First report 28 Aug 2013•Latest report 27 Feb 2026
Recipient record
Reports, concerns and published responses
Health and care · Local health board. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.
Reports
29
Naming this recipient
Published responses
66%
Found for named reports
Concerns addressed
48
Across all linked responses
Stated actions
177
Described in responses
Reports over time
Reports over time
Reports naming this recipient by issue year.
Evidence profile
Report topics
Share of this recipient’s reports compared with all other recipients.
66%published responses found
177stated actions described
Topic comparisons are not available in the current evidence snapshot.
Concerns and recipient responses
Statements from Swansea Bay University Local Health Board linked to the concerns in each report. Select any concern, action or position to view the source wording.
Powys, Bridgend and Glamorgan Valleys
Concerns raised3
Lack of transfer handover information about high falls risk
Failure to carry out falls risk assessments on readmission and after successive falls
Insufficient staffing for required one-to-one nursing observation of patients at high risk of falls
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.
Powys, Bridgend and Glamorgan Valleys
Concerns raised3
Unwitnessed patient falls
Failure to prevent falls among patients identified as being at high risk of falling
Failure to complete transfer documentation between wards
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.
Addressed to “Abertawe Bro Morgannwg University Health Board”, a former name of Swansea Bay University Local Health Board.
Powys, Bridgend & Glamorgan Valleys
Concerns raised2
Failure of paper records to accurately document Consultant patient review
Unavailability of Community medical records at hospital admission
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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.6
Action
Replace tick-box tracking with standardized ED and AMU registers requiring consultant signatures to provide auditable confirmation of patient review.
Stated completedThe respondent said that this action was complete when they made their response on 4 March 2015.
Action
Implement ward documentation requiring the senior reviewing clinician to record completion and timing of review for ward staff.
Stated completedThe respondent said that this action was complete when they made their response on 4 March 2015.
Action
Implement the national Symphony emergency department system across Health Board emergency and assessment units, beginning at specified hospitals in September 2015 and continuing in November 2015.
Stated plannedThe respondent said that this action was planned when they made their response on 4 March 2015.
Action
Continue monitoring the review-tracking system and have the Clinical Director review consultant working practices while supporting development of an electronic system.
Stated in progressThe respondent said that this action was in progress when they made their response on 4 March 2015.
Action
Reinforce with consultants and nursing staff their responsibilities for authenticating and checking documentation of senior patient review.
Stated completedThe respondent said that this action was complete when they made their response on 4 March 2015.
Action
Pilot a live electronic work list to notify teams about patients requiring review and treatment decisions, with auditable, time-stamped entries.
Stated in progressThe respondent said that this action was in progress when they made their response on 4 March 2015.
Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2
Position
Electronic community health records cannot be provided locally until national pilot studies are completed and the service is extended to hospital emergency settings.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Existing clinical assessment documentation and nursing escalation arrangements sufficiently notify ward staff whether senior review has occurred.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Powys, Bridgend and Glamorgan Valleys
Concerns raised3
Failure of communication between the care home, district nurses and out of hours GP
Failure to provide timely clinical assessment of a patient's condition
Lack of direct monitoring of oral input and urinary output at the care home
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.6
Action
Develop a clear out-of-hours escalation process for resolving disputed clinical issues.
Stated plannedThe respondent said that this action was planned when they made their response on 28 August 2013.
Action
Implement clear, auditable message sheets for out-of-hours district nursing referrals through the Princess of Wales Hospital switchboard.
Stated completedThe respondent said that this action was complete when they made their response on 28 August 2013.
Action
Introduce a Bridgend weekend rota of on-duty district nurse mobile telephone numbers for the out-of-hours GP service.
Stated plannedThe respondent said that this action was planned when they made their response on 28 August 2013.
Action
Implement SBAR referral and handover documentation for district nursing and out-of-hours GP communication, with staff training on its use.
Stated completedThe respondent said that this action was complete when they made their response on 28 August 2013.
Action
Disseminate reminders to out-of-hours GPs requiring direct discussion with the clinician accepting responsibility for a patient's care.
Stated completedThe respondent said that this action was complete when they made their response on 28 August 2013.
Action
Require direct clinician-to-clinician handover of care and verbal communication of outstanding problems during shift changes.
Stated plannedThe respondent said that this action was planned when they made their response on 28 August 2013.
Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1
Position
The district nursing assessment was appropriate because the catheter was draining freely; the patient required medical rather than nursing assessment.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Request correction
Addressed to “Abertawe Bro Morgannwg University Health Board”, a former name of Swansea Bay University Local Health Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations