Welsh GovernmentIncludes reports addressed to a minister or senior office-holder acting for this organisation.

Central government · Devolved government

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First report 17 Dec 2013•Latest report 6 May 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
62

Naming this recipient

Published responses
52%

Found for named reports

Concerns addressed
63

Across all linked responses

Stated actions
174

Described in responses

Concerns and recipient responses

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

  1. Cardiff and the Vale of Glamorgan

    AI-generated summary

    Kathleen Ludmila Neville · 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

    Kathleen Ludmila Neville was admitted to hospital after an accidental fall that fractured her femur and later died following complications after surgery and a prolonged hospital stay. Her regular thyroid medication was omitted for five weeks because it was not recorded on the drug chart and the hospital lacked a Medication Reconciliation Policy; this contributed to lassitude and confusion but not to her death. The principal concern was that the absence of such a policy could allow medication errors to persist and potentially contribute to future deaths, particularly with medicines whose omission could be fatal.

    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of a medication reconciliation policy at the University Hospital of Wales

    Wider context from the report

    “(1) The absence of a Medication Reconciliation Policy at the University Hospital of Wales over the relevant period made it much harder for the individual failures of the admitting doctor and initial pharmacist to be picked up. As a consequence Kathleen Neville was deprived of her medication for a much longer period than would otherwise have been the case. (2) While the Coroner found in this inquest that the omission of Levothyroxine did not contribute to the eventual outcome, the position would have been far different in the case of other drugs where omission of medication might lead directly to death (e.g. in insulin). In such cases the absence of a Medication Reconciliation Policy assist in picking up individual failures could lead to future deaths. The Coroner found that any system that relies solely on individual human excellence without a supporting policy is eventually bound to fail through individual human error. ”
    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of medication reconciliation policies at other Health Boards across Wales

    Wider context from the report

    “(4) The Coroner is concerned that there may be other Health Boards across Wales that have still not adopted a Medication Reconciliation Policy as recommended by NICE. Future lives may be lost if a Health Board does not have such a policy and similar prescription errors are made. The Coroner is concerned that all Health Boards across Wales should learn the lessons of this inquest and have a Medication Reconciliation Policy in place to prevent future deaths in similar circumstances. ”
    Open source report

  2. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Mr. Arthur Cook · 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. Arthur Cook had poor circulation and a chronic open wound that developed into an MRSA-infected category 4 pressure ulcer while he was resident at Four Seasons Healthcare Residential Home. He failed to respond to treatment and died. Concerns included insufficient tissue viability nursing capacity, inadequate pressure-ulcer documentation and repositioning charts, and a lack of integrated skin care across services.

    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient staffing of Tissue Viability Nurses

    Wider context from the report

    “(1) Staffing levels of Tissue Viability Nurses within the Aneurin Bevan Health Board are low and to the extent that at times this service cannot be provided according to need; ”
    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain adequate repositioning charts

    Wider context from the report

    “(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal. ”
    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain adequate pressure ulcer documentation

    Wider context from the report

    “(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal. ”
    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of integrated skin care across Health Boards and Primary healthcare services

    Wider context from the report

    “(3) An apparent lack of integrated skin care within and between Health Boards and Primary healthcare services. ”
    Open source report

  3. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Mr. Alun Walters · 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. Alun Walters, who was prescribed Warfarin following receipt of a metallic heart valve, died after a gastro-intestinal haemorrhage in circumstances of suspected elevated Warfarin levels and failed INR monitoring. His prescriptions continued despite no INR tests after November 2013, and 51 prescriptions were provided without dosage assessment. Concerns included failures by the medical practice in monitoring, prescription systems and notifying the pharmacy that Warfarin had been withdrawn, while the pharmacy supplied Warfarin without a valid prescription.

    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to advise the pharmacy of Warfarin withdrawal due to lack of INR safety testing

    Wider context from the report

    “The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to develop and maintain an anti-coagulation treatment register

    Wider context from the report

    “The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to use computer software to support prescription decisions

    Wider context from the report

    “The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to implement notification of failed attendance for INR testing

    Wider context from the report

    “The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
    Open source report

  4. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Mrs. Gail Prentice · 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

    Mrs. Gail Prentice, aged 46, died after severe bleeding during an attempted percutaneous tracheostomy, caused by transection of the brachiocephalic artery. The report describes concerns about tracheostomy in altered neck anatomy following previous surgery, including the need for appropriate imaging and site selection, and about surgeons acknowledging relevant hospital and other guidelines.

    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure surgeons acknowledge having read applicable clinical guidelines

    Wider context from the report

    “(1) The requirement for surgeons to acknowledge having read the Health Board’s Hospital Guidelines and those of other bodies e.g. NICE Guidelines ”
    Open source report

  5. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Mrs. Hilda May Harris · 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

    Mrs. Hilda May Harris, aged 86, suffered a cerebral infarction with an intracerebral haemorrhage on 04.01.15 after an additional INR test was not undertaken while she was taking Warfarin alongside medication for gout. The report identified unreliable systems for booking community INR tests and for notifying or acting on omissions.

    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Unreliable booking system for community INR testing

    Wider context from the report

    “(1) The current booking system for community INR testing is unreliable with scope for appointments not being transferred from one set of papers to another. (2) Where an omission occurs, the notification system (by the family or carers) also appears unreliable. ”
    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Unreliable notification system for omissions by family or carers

    Wider context from the report

    “(1) The current booking system for community INR testing is unreliable with scope for appointments not being transferred from one set of papers to another. (2) Where an omission occurs, the notification system (by the family or carers) also appears unreliable. ”
    Open source report

  6. Carmarthenshire and Pembrokeshire

    AI-generated summary

    Efan Robert James · 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

    Efan Robert James was found unresponsive after being placed in a bed shared by his mother and a friend, and died after being taken to hospital. The report raised concern that government advice about bed-sharing was confusing because assessing whether parents feel “very tired” was considered unrealistic.

    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Confusing and unrealistic guidance on bed-sharing when parents feel tired

    Wider context from the report

    “That the advice given by Welsh Assembly Government in the publication “Reduce the risk of cot death” is confusing. It suggests that parents should not share a bed with their baby if they “feel very tired”. Parents of young children will frequently feel tired and gauging whether they are “very tired” is an unrealistic test. ”
    Open source report

  7. Powys, Bridgend & Glamorgan Valleys

    AI-generated summary

    Mr. Brian Francis · 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. Brian Francis was admitted to Princess of Wales Hospital on 5 September 2014 after several days of illness and was treated for presumed chest sepsis. He died of a pulmonary embolism the following day. Concerns included a failed process for recording Consultant attendance and the unavailability of Community medical records, which may have affected assessment and the commencement of anti-coagulation therapy.

    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of paper records to accurately document Consultant patient review

    Wider context from the report

    “(1) The process of a Consultant’s attendance on patient being noted by a ‘tick in the box’ on a paper record failed. The box had been ticked when in fact the patient had not been reviewed by the Consultant. ”
    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of Community medical records at hospital admission

    Wider context from the report

    “(2) Had the Community medical records been available at the time of hospital admission the patient would most probably have been assessed differently and in all probability, anti-coagulation therapy commenced immediately or shortly thereafter. ”
    Open source report

  8. Swansea and Neath Port Talbot

    AI-generated summary

    Alan Vaughan Jones · 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 Vaughan Jones had Addison’s disease and became unable to take his steroid medication after developing gastroenteritis. His condition deteriorated, and he died at 08.50 hours on 8 April 2011; the inquest concluded that Addison’s Disease resulted from neglect. Concerns included inadequate training in the use of electronic patient-record software and failures of the software to highlight important diagnosed conditions as alerts.

    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of software programs to provide interruptive alerts for important diagnosed conditions

    Wider context from the report

    “(2) An apparent failure in the software programs themselves to highlight important diagnosed conditions as an alert, when the patient record is opened and to prevent any further steps being taken to navigate the program (and make any entries) without consciously closing the “alert” first. ”
    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of adequate training on the use of electronic software systems

    Wider context from the report

    “(1) An apparent lack of adequate training on the use of the software systems. This meant that important clinical information could not be made available easily. The expert GP gave evidence that this training deficit was not uncommon. He had the experience of using 4 different software programs in his career and had identical issues over lack of training. ”
    Open source report

  9. Addressed to: Dr Andrew Goodall, Chief Executive, NHS Wales.

    Cardiff & Vale of Glamorgan

    AI-generated summary

    Phyllis Eleanor Barlow · 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

    Phyllis Eleanor Barlow, who was taking warfarin, fell and struck her head in a GP surgery car park on 29 September 2014 but was not admitted to hospital. She fell again at home the following day, sustaining a subdural haemorrhage and hip fracture, and died on 8 November 2014; the concern was that GP surgeries were not sufficiently aware of NICE guidance requiring hospital admission and CT scanning after a head injury in a person taking warfarin.

    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of GP awareness of NICE head-injury guidelines for patients treated with warfarin

    Wider context from the report

    “(1) At the time of her fall in the GP car park on 29th September 2014 NICE guidelines (on head injuries) were in place to the effect that anyone suffering a head injury who was on warfarin should be admitted to hospital forthwith and undergo a CT scan. ████████ who appeared at the inquest on behalf of the GP practice testified that these NICE guidelines were not known or appreciated by her GP practice at the time even though they were in force. Mrs Barlow was not admitted to hospital as she should have been on 29th September 2014. ████████ subsequent enquiries have revealed that there is widespread ignorance of these NICE guidelines among GP colleagues, although they are appreciated by the ambulance service, and A&E departments. The Coroner is concerned that steps should be taken to make GP surgeries in Wales aware of the importance of these NICE guidelines, and that anyone who suffers a head injury while being treated with Warfarin should be admitted to hospital forthwith and a CT scan undertaken on 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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to admit patients with head injuries treated with warfarin to hospital forthwith

    Wider context from the report

    “(1) At the time of her fall in the GP car park on 29th September 2014 NICE guidelines (on head injuries) were in place to the effect that anyone suffering a head injury who was on warfarin should be admitted to hospital forthwith and undergo a CT scan. ████████ who appeared at the inquest on behalf of the GP practice testified that these NICE guidelines were not known or appreciated by her GP practice at the time even though they were in force. Mrs Barlow was not admitted to hospital as she should have been on 29th September 2014. ████████ subsequent enquiries have revealed that there is widespread ignorance of these NICE guidelines among GP colleagues, although they are appreciated by the ambulance service, and A&E departments. The Coroner is concerned that steps should be taken to make GP surgeries in Wales aware of the importance of these NICE guidelines, and that anyone who suffers a head injury while being treated with Warfarin should be admitted to hospital forthwith and a CT scan undertaken on them.. ”
    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 Patient Safety Notice raising awareness of NICE head-injury guidance for local health boards and general practices.

    Verbatim wording from the response

    “A lack of awareness of this important guideline is apparent from the detail of your report. In response to your concerns, Welsh Government officials are in the process of developing a Patient Safety Notice which will be issued to all local health boards and general practices in Wales.”

    Source location

    2015-0027-Response-by-NHS-Wales
    Page 1 · response
    Published 29 January 2015

    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

    Issue the Patient Safety Notice to all local health boards and general practices in Wales.

    Verbatim wording from the response

    “A lack of awareness of this important guideline is apparent from the detail of your report. In response to your concerns, Welsh Government officials are in the process of developing a Patient Safety Notice which will be issued to all local health boards and general practices in Wales.”

    Source location

    2015-0027-Response-by-NHS-Wales
    Page 1 · response
    Published 29 January 2015

    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

    Monitor compliance with the Patient Safety Notice after circulation.

    Verbatim wording from the response

    “The notice will be issued shortly and will raise awareness of the importance of this NICE guideline. Full compliance with this notice will be expected within a month of the notice being circulated and will be monitored.”

    Source location

    2015-0027-Response-by-NHS-Wales
    Page 2 · response
    Published 29 January 2015

    Open published response

  10. Gwent

    AI-generated summary

    JOANNA LYNDSEY GREENSMITH · 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

    Mrs. Joanna Lyndsey Greensmith was driving on the A465 near Llangua when her vehicle travelled through black ice, left the carriageway and collided with a tree, causing fatal injuries. The road surface had not been treated in accordance with the relevant adverse-weather guidance, and no report had been made of running water across the carriageway at that location.

    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to report running water across the carriageway

    Wider context from the report

    “The road surface had not been treated in accordance with the guidance contained within the decision guide and treatment matrices provided in the SWTRA Adverse Weather Plan (2013/14) in accordance with WGTRMM Part 5 Adverse Weather (02/07/12) and the Route Steward had not reported any running water across the carriageway at this location. ”
    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to treat the road surface in accordance with adverse weather treatment guidance

    Wider context from the report

    “The road surface had not been treated in accordance with the guidance contained within the decision guide and treatment matrices provided in the SWTRA Adverse Weather Plan (2013/14) in accordance with WGTRMM Part 5 Adverse Weather (02/07/12) and the Route Steward had not reported any running water across the carriageway at this location. ”
    Open source report

  11. Swansea and Neath Port Talbot

    AI-generated summary

    Hope Erin Evans · 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

    Hope Erin Evans, a premature baby born at 26 weeks, died from sepsis contributed to by ESBL E. coli contracted in hospital. The report states that the source was likely another baby, although the means of transfer was unknown. Concerns included important patient history not being captured and passed between hospitals, and the failure to complete All Wales Inter Hospital Transfer documentation.

    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to pass important patient history to the receiving hospital

    Wider context from the report

    “1. I have concerns that important patient history was not captured by the admitting hospital and passed to the receiving hospital. Mother A had received IVF treatment in India and had there acquired the ESBL E. coli. This important information was recorded in her medical notes which were with her. If the receiving hospital was aware of this the certainly the treatment of the twins would have been different and barrier nursing would have been implemented. ”
    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to capture important patient history at admission

    Wider context from the report

    “1. I have concerns that important patient history was not captured by the admitting hospital and passed to the receiving hospital. Mother A had received IVF treatment in India and had there acquired the ESBL E. coli. This important information was recorded in her medical notes which were with her. If the receiving hospital was aware of this the certainly the treatment of the twins would have been different and barrier nursing would have been implemented. ”
    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete All Wales Inter Hospital Transfer documentation

    Wider context from the report

    “2. The All Wales Inter Hospital Transfer documentation was not completed and revision of the documentation should be considered. ”
    Open source report

  12. Cardiff & the Vale of Glamorgan

    AI-generated summary

    John Elvet 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

    John Elvet Morgan, who had Alzheimer’s dementia, was admitted for respite care and collapsed on 30 August 2013. Staff did not resuscitate him because they relied on an erroneous red DNR star left on the ward whiteboard, although no DNR agreement or form existed; the post-mortem report showed pulmonary embolism. The concerns identified included reliance on whiteboard information instead of patient notes, human error in recording information, and the possible use of similar DNR systems elsewhere in Wales.

    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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure accurate information on whiteboards

    Wider context from the report

    “(1) The Whiteboard (or PSAG) is in use throughout Wales as a quick reference guide to the patients on the ward. It was introduced as part of the “Transforming Care at the bedside “TCAB” programme. Dr ███████ Clinical Director for the University Hospital for Wales Board, confirmed that the information which is put on the whiteboard is a matter for local discretion. While the red “DNR” star system has been removed from the whiteboards in use in Cardiff and the Vale Local Health Board he could not say whether similar systems are not in use elsewhere in Wales. (2) The whiteboard system is a useful reference point for patient care but there is a danger that the information held on the whiteboard is relied upon instead of the patient’s notes. (3) Human error may mean that erroneous information is held on the whiteboard to the detriment of patient care. (4) A similar DNR “red star” system may be in use on whiteboards in other Health Board areas in Wales with the possibility that a similar chain of events may occur elsewhere 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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Potential continued use of DNR red star systems on whiteboards in Welsh Health Board areas

    Wider context from the report

    “(1) The Whiteboard (or PSAG) is in use throughout Wales as a quick reference guide to the patients on the ward. It was introduced as part of the “Transforming Care at the bedside “TCAB” programme. Dr ███████ Clinical Director for the University Hospital for Wales Board, confirmed that the information which is put on the whiteboard is a matter for local discretion. While the red “DNR” star system has been removed from the whiteboards in use in Cardiff and the Vale Local Health Board he could not say whether similar systems are not in use elsewhere in Wales. (2) The whiteboard system is a useful reference point for patient care but there is a danger that the information held on the whiteboard is relied upon instead of the patient’s notes. (3) Human error may mean that erroneous information is held on the whiteboard to the detriment of patient care. (4) A similar DNR “red star” system may be in use on whiteboards in other Health Board areas in Wales with the possibility that a similar chain of events may occur elsewhere 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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of standardisation in information put on whiteboards

    Wider context from the report

    “(1) The Whiteboard (or PSAG) is in use throughout Wales as a quick reference guide to the patients on the ward. It was introduced as part of the “Transforming Care at the bedside “TCAB” programme. Dr ███████ Clinical Director for the University Hospital for Wales Board, confirmed that the information which is put on the whiteboard is a matter for local discretion. While the red “DNR” star system has been removed from the whiteboards in use in Cardiff and the Vale Local Health Board he could not say whether similar systems are not in use elsewhere in Wales. (2) The whiteboard system is a useful reference point for patient care but there is a danger that the information held on the whiteboard is relied upon instead of the patient’s notes. (3) Human error may mean that erroneous information is held on the whiteboard to the detriment of patient care. (4) A similar DNR “red star” system may be in use on whiteboards in other Health Board areas in Wales with the possibility that a similar chain of events may occur elsewhere 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 Welsh Government; that does not assign responsibility.

    PFD Monitor interpretation

    Reliance on whiteboard information instead of patients’ notes

    Wider context from the report

    “(1) The Whiteboard (or PSAG) is in use throughout Wales as a quick reference guide to the patients on the ward. It was introduced as part of the “Transforming Care at the bedside “TCAB” programme. Dr ███████ Clinical Director for the University Hospital for Wales Board, confirmed that the information which is put on the whiteboard is a matter for local discretion. While the red “DNR” star system has been removed from the whiteboards in use in Cardiff and the Vale Local Health Board he could not say whether similar systems are not in use elsewhere in Wales. (2) The whiteboard system is a useful reference point for patient care but there is a danger that the information held on the whiteboard is relied upon instead of the patient’s notes. (3) Human error may mean that erroneous information is held on the whiteboard to the detriment of patient care. (4) A similar DNR “red star” system may be in use on whiteboards in other Health Board areas in Wales with the possibility that a similar chain of events may occur elsewhere in Wales. ”
    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

Data last updated 7 September 2026