Ty Nant Nursing Home

Private and voluntary organisations · Nursing home

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First report 26 Sep 2017•Latest report 26 Sep 2017

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from Ty Nant Nursing Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

26 Sep2017
South Wales Central
Concerns raised8
1. Failure to flush indwelling catheters when required
2. Failure to use the Catheter Care Bundle
3. Lack of training in male catheterisation
1. Lack of understanding, knowledge and training in long-term indwelling catheter management
2. Failure to provide written handover to incoming nursing teams
3. Failure to recognise and escalate absent urine output
4. Failure to actively monitor urine output
5. Failure to use fluid balance charts to monitor fluid intake and urine output
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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 Ty Nant Nursing Home; 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 Ty Nant Nursing Home; 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 Ty Nant Nursing Home; 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 Ty Nant Nursing Home; 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 Ty Nant Nursing Home; 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 Ty Nant Nursing Home; 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 Ty Nant Nursing Home; 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 Ty Nant Nursing Home; 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

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised8

Failure to flush indwelling catheters when required

Failure to use the Catheter Care Bundle

Lack of training in male catheterisation

Lack of understanding, knowledge and training in long-term indwelling catheter management

Failure to provide written handover to incoming nursing teams

Failure to recognise and escalate absent urine output

Failure to actively monitor urine output

Failure to use fluid balance charts to monitor fluid intake and urine output