Velindre NHS Trust

Health and care · NHS trust

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First report 6 Oct 2025•Latest report 27 Feb 2026

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: 2
Published responses: 50%
Concerns addressed: 3
Stated actions: 19

Concerns and recipient responses

Statements from Velindre NHS Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

27 Feb2026
South Wales Central
Concerns raised1
1. Lack of standardised crash trolleys across hospital settings
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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.

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 Velindre NHS Trust; 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
6 Oct2025
Gwent
Concerns raised3
1. Failure to govern and monitor decisions on face to face dietetic appointments
2. Lack of adequate dietetic assessment
3. Failure of communication between hospital and community dietetic teams
Actions described in response 14
1. Action
  Maintain read-only Clinical WorkStation access for all Velindre dietitians as part of routine practice.
2. Action
  Complete ratification and implementation of the multidisciplinary team checklist for complex nutritional care patients.
3. Action
  Audit the multidisciplinary team checklist and share learning through quality and safety governance.
1. Action
  Continue monthly joint dietetic professional meetings with Aneurin Bevan University Health Board.
2. Action
  Implement the approved dietetic Standard Operating Procedure across relevant Velindre Cancer Service teams.
3. Action
  Engage with Welsh dietetic leaders to strengthen cross-boundary referral and patient handover processes.
4. Action
  Develop dietetic assessment standards and a Standard Operating Procedure for telephone reviews and face-to-face consultations.
5. Action
  Audit the implemented dietetic Standard Operating Procedure and share learning through quality and safety governance.
6. Action
  Strengthen dietetic governance through enhanced risk reporting, service-risk visibility and oversight of multidisciplinary clinical standards.
7. Action
  Implement a joint communication protocol for shared-care patients across hospital and community dietetic services.
8. Action
  Use the interim shared-care transfer document for transfers between Velindre Cancer Service and Aneurin Bevan University Health Board.
9. Action
  Formalise digital access arrangements across all health boards commissioned to provide services to Velindre Cancer Service.
10. Action
  Replicate pathway, communication and transfer safety processes across all health boards commissioned to provide services to Velindre Cancer Service.
11. Action
  Finalise the dietetic Standard Operating Procedure and submit it for internal governance approval.
Respondent positions 1
1. Position
  The actions taken are considered robust enough to prevent future deaths related to dietetic support and provision.
  Existing arrangements considered sufficient
AI-generated summary

Steven Paul TURZYNSKI · 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

Steven Paul Turzynski, who had lung cancer and a history of treated oropharyngeal cancer, died from the effects of lung cancer on 29 July 2024. The report identified very limited communication between the two dietetic teams, lack of shared records, and inadequate nutritional assessment, with significant undernutrition by the time of 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 Velindre NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to govern and monitor decisions on face to face dietetic appointments
Wider context from the report
“Steven Paul Turzynski died from the effects of cancer, which was also responsible for his nutritional status. However the almost absent communication between the two dietetic teams and the lack of adequate assessment during the last 12 months of Steven’s life contributed to his poor nutritional state. I was informed at the inquest that the need for a face to face appointment is entirely a matter for the individual dietician. However, this decision making is not governed by guidelines nor is it monitored and can lead to an over-reliance of telephone assessments. ”
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 Velindre NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of adequate dietetic assessment
Wider context from the report
“Steven Paul Turzynski died from the effects of cancer, which was also responsible for his nutritional status. However the almost absent communication between the two dietetic teams and the lack of adequate assessment during the last 12 months of Steven’s life contributed to his poor nutritional state. I was informed at the inquest that the need for a face to face appointment is entirely a matter for the individual dietician. However, this decision making is not governed by guidelines nor is it monitored and can lead to an over-reliance of telephone assessments. ”
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 Velindre NHS Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure of communication between hospital and community dietetic teams
Wider context from the report
“Steven Paul Turzynski died from the effects of cancer, which was also responsible for his nutritional status. However the almost absent communication between the two dietetic teams and the lack of adequate assessment during the last 12 months of Steven’s life contributed to his poor nutritional state. I was informed at the inquest that the need for a face to face appointment is entirely a matter for the individual dietician. However, this decision making is not governed by guidelines nor is it monitored and can lead to an over-reliance of telephone assessments. ”
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 read-only Clinical WorkStation access for all Velindre dietitians as part of routine practice.

Verbatim wording from the response
“1. Safety action description (SMART): To ensure all Dietitians have access to Clinical WorkStation (CWS) to enable full notes to be accessible between VCS and ABUHB.”

Source location
Response from Velindre University NHS Trust
Page 10 · response
Published 9 October 2025
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
Complete ratification and implementation of the multidisciplinary team checklist for complex nutritional care patients.

Verbatim wording from the response
“3. Safety action description (SMART): To improve multi-disciplinary communication and working processes between VCS and ABUHB by introducing a shared communication protocol/checklist and establishing when urgent joint MDT meetings are required.”

Source location
Response from Velindre University NHS Trust
Page 7 · response
Published 9 October 2025
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 the multidisciplinary team checklist and share learning through quality and safety governance.

Verbatim wording from the response
“Proposed action: Draft MDT checklist will go through the internal ratification process and be implemented. To ensure the checklist is robust and fit for purpose, it is necessary to undertake an audit of the checklist. This will be recorded and tracked on our internal audit governance system (AMaT) and will be reported through internal governance at quality and safety board meetings.”

Source location
Response from Velindre University NHS Trust
Page 7 · response
Published 9 October 2025
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
Continue monthly joint dietetic professional meetings with Aneurin Bevan University Health Board.

Verbatim wording from the response
“• Quarterly joint dietetic meetings with ABUHB to support shared learning and early escalation of any potential risks or issues”

Source location
Response from Velindre University NHS Trust
Page 2 · response
Published 9 October 2025
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 the approved dietetic Standard Operating Procedure across relevant Velindre Cancer Service teams.

Verbatim wording from the response
“We also recognised following the inquest the risk of not seeing patients face to face and we have developed plans and guidelines to ensure the adequacy of dietetic assessments over the phone, and a minimum standard set for face-to-face consultations. The steps we have taken to date include benchmarking locally, regionally and nationally to help inform the development of a draft Standard Operating Procedure which, following approval, will be evaluated to ensure that it is embedded into practice.”

Source location
Response from Velindre University NHS Trust
Page 3 · response
Published 9 October 2025
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
Engage with Welsh dietetic leaders to strengthen cross-boundary referral and patient handover processes.

Verbatim wording from the response
“• Active engagement with the Welsh Dietetic Leaders Advisory Group (WDLAG) to strengthen cross-boundary referral processes”

Source location
Response from Velindre University NHS Trust
Page 3 · response
Published 9 October 2025
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
Develop dietetic assessment standards and a Standard Operating Procedure for telephone reviews and face-to-face consultations.

Verbatim wording from the response
“We also recognised following the inquest the risk of not seeing patients face to face and we have developed plans and guidelines to ensure the adequacy of dietetic assessments over the phone, and a minimum standard set for face-to-face consultations. The steps we have taken to date include benchmarking locally, regionally and nationally to help inform the development of a draft Standard Operating Procedure which, following approval, will be evaluated to ensure that it is embedded into practice.”

Source location
Response from Velindre University NHS Trust
Page 3 · response
Published 9 October 2025
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 the implemented dietetic Standard Operating Procedure and share learning through quality and safety governance.

Verbatim wording from the response
“2. Safety action description (SMART): To provide assurance that the SOP developed under safety action #1 is robust and embedded into practice.”

Source location
Response from Velindre University NHS Trust
Page 12 · response
Published 9 October 2025
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
Strengthen dietetic governance through enhanced risk reporting, service-risk visibility and oversight of multidisciplinary clinical standards.

Verbatim wording from the response
“To ensure sustained system-wide improvements, Velindre Cancer Service has strengthened its governance arrangements relating to dietetic care, including enhanced reporting mechanisms, improved visibility of service risks, and increased oversight of multi-professional clinical standards. We have implemented a series of measures to improve co-working and communication between hospital and community dietetic services, including:”

Source location
Response from Velindre University NHS Trust
Page 2 · response
Published 9 October 2025
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 joint communication protocol for shared-care patients across hospital and community dietetic services.

Verbatim wording from the response
“To ensure sustained system-wide improvements, Velindre Cancer Service has strengthened its governance arrangements relating to dietetic care, including enhanced reporting mechanisms, improved visibility of service risks, and increased oversight of multi-professional clinical standards. We have implemented a series of measures to improve co-working and communication between hospital and community dietetic services, including:”

Source location
Response from Velindre University NHS Trust
Page 2 · response
Published 9 October 2025
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
Use the interim shared-care transfer document for transfers between Velindre Cancer Service and Aneurin Bevan University Health Board.

Verbatim wording from the response
“• Development of an interim shared care transfer document until the All-Wales standard is formally approved”

Source location
Response from Velindre University NHS Trust
Page 2 · response
Published 9 October 2025
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
Formalise digital access arrangements across all health boards commissioned to provide services to Velindre Cancer Service.

Verbatim wording from the response
“3. Safety action description (SMART): To ensure replication of safety action #1 & 2 above, across all VCS commissioned health boards in Wales.”

Source location
Response from Velindre University NHS Trust
Page 11 · response
Published 9 October 2025
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
Replicate pathway, communication and transfer safety processes across all health boards commissioned to provide services to Velindre Cancer Service.

Verbatim wording from the response
“5. To ensure replication of safety action #1,3 &4 above, across all VCS commissioned health boards in Wales.”

Source location
Response from Velindre University NHS Trust
Page 9 · response
Published 9 October 2025
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
Finalise the dietetic Standard Operating Procedure and submit it for internal governance approval.

Verbatim wording from the response
“Proposed action: To finalise the Standard Operating Procedure (SOP) for dietetic provision of care and submit it through the Velindre Cancer Service (VCS) internal governance process for approval.”

Source location
Response from Velindre University NHS Trust
Page 11 · response
Published 9 October 2025
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 actions taken are considered robust enough to prevent future deaths related to dietetic support and provision.

Verbatim wording from the response
“I hope that this response provides you with the assurance required that the action we have taken is robust enough to prevent future deaths related to dietetic support and provision.”

Source location
Response from Velindre University NHS Trust
Page 3 · response
Published 9 October 2025
Open published response