Recipient

Velindre NHS Trust

First report 6 Oct 2025•Latest report 27 Feb 2026

Recipient record

Reports, concerns and published responses

Health and care · NHS trust. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
2

Naming this recipient

Published responses
50%

Found for named reports

Concerns addressed
3

Across all linked responses

Stated actions
19

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.

50%published responses found
19stated actions described

Topic comparisons are not available in the current evidence snapshot.

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.

  1. South Wales Central

    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
  2. Gwent

    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
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

50%
50%All other recipients 58%
0%100%

How actions were described at the time

This respondent
26%26%47%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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