gaps of several hours between observations. He should have been monitored every 30 minutes but was in fact, according to the evidence monitored at 20:15, 21:00, 22:00, 23:00, 01:00, 04:00, 07:30 and 08:50.
“NEWS” observations were carried out and one was carried out at 06:20 on the morning of the 7th March which revealed an elevation in blood pressure and pulse. That was not acted upon for approximately another hour. The evidence suggested that the observations may have undertaken but not recorded.
The clear concern is that observations were not carried out in accordance with local and national guidance. There was no clear evidence in this case that the lack of observations had in fact caused or contributed to the death of Mr Redmore but this must give rise to a concern for the welfare of others.
No appropriate management of the nurse responsible for the observations was in place to ensure the checks were carried out.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Delay in acting on abnormal NEWS observations
Wider context from the report “(1) There where clear failures to monitor the deceased neurologically with gaps of several hours between observations. He should have been monitored every 30 minutes but was in fact, according to the evidence monitored at 20:15, 21:00, 22:00, 23:00, 01:00, 04:00, 07:30 and 08:50.
“NEWS” observations were carried out and one was carried out at 06:20 on the morning of the 7th March which revealed an elevation in blood pressure and pulse. That was not acted upon for approximately another hour. The evidence suggested that the observations may have undertaken but not recorded.
The clear concern is that observations were not carried out in accordance with local and national guidance. There was no clear evidence in this case that the lack of observations had in fact caused or contributed to the death of Mr Redmore but this must give rise to a concern for the welfare of others.
No appropriate management of the nurse responsible for the observations was in place to ensure the checks were carried out.
” 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 Reiterate the leadership and delegation responsibilities of the nurse in charge to the AMU nursing team.
Verbatim wording from the response “• Ward sister to reiterate to the nursing team on AMU the Leadership and delegation responsibilities of the nurse in charge of each shift” Source location 2017-0315-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff to follow ABMU neurological observation guidelines and disseminate the guidance through nursing leadership and professional forums.
Verbatim wording from the response “• Staff to be reminded of the need to adhere to the ABMU neurological guidelines” Source location 2017-0315-Response-by-University-Health-Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit October AMU fall-patient documentation for compliance with neurological observation requirements and identify improvement and support needs.
Verbatim wording from the response “• For the month of October 2017 documentation to be reviewed (audit) on all patients who have sustained a fall on AMU which will include compliance with neurological observations” Source location 2017-0315-Response-by-University-Health-Board
Open published response
27 Apr 2017 Anton Kusz · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Delays in hospital handover causing unavailability of ambulances View source Insufficient clinician capacity for timely secondary triage of 999 calls View source Prolonged immobilisation in pain on the floor for seriously injured people awaiting ambulance care View source Delays in providing ambulance responses to urgent 999 calls View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Anton Kusz · 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
Anton Kusz, an 88-year-old care home resident, fell at breakfast on 5 January, fractured his right hip and was taken to hospital after a delay of over eight hours. He underwent surgery the following day and died on 7 January after a sudden cardiac arrest. The principal concern was the prolonged ambulance delay, including the impact of hospital handover delays and limited ambulance service resources, leaving him on the floor in pain for over eight 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital handover causing unavailability of ambulances
Wider context from the report “(1) There was a delay of over eight hours before an ambulance crew was able to convoy Mr Kusz to the hospital.
The initial 999 call was made at 0822 hours and was then chased on at least seven different occasions by the care home and also his General Practitioner who saw him in the position in which he fell 5 hours after the fall. The evidence revealed that the General Practitioner reported an occasional irregular heart beat and asked that an urgent ambulance was sent. It was not until 1447 that a Clinician, employed by the Ambulance Service reviewed and undertook a secondary triage of Mr Kusz’s case which escalated his status to a more urgent case which, if known before may have resulted in an earlier response. The evidence went on to reveal that at that time there were just three Clinicians employed by the Welsh Ambulance Service reviewing all 999 calls for across Wales.
One of the main factors accounting for the significant delay was the unavailability of resources/ambulances caused by extensive delays at hospitals across the region handing over patients at Accident and Emergency Departments. Delays of three to four hours were widely reported when the optimum period of time is fifteen minutes. This was so even though the escalation policy to “level three” (indicating severe pressure on the system) was in operation.
Whilst the evidence was equivocal as to whether the delay had directly led to Mr Kusz’s death the fact that an 88 year old gentleman with a serious injury such as a fractured hip had to remain on the floor in the same position in pain for over eight hours raises a real concern for the safety of others.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinician capacity for timely secondary triage of 999 calls
Wider context from the report “(1) There was a delay of over eight hours before an ambulance crew was able to convoy Mr Kusz to the hospital.
The initial 999 call was made at 0822 hours and was then chased on at least seven different occasions by the care home and also his General Practitioner who saw him in the position in which he fell 5 hours after the fall. The evidence revealed that the General Practitioner reported an occasional irregular heart beat and asked that an urgent ambulance was sent. It was not until 1447 that a Clinician, employed by the Ambulance Service reviewed and undertook a secondary triage of Mr Kusz’s case which escalated his status to a more urgent case which, if known before may have resulted in an earlier response. The evidence went on to reveal that at that time there were just three Clinicians employed by the Welsh Ambulance Service reviewing all 999 calls for across Wales.
One of the main factors accounting for the significant delay was the unavailability of resources/ambulances caused by extensive delays at hospitals across the region handing over patients at Accident and Emergency Departments. Delays of three to four hours were widely reported when the optimum period of time is fifteen minutes. This was so even though the escalation policy to “level three” (indicating severe pressure on the system) was in operation.
Whilst the evidence was equivocal as to whether the delay had directly led to Mr Kusz’s death the fact that an 88 year old gentleman with a serious injury such as a fractured hip had to remain on the floor in the same position in pain for over eight hours raises a real concern for the safety of others.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Prolonged immobilisation in pain on the floor for seriously injured people awaiting ambulance care
Wider context from the report “(1) There was a delay of over eight hours before an ambulance crew was able to convoy Mr Kusz to the hospital.
The initial 999 call was made at 0822 hours and was then chased on at least seven different occasions by the care home and also his General Practitioner who saw him in the position in which he fell 5 hours after the fall. The evidence revealed that the General Practitioner reported an occasional irregular heart beat and asked that an urgent ambulance was sent. It was not until 1447 that a Clinician, employed by the Ambulance Service reviewed and undertook a secondary triage of Mr Kusz’s case which escalated his status to a more urgent case which, if known before may have resulted in an earlier response. The evidence went on to reveal that at that time there were just three Clinicians employed by the Welsh Ambulance Service reviewing all 999 calls for across Wales.
One of the main factors accounting for the significant delay was the unavailability of resources/ambulances caused by extensive delays at hospitals across the region handing over patients at Accident and Emergency Departments. Delays of three to four hours were widely reported when the optimum period of time is fifteen minutes. This was so even though the escalation policy to “level three” (indicating severe pressure on the system) was in operation.
Whilst the evidence was equivocal as to whether the delay had directly led to Mr Kusz’s death the fact that an 88 year old gentleman with a serious injury such as a fractured hip had to remain on the floor in the same position in pain for over eight hours raises a real concern for the safety of others.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Delays in providing ambulance responses to urgent 999 calls
Wider context from the report “(1) There was a delay of over eight hours before an ambulance crew was able to convoy Mr Kusz to the hospital.
The initial 999 call was made at 0822 hours and was then chased on at least seven different occasions by the care home and also his General Practitioner who saw him in the position in which he fell 5 hours after the fall. The evidence revealed that the General Practitioner reported an occasional irregular heart beat and asked that an urgent ambulance was sent . It was not until 1447 that a Clinician, employed by the Ambulance Service reviewed and undertook a secondary triage of Mr Kusz’s case which escalated his status to a more urgent case which, if known before may have resulted in an earlier response. The evidence went on to reveal that at that time there were just three Clinicians employed by the Welsh Ambulance Service reviewing all 999 calls for across Wales.
One of the main factors accounting for the significant delay was the unavailability of resources/ambulances caused by extensive delays at hospitals across the region handing over patients at Accident and Emergency Departments. Delays of three to four hours were widely reported when the optimum period of time is fifteen minutes. This was so even though the escalation policy to “level three” (indicating severe pressure on the system) was in operation.
Whilst the evidence was equivocal as to whether the delay had directly led to Mr Kusz’s death the fact that an 88 year old gentleman with a serious injury such as a fractured hip had to remain on the floor in the same position in pain for over eight hours raises a real concern for the safety of others.
” Open source report
22 Dec 2016 Edwina Rose Moses · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Unavailability of additional nursing cover for one-to-one support View source Failure to clearly allocate responsibility for requesting and securing additional nursing cover for one-to-one support View source Inadequate ward staffing levels for safely caring for patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Edwina Rose Moses · 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
Edwina Rose Moses was admitted to hospital after a fall at home that fractured her left hip. While in hospital, she fell from her bed at a time when she should have been receiving one-to-one nursing care, fractured her right hip, and later died following an upper gastrointestinal bleed; concerns included poor systems for arranging additional nursing cover and inadequate staffing when such cover was unavailable.
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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of additional nursing cover for one-to-one support
Wider context from the report “2. The evidence showed that it was common place for additional nursing cover not to attend and staff were then left to provide one to one cover alongside their main stream duties – which was wholly unrealistic. Given the apparent frequency in which additional nursing cover is “unavailable” , often in the context of dealing with patients suffering with dementia, the issue of appropriate staffing levels on wards and the ability of staff to safely look after patients must be a concern.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly allocate responsibility for requesting and securing additional nursing cover for one-to-one support
Wider context from the report “1. The evidence revealed that there was a poor system in place for requesting additional nursing cover to provide one to one support . There was confusion by front line staff as to who was responsible for identifying, booking and ensuring that such help was provided .
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate ward staffing levels for safely caring for patients
Wider context from the report “2. The evidence showed that it was common place for additional nursing cover not to attend and staff were then left to provide one to one cover alongside their main stream duties – which was wholly unrealistic . Given the apparent frequency in which additional nursing cover is “unavailable”, often in the context of dealing with patients suffering with dementia, the issue of appropriate staffing levels on wards and the ability of staff to safely look after patients must be a concern .
” 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 Establish daily staffing monitoring that identifies patients requiring enhanced observation, includes out-of-hours handover, and checks Nurse Bank availability.
Verbatim wording from the response “The Princess of Wales Hospital Managed Unit has reviewed its process around enhanced observation. The review included the standard of completion of Risk Assessments and introducing a process to monitor staffing levels across the site which will include the identification of all patients requiring enhanced observation. There is daily monitoring of staffing levels in place which is subsequently handed over to the Out of Hours team for evenings and weekends. All staff have been made aware of the process to check the Nurse Bank system. This work will link into the Health Board Falls Management group as prevention of falls is one of the main criteria for requesting enhanced observation.” Source location 2016-0462-Response-by-University-Health-Board.pdf
Open published response
21 Dec 2016 David Bassett COOPER · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Lack of comprehensive transfer handover of falls risk View source Shortcomings in booking additional staff for 1:1 care View source Failure to integrate and respond to the whole picture of ongoing falls risk View source Inaccurate and incomplete nursing notes and falls records View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Bassett COOPER · 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
David Bassett Cooper was admitted to hospital after a serious head injury caused by a fall in the community and sustained nine further falls while being transferred between wards. He died from a subdural haematoma caused by the final fall on 5 March 2016. The concerns included inadequate handovers about falls risk, incomplete nursing records, a failure to see the overall pattern of falls, and shortcomings in arranging additional one-to-one nursing care.
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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of comprehensive transfer handover of falls risk
Wider context from the report “1. When transfers between wards took place, the evidence revealed that there was a lack of comprehensive hand-over by the transferring ward to the receiving ward especially in terms of identifying the patient’s risk of falls . For example, on ward 18 Mr Cooper was in receipt of ‘1:1’ nursing care, but on transfer to ward 21, not only was that never given, but the evidence suggested it was not considered.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Shortcomings in booking additional staff for 1:1 care
Wider context from the report “4. As with many other cases involving patients at high risk of falls, the evidence revealed shortcomings in the system used for booking additional staff to provide ‘1:1’ care , revealing a system which left front line nursing staff unable to cope with the challenges in looking after the most vulnerable.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Failure to integrate and respond to the whole picture of ongoing falls risk
Wider context from the report “3. The evidence revealed that there was a distinct lack of “joined up” thinking and a failure to see the “whole picture” . Mr Cooper’s risk of falling was as high when he was admitted in October 2015 as it was when he died in March 2016, but still he sustained 9 falls.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and incomplete nursing notes and falls records
Wider context from the report “2. The accuracy and completeness of nursing notes and records left much to be desired . For example, on Ward 21 when he fell three times, there was no entry made in the Falls Diary – a document which was supposed to act as a tool for nursing staff to assess whether there was a pattern to the numerous falls being sustained – save for the last fall on 5th March. This deprived staff of the opportunity to see the ‘whole picture’ and to take into consideration the eight falls which he had sustained up to that point.
” 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 Falls Management Group scrutiny of training, individual falls reviews and performance data.
Verbatim wording from the response “The Falls Management Group will continue to meet as a scrutiny panel to ensure that appropriate training and individual falls scrutiny is being undertaken along with continued review of performance data. ████████ Consultant Physician and Geriatrician, will be leading the Falls Management Group.” Source location 2016-0459-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce National Patient Safety Agency falls risk assessments.
Verbatim wording from the response “The Health Board established a Falls Management Group in September 2015. This was a task and finish group that reviewed policies and training requirements in relation to falls management. The Health Board introduced the National Patient Safety Agency’s Risk Assessments and I enclose the Health Board’s Falls Policy and other supporting information for your review. The Falls Management Group last met in December 2016 and devolved falls management to the Directly Managed Units to ensure clinical orientation and responsibility.” Source location 2016-0459-Response-by-University-Health-Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Falls management is devolved to directly managed units, while the Falls Management Group retains scrutiny and performance-review functions.
Verbatim wording from the response “The Health Board established a Falls Management Group in September 2015. This was a task and finish group that reviewed policies and training requirements in relation to falls management. The Health Board introduced the National Patient Safety Agency’s Risk Assessments and I enclose the Health Board’s Falls Policy and other supporting information for your review. The Falls Management Group last met in December 2016 and devolved falls management to the Directly Managed Units to ensure clinical orientation and responsibility.” Source location 2016-0459-Response-by-University-Health-Board
Open published response
5 Sep 2016 Dr Imad Hassan · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Lack of a bed management pathway View source Lack of an agreed tertiary-services pathway for unconscious STEMI patients requiring PCI View source Insufficient capacity for admission to designated hospitals for PCI View source Lack of capacity for rescue PCI at designated hospitals View source Lack of an agreed pathway to access adult critical care beds outside Wales View source Lack of a formal backup plan for PCI when designated hospitals cannot accept a patient View source See 3 more concerns
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
Dr Imad Hassan · 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
On 17 April 2016, Dr Imad Hassan suffered an out-of-hospital heart attack and cardiac arrest, was resuscitated, and taken to Prince Charles Hospital. He suffered a further cardiac arrest and died at 04:35 on 18 April 2016. The report raised concerns about the lack of a formal backup and transfer pathway for patients requiring PCI when capacity was unavailable at the relevant hospitals, including for unconscious STEMI patients.
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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a bed management pathway
Wider context from the report “3) As per the evidence of ████████ given at inquest, an agreed short term pathway needs to be put in place to access adult critical care beds outside Wales and a bed management pathway put in place .
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed tertiary-services pathway for unconscious STEMI patients requiring PCI
Wider context from the report “4) There is currently no agreed pathway for an unconscious STEMI patient requiring PCI in tertiary services as there is currently for conscious patients with STEMI. Although in the case of Dr Hassan transfer to another hospital for a rescue PCI was not clinically indicated, that may not necessarily be the case in the future, particularly in a patient who has had a short period of unconsciousness and a PCI is clinically indicated.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity for admission to designated hospitals for PCI
Wider context from the report “2) In such circumstances, a patient meeting the criteria for PCI is unable to undergo that procedure, increasing the risk of his/her death, until there is such capacity for that patient to be admitted to UHW or Morriston Hospitals for PCI .
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of capacity for rescue PCI at designated hospitals
Wider context from the report “5) In similar circumstances as pertained on the evening prior to / the morning of Dr Hassan's death such a patient (as described in 4)) may be deprived the opportunity of undergoing rescue PCI due to lack of capacity at either UHW in Cardiff or Morriston in Swansea .
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed pathway to access adult critical care beds outside Wales
Wider context from the report “3) As per the evidence of ████████ given at inquest, an agreed short term pathway needs to be put in place to access adult critical care beds outside Wales and a bed management pathway put in place.
” 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 Swansea Bay University Local Health Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal backup plan for PCI when designated hospitals cannot accept a patient
Wider context from the report “1) In the event that a patient at Prince Charles Hospital is deemed suitable for PCI there is currently no formal back up plan in place , to enable the PCI to proceed, should UHW in Cardiff or Morriston Hospital in Swansea be unable to accept that patient.
” 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