Concerns raised 1 Failure to replace old style barriers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Suzanne Regan · 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
Suzanne Regan was driving on the M4 westbound when her car collided with a concrete bullnose/Armco barrier, travelled along it, overturned and came to rest on its roof. She was pronounced dead at the scene; the concern was that failure to replace old-style barriers risked further deaths and serious injuries, and that modern replacements were available.
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 replace old style barriers
Wider context from the report “(1) The failure to replace these old style barriers runs the risk of further deaths and serious injuries occurring . My understanding is that modern replacements are available.
” Open source report
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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 Replace the non-compliant terminal at Junction 45 of the M4 westbound by April 2023.
Verbatim wording from the response “The terminal at this location was not damaged as a result of the incident, nor were any concerns about the terminal brought to the attention of the Welsh Government at the time of the incident. Therefore, and in line with CD 377 it was not considered for upgrade. As a consequence of this being brought to its attention in your report, the Welsh Government has also committed to replacing this terminal by April 2023.” Source location 2021-0247-Response-from-Welsh-Government_Published
Open published response
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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 Replace the non-compliant terminal at Junction 44 of the M4 westbound by April 2023.
Verbatim wording from the response “The terminal was not upgraded immediately after the incident in January 2021 as there was no damage incurred and in line with national standards, this was not warranted. Due to the age of the adjoining safety fence systems at this location, upgraded terminals will have to be designed specifically to ensure a compliant transition between systems. A level difference between the M4 motorway and the exit slip road also presents design challenges. However, further to your report and as detailed below, the Welsh Government has committed to undertaking this work by April 2023.” Source location 2021-0247-Response-from-Welsh-Government_Published
Open published response
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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 proactively replacing non-compliant terminals in line with CD 377.
Verbatim wording from the response “Consequently, there are significant numbers still on the network, including at this location, they are however, being continually upgraded in line with the DMRB and CD 377.” Source location 2021-0247-Response-from-Welsh-Government_Published
Open published response
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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 Review terminals at all motorway exit slip roads in Wales and develop a prioritised replacement programme.
Verbatim wording from the response “• A review of terminals at all motorway exit slip roads in Wales. This review has already been commissioned and is to be completed by April 2022. A prioritised replacement programme will be developed and timescales for replacement will be based on that programme, taking into account of the availability of funding.” Source location 2021-0247-Response-from-Welsh-Government_Published
Open published response
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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 Historical non-compliant terminals need not be upgraded immediately; CD377 requires replacement only when opportunities arise and upgrades are cost-effective.
Verbatim wording from the response “There is no specific requirement within CD 377 stipulating that historical systems should be upgraded. However, section 1.4 of CD 377 provides that ‘where a road restraint system (RRS) can be made compliant with current requirements without significant undue additional expense and or delay, the opportunity shall be taken.’” Source location 2021-0247-Response-from-Welsh-Government_Published
Open published response
Concerns raised 2 Lack of funding and implementation of the Integrated Drug Treatment System in Wales View source Failure to automatically offer opiate substitution therapy on the day of arrival to eligible prisoners View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
DEAN GARY GEORGE · 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
DEAN GARY GEORGE was found hanging in his cell at HMP Swansea on 16 March 2016 and the inquest concluded that his death was a suicide caused by hanging. Concerns included unequal access to opiate substitution therapy in Welsh prisons, inadequate risk assessment, insufficient information sharing between medical and prison staff, inadequate ACCT training, and an inequitable opiate detoxification system.
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 funding and implementation of the Integrated Drug Treatment System in Wales
Wider context from the report “The evidence was that drug treatment in Wales is organised differently to that in England. Integrated Drug Treatment System had not been funded and implemented in Wales. The main difference between English and Welsh prisons is that those arriving from the community who are addicted to opiates but not engaged with community treatment are not automatically offered opiate substitution therapy on the day of arrival. There is a concern over this inequality in health care provision There have been Inquiries into this in the Welsh Assembly the most recent in 2019.
” 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 automatically offer opiate substitution therapy on the day of arrival to eligible prisoners
Wider context from the report “The evidence was that drug treatment in Wales is organised differently to that in England. Integrated Drug Treatment System had not been funded and implemented in Wales. The main difference between English and Welsh prisons is that those arriving from the community who are addicted to opiates but not engaged with community treatment are not automatically offered opiate substitution therapy on the day of arrival . There is a concern over this inequality in health care provision There have been Inquiries into this in the Welsh Assembly the most recent in 2019.
” Open source report
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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 new Substance Misuse Treatment Framework for prison services in Wales.
Verbatim wording from the response “In 2018, an Early Days Opiate Treatment Pilot was launched in HMP Swansea which provides a pathway for opiate substitution therapy on the day of arrival. The pilot has been formally reviewed by Public Health Wales and will inform future planned improvements to substance misuse services in the prisons in Wales. Through the Partnership Agreement on Prison Health, Welsh Government is working with Public Health Wales to develop a new Substance Misuse Treatment Framework for prisons. The new Substance Misuse Treatment Framework will underpin the provision of services in prisons in Wales, and the draft of the SMTF will be available by Autumn 2020.” Source location 2020-0104-Response-from-Welsh-Government-Redacted.pdf
Open published response
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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 Provide a pathway for opiate substitution therapy on the day of arrival through the Early Days Opiate Treatment Pilot at HMP Swansea.
Verbatim wording from the response “In 2018, an Early Days Opiate Treatment Pilot was launched in HMP Swansea which provides a pathway for opiate substitution therapy on the day of arrival. The pilot has been formally reviewed by Public Health Wales and will inform future planned improvements to substance misuse services in the prisons in Wales. Through the Partnership Agreement on Prison Health, Welsh Government is working with Public Health Wales to develop a new Substance Misuse Treatment Framework for prisons. The new Substance Misuse Treatment Framework will underpin the provision of services in prisons in Wales, and the draft of the SMTF will be available by Autumn 2020.” Source location 2020-0104-Response-from-Welsh-Government-Redacted.pdf
Open published response
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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 Offer opiate substitution therapy routinely on the day after admission where appropriate and safe.
Verbatim wording from the response “Opiate substitution therapy is now offered routinely in HMP Swansea, the day following admission, where appropriate and safe. In addition, the healthcare team in the prison is expanding to provide a more joined up service (with GPs employed by the Health Board alongside nursing and pharmacy staff) and strengthening the availability of mental health support for primary mental health issues and crisis response.” Source location 2020-0104-Response-from-Welsh-Government-Redacted.pdf
Open published response
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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 Allocate additional annual funding to improve access to health services in Wales’s public prison estate.
Verbatim wording from the response “Welsh Government has also identified prison health and wellbeing as a priority for health boards, and has allocated an additional £1million per year to improve access to health services in the public prison estate. This includes the provision of an additional £329,026 for 2020/21 (reoccurring) for Swansea Bay University Health Board. This funding is being used to provide a team of mental health practitioners to broadly fulfil the tasks of the Primary Mental Health Service in the community, as well as providing a service to those in mental health crisis. The Substance Misuse Nurse Prescriber (SMNP) in the healthcare team in HMP Swansea works directly with the new mental health team in planning care for those with a dual diagnosis and in continuing to support the Early Days Opiate Treatment Pilot.” Source location 2020-0104-Response-from-Welsh-Government-Redacted.pdf
Open published response
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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 Welsh prisons need not implement England’s IDTS because existing Welsh guidance and comparative opioid-substitution services provide equivalent treatment options.
Verbatim wording from the response “Although, in Wales, we do not have IDTS, we do offer comparative services, which are set out in the Welsh Government’s Substance misuse: Treatment of offenders (2009) guidance, and in the 2017 UK Guidelines on Clinical Management Drug Misuse and Dependence (the Orange Book).” Source location 2020-0104-Response-from-Welsh-Government-Redacted.pdf
Open published response
Concerns raised 1 Failure to provide appropriate channels of support to high-profile persons removed from Government roles View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Carl Sargeant · 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
Carl Sargeant was removed from his Welsh Government ministerial role amid allegations of inappropriate behaviour, after which media interest was followed by a deterioration in his mental well-being and he took his own life on 7 November 2017. The report raised concern that high-profile people removed from Government roles may not receive appropriate support, regardless of mental vulnerabilities or the reason for their removal.
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 provide appropriate channels of support to high-profile persons removed from Government roles
Wider context from the report “That in the future, persons of a high profile who are removed from a role in Government, and whose removal from office will attract significant media interest, may not be provided with appropriate channels of support regardless of whether or not that person has any mental vulnerabilities or the reason for the loss of their role.
This concern is regardless of the fact that they may continue as Assembly Members.
” Open source report
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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 Add a “Ministers and their Wellbeing” section to the Welsh Government Ministerial Code.
Verbatim wording from the response “4. I think that it is important that I should signal very clearly that as First Minister I regard myself as having a responsibility to help promote and safeguard the wellbeing of my Cabinet colleagues throughout the period of their time in Government, from first joining the Cabinet through to their departure from office. I hope that in practice I have acted with this responsibility in mind since I became First Minister. You will recall from my earlier evidence to you that when I formed my Cabinet, on becoming First Minister, I was careful to ensure that those affected were aware of the support services available. I will now take steps formally to acknowledge and codify this responsibility. I will do so by adding a new section to the Ministerial Code for the Welsh Government.” Source location 2019-0236-Response-by-Welsh-Government
Open published response
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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 Create a standardised departure pack covering support services, liaison arrangements, practical departure matters and media assistance.
Verbatim wording from the response “10. As part of the protocol there will be a standardised pack of information for Ministers who are departing from Government. This will include a reminder of the support services available to them in their capacity as an Assembly Member, and will also give them details of a named official in my Cabinet Division who will act as their liaison point for any practical queries or issues in relation to their departure, including to ensure the orderly completion of any outstanding matters – collection of belongings, return of papers, for example – which remain to be transacted. It will also remind them of assistance which could be available to them, through their own Assembly Member office or trade union, for dealing with any immediate press or media issues which may arise as a result of their departure.” Source location 2019-0236-Response-by-Welsh-Government
Open published response
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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 Have the Chief Whip contact departing Ministers after departure to assess whether further assistance is appropriate.
Verbatim wording from the response “9. Particular care will be taken to consider the wellbeing of a departing Minister if the circumstances of their departure are difficult and high-profile, such as an alleged breach of the Ministerial Code. I see the Chief Whip of my Government as having an important role to play in this process, and the Chief Whip will make contact with the individual following their departure to see if any further assistance of any kind would be appropriate.” Source location 2019-0236-Response-by-Welsh-Government
Open published response
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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 Request inclusion of a proactive counselling role in renewed occupational health contracts.
Verbatim wording from the response “12. The Assembly Commission has told me that it is currently renewing contracts for occupational health services which provides a timely opportunity to enhance provision for counselling, and I have asked that the new contracts should include provision for a more proactive role to be played by a professional counsellor where that would be appropriate and necessary. I have also asked that staff who support Ministers can work with Commission staff to ensure that the particular circumstances of Members who have left the Government are taken fully into account.” Source location 2019-0236-Response-by-Welsh-Government
Open published response
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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 Ensure Ministers remain aware of available support services throughout their tenure.
Verbatim wording from the response “11. You will be aware from the proceedings of the Inquest of the support services available to all Members, including Ministers, from the Assembly Commission. This includes access to an Occupational Health Nurse and an Employee Assistance Programme which provides a confidential 24-hour helpline providing emotional and practical support for issues at home or work. As well as reminding departing Ministers of the availability of this service, I will ensure that Ministers remain aware of it throughout their tenure. The Welsh Government also has its own Employee Assistance Programme, which has been made available to serving Ministers, and in relation to which enhancements to the support available are currently being procured. Specifically these arrangements will offer access to Occupational Health (OH) support and Cognitive Behavioural Therapy.” Source location 2019-0236-Response-by-Welsh-Government
Open published response
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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 Request coordination between ministerial support staff and Assembly Commission staff for Members leaving Government.
Verbatim wording from the response “12. The Assembly Commission has told me that it is currently renewing contracts for occupational health services which provides a timely opportunity to enhance provision for counselling, and I have asked that the new contracts should include provision for a more proactive role to be played by a professional counsellor where that would be appropriate and necessary. I have also asked that staff who support Ministers can work with Commission staff to ensure that the particular circumstances of Members who have left the Government are taken fully into account.” Source location 2019-0236-Response-by-Welsh-Government
Open published response
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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 Assembly Commission, rather than the Welsh Government, manages support arrangements for Assembly Members, including Ministers.
Verbatim wording from the response “3. To assist my thinking, I have consulted all current Ministers in my Cabinet as well as those former Ministers who are still Assembly Members. I have also consulted the family of the late Carl Sargeant and sought to incorporate the views they were able to provide at that stage. The Permanent Secretary on my behalf has contacted the Assembly Commission since it is the Commission, rather than the Welsh Government, which manages the arrangements for making support available to Assembly Members, including Ministers. My response here is informed by all of the replies that I received.” Source location 2019-0236-Response-by-Welsh-Government
Open published response
10 Jun 2019 Glenys Button · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Lack of backup neurosurgical specialist capacity to field referrals View source Failure of the neurosurgical referral system to provide timely and reliable communication View source
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.
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AI-generated summary
Glenys Button · 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
Glenys Button, aged 78, died at Royal Glamorgan Hospital on 5 November 2018 after sustaining a head injury, including a basal skull fracture, pneumocephalus and brain bleed, following a likely accidental fall at home. The report raised concerns about delays, miscommunication, confusion and inadequate documentation in referrals to on-call neurosurgery, including uncertainty and changes over her potential transfer to Cardiff.
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 backup neurosurgical specialist capacity to field referrals
Wider context from the report “(1) There are a high number of referrals to the single rota’d on-call neurosurgical specialist registrar every day. The system for making and receiving the referrals is not fit for purpose, with inefficient delays, miscommunications and confusion occurring. The use of the UHW switchboard and bleeping the doctor is archaic, and does not utilise technology as it should. Further, if the on-call doctor is in surgery or dealing with an emergency, there is no back up doctor to field the referrals, which can often be time critical.
” 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 of the neurosurgical referral system to provide timely and reliable communication
Wider context from the report “(1) There are a high number of referrals to the single rota’d on-call neurosurgical specialist registrar every day. The system for making and receiving the referrals is not fit for purpose, with inefficient delays, miscommunications and confusion occurring. The use of the UHW switchboard and bleeping the doctor is archaic, and does not utilise technology as it should. Further, if the on-call doctor is in surgery or dealing with an emergency, there is no back up doctor to field the referrals, which can often be time critical.
” Open source report
Concerns raised 1 Failure of the barrier to safely redirect heavy vehicles along its length View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lyn 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
Lyn Morgan died from traumatic injuries in a road traffic collision on 25 April 2013 when a lorry crossed the central reservation of the A465 and collided with Lyn’s vehicle. Concerns were raised that the road barrier redirected the lorry back onto the carriageway contrary to its design, and that the road’s extensive use by heavy vehicles meant similar circumstances could arise again.
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 the barrier to safely redirect heavy vehicles along its length
Wider context from the report “1. The barrier is designed to redirect the vehicle along its length, so that it doesn’t flip over or be redirected back onto the carriageway. On this occasion the height of the wheels and the lack of input on the steering wheel deflected the wheels and therefore redirected the lorry back onto the carriageway contrary to its design.
2. The road in question is extensively used by heavy vehicles and therefore the potential is there for these circumstances to arise again.
” Open source report
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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 monitoring incidents and review containment policy and practice when future data indicate emerging risks.
Verbatim wording from the response “• Continue to monitor incidents of this type and review containment policy and practice should future data indicate emerging risks such as central reserve breaches involving HGVs.” Source location Response from Welsh Government
Open published response
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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 collaborating with National Highways on reviews of modern default barrier-containment levels, including data contribution and discussion.
Verbatim wording from the response “• not be supported by national evidence on risk frequency.
Changes of this scale are led at a UK national level by National Highways, who are currently carrying out research into future containment policy. Welsh Government continues to contribute network data and engage in these discussions.” Source location Response from Welsh Government
Open published response
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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 Apply national barrier-containment standards consistently across the Strategic Road Network.
Verbatim wording from the response “As stated above, the Welsh Government is committed to improving road safety. In line with this commitment, it will ensure that the following policy positions and forward actions are taken forward:” Source location Response from Welsh Government
Open published response
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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 No site-specific factors justified higher containment, so the concern that N2 was inadequate is disputed.
Verbatim wording from the response “Based on site characteristics, traffic volumes, and risk factors at the time of construction, there was no engineering justification to apply higher containment (e.g., H1/H2). National guidance requires such upgrades only where:” Source location Response from Welsh Government
Open published response
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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 Retaining N2 containment was considered appropriate because it complied with national standards and policy.
Verbatim wording from the response “Historic as-built records and information from our Operational Agent confirm that the nearside and central reserve barriers installed at the location at the time of the 2013 incident were systems of N2 containment level.
N2 containment was, and continues to be, the nationally recognised default containment level for this category of dual carriageway. This aligns with long standing UK practice and the national standards applicable at the time.” Source location Response from Welsh Government
Open published response
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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 A higher default containment level was not pursued because it would be disproportionately costly and require extensive network-wide reconstruction.
Verbatim wording from the response “• specific hazards such as structures or significant embankments.
No such factors were present at this location. Retaining N2 containment was therefore appropriate and consistent with national policy.
Introducing a higher default containment level across Wales would:” Source location Response from Welsh Government
Open published response
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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 Changes to default containment policy are led nationally by National Highways, which is researching future policy.
Verbatim wording from the response “• not be supported by national evidence on risk frequency.
Changes of this scale are led at a UK national level by National Highways, who are currently carrying out research into future containment policy. Welsh Government continues to contribute network data and engage in these discussions.” Source location Response from Welsh Government
Open published response
30 Jul 2018 Mr Richard Thomas Peter Barrett · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Failure to request police assistance for welfare checks when ambulance resources are constrained View source Delays in making and chasing-up welfare calls View source Failure to re-categorise incidents when welfare-call information indicates increased risk View source Failure of demand analysis to accurately estimate required ambulance capacity View source Unrealistic target turnaround time for ambulances at A&E View source Failure of call handlers to establish relevant overdose risk information View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Richard Thomas Peter Barrett · 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
On 20 April 2018, Mr Richard Thomas Peter Barrett took a large overdose of medication with alcohol, called 999 for help, and died before an ambulance reached his flat. Concerns included underestimated ambulance demand, delays in welfare checks and ambulance dispatch, unrealistic hospital turnaround targets, and the failure to ask police to conduct a welfare check.
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 request police assistance for welfare checks when ambulance resources are constrained
Wider context from the report “(4) The police could have been asked to perform a welfare check.
Evidence showed that the Ambulance Trust is pessimistic in assuming that the police are also under-resourced and would not be able to assist in such a task. Here the police were not even asked if they could help. Had he been found earlier, whether by police or ambulance, there is a chance that the deceased may have been able to be given first aid and had a better chance of survival.
” 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 Delays in making and chasing-up welfare calls
Wider context from the report “(2) There does not seem to be a reliable system for the making and chasing-up of ‘welfare calls’.
Evidence showed that it was not until 2 hours 45 minutes after the initial call that an attempt was made to ring the patient back . It was known that the patient had taken a massive overdose of sleeping tablets at 01:50. It was not enquired by the call handler as to whether he had also taken alcohol, or whether he was alone. When there was no response from his telephone at 05:13 there was a missed opportunity to re-categorise the incident.
” 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 re-categorise incidents when welfare-call information indicates increased risk
Wider context from the report “(2) There does not seem to be a reliable system for the making and chasing-up of ‘welfare calls’.
Evidence showed that it was not until 2 hours 45 minutes after the initial call that an attempt was made to ring the patient back. It was known that the patient had taken a massive overdose of sleeping tablets at 01:50. It was not enquired by the call handler as to whether he had also taken alcohol, or whether he was alone. When there was no response from his telephone at 05:13 there was a missed opportunity to re-categorise the incident .
” 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 of demand analysis to accurately estimate required ambulance capacity
Wider context from the report “(1) ‘Demand analysis’ seriously underestimated the number of ambulances required in Cardiff and the Vale that night.
Evidence showed that only 7 ambulances were available up until 2am, then 5 available up until 3am . Also 7 hours of ambulance time was lost during the period 02:26 – 06:30 due to delays at A&E.
” 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 Unrealistic target turnaround time for ambulances at A&E
Wider context from the report “(3) The target turnaround time for ambulances at A&E is wildly unrealistic.
Evidence showed that both the University Hospital of Wales and Llandough Hospital were averaging 3 times the target of 15 minutes that night with the longest turnaround being over 100 minutes . Such delay must have a knock-on effect upon the ‘demand analysis’.
” 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 of call handlers to establish relevant overdose risk information
Wider context from the report “(2) There does not seem to be a reliable system for the making and chasing-up of ‘welfare calls’.
Evidence showed that it was not until 2 hours 45 minutes after the initial call that an attempt was made to ring the patient back. It was known that the patient had taken a massive overdose of sleeping tablets at 01:50. It was not enquired by the call handler as to whether he had also taken alcohol, or whether he was alone. When there was no response from his telephone at 05:13 there was a missed opportunity to re-categorise the incident.
” Open source report
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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 Direct health board chief executives to reduce and eradicate ambulance handover delays through coordinated patient-flow improvements and alternative unscheduled-care pathways.
Verbatim wording from the response “We expect health boards to monitor all patients, especially those with time-critical and acute conditions or injuries to ensure they are handed over to the care of specialist staff as soon as possible, in order to improve patient outcomes and manage the associated risk. The Cabinet Secretary has also been clear with health board chief executives that they must take responsibility to reduce and eradicate patient handover delays by working with the Welsh ambulance service and partner organisations to improve patient flow through hospitals and receive patients from ambulance crews in a safe and timely manner. In addition they must explore alternative pathways and be able to divert demand to other unscheduled care services to reduce pressure at emergency departments during busy periods.” Source location 2018-0249-Response-by-Welsh-Government
Open published response
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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 patient handover delays daily and challenge health boards where appropriate.
Verbatim wording from the response “It should be noted that there is no time-based target for the handover of patients from ambulance crews to emergency department staff. However, the Welsh Health Circular on NHS Wales Hospital Handover Guidance, published in May 2016, sets out good practice for patient handover, including an expectation for patients to be handed over within 15 minutes. Officials continue to monitor patient handover delays closely on a daily basis and challenge health boards where appropriate.” Source location 2018-0249-Response-by-Welsh-Government
Open published response
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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 WAST is responsible for planning and delivering a safe, timely ambulance service with sufficient staffing and resource capacity.
Verbatim wording from the response “The Welsh Government expects the Welsh Ambulance Services NHS Trust (WAST) to plan and deliver a safe and timely service to the people of Wales, based on an assessment of demand, ensuring there is sufficient staffing and resource cover in its clinical contact centres and in the community to meet demand, and to flex capacity at times of increased pressure.” Source location 2018-0249-Response-by-Welsh-Government
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 Health boards are responsible for reducing patient handover delays, improving hospital flow and receiving ambulance patients safely and promptly.
Verbatim wording from the response “We expect health boards to monitor all patients, especially those with time-critical and acute conditions or injuries to ensure they are handed over to the care of specialist staff as soon as possible, in order to improve patient outcomes and manage the associated risk. The Cabinet Secretary has also been clear with health board chief executives that they must take responsibility to reduce and eradicate patient handover delays by working with the Welsh ambulance service and partner organisations to improve patient flow through hospitals and receive patients from ambulance crews in a safe and timely manner. In addition they must explore alternative pathways and be able to divert demand to other unscheduled care services to reduce pressure at emergency departments during busy periods.” Source location 2018-0249-Response-by-Welsh-Government
Open published response
Concerns raised 5 Absence of a westbound left-turn filter lane from the A40 onto Redstone Road View source Insufficient length and width of both filter lanes on the A40 View source Insufficient speed control or warning at the upcoming bend and junction View source Inadequate positioning of national speed limit signs near the junction mouth View source Lack of road markings and early warning signs on the approach to the main A40 from Redstone Road View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Herbert John Bernard 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
Herbert John Bernard Francis was driving towards the A40 when he failed to stop at the junction and collided with an articulated heavy goods vehicle, dying at the scene from injuries sustained in the collision. The concerns identified related to road safety measures, including improved markings and warning signs, changes to filter lanes, and consideration of lower or advisory speed limits.
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 westbound left-turn filter lane from the A40 onto Redstone Road
Wider context from the report “(4) That filter lanes should also be introduced on the A40 for vehicles heading westbound and intending to turn left onto Redstone Road .
” 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 Insufficient length and width of both filter lanes on the A40
Wider context from the report “(2) That both filter lanes on the A40 at this location should be made longer and wider .
” 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 Insufficient speed control or warning at the upcoming bend and junction
Wider context from the report “(3) That consideration should be given to lowering the speed limit along this stretch of road, or by placing advisory speed limit signs at the location to warn motorists of the upcoming bend and junction .
” 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 Inadequate positioning of national speed limit signs near the junction mouth
Wider context from the report “(1) The approach to the main A40 from Redstone Road could be further enhanced with the introduction of road markings and early warning signs. That consideration should be given to the re-positioning of the national speed limit signs from their current location to closer to the mouth of the junction .
” 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 road markings and early warning signs on the approach to the main A40 from Redstone Road
Wider context from the report “(1) The approach to the main A40 from Redstone Road could be further enhanced with the introduction of road markings and early warning signs . That consideration should be given to the re-positioning of the national speed limit signs from their current location to closer to the mouth of the junction.
” 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 Conduct a three-year speed-limit review, prioritising the report’s concerns and recommendations for consideration in the first tranche of sites.
Verbatim wording from the response “My officials are currently in the process of carrying out a three year speed limit review looking at road safety issues at over 600 sites on all trunk roads in Wales. I have asked my officials to consider the concerns and recommendations raised in the report are considered as a priority as part of the review and addressed within the first tranche of sites reviewed during this financial year.” Source location 2018-0242-Response-by-Welsh-Government
Open published response
5 Dec 2017 Stephanie Cave · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 5 Lack of training on completing and recording enhanced observations View source Lack of written guidelines for completing and recording enhanced observations View source Inconsistent conduct of enhanced observations View source Inconsistent recording of enhanced observations View source Failure to routinely record precise times of enhanced observations View source See 2 more concerns
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.
×
AI-generated summary
Stephanie Cave · 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
Stephanie Cave had a history of deteriorating mental health, self-harm and attempts to end her life, and died after being found with a ligature around her neck on 17 August 2017 while in hospital care. The concerns identified included inconsistent enhanced observations, lack of training and written guidance for conducting and recording observations, and failure to routinely record precise observation times.
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 training on completing and recording enhanced observations
Wider context from the report “(2) The evidence also revealed that there was no training provided and no written guidelines on how such observations should be completed and how they should be recorded in the observation forms.
” 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 written guidelines for completing and recording enhanced observations
Wider context from the report “(2) The evidence also revealed that there was no training provided and no written guidelines on how such observations should be completed and how they should be recorded in the observation forms .
” 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 Inconsistent conduct of enhanced observations
Wider context from the report “(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording enhanced observations on patients detained under the Mental Health Act and at risk of self-harm and suicide when asleep.
” 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 Inconsistent recording of enhanced observations
Wider context from the report “(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording enhanced observations on patients detained under the Mental Health Act and at risk of self-harm and suicide when asleep.
” 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 routinely record precise times of enhanced observations
Wider context from the report “(3) The evidence also revealed that precise times of such observations were not routinely being recorded .
” Open source report
22 Oct 2017 Lesley Hanson · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Lack of clear responsibility for the environment and resident safety control measures View source Failure of care and risk assessments to consider stair-gate and locking-mechanism risks View source
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.
×
AI-generated summary
Lesley Hanson · 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
Lesley Hanson, who had severe learning disabilities and poor stability, gained access to stairs at her supported accommodation on 11 March 2017 and fell, sustaining injuries that led to her death. The concerns were that care and risk assessments did not address the gate being left open, the type of stair-gate or locking mechanism, and that responsibility for environmental safety controls was unclear. The inquest jury found the arrangements inadequate, including failure to follow the service plan and repeated occasions when the stair-gate had been left open.
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 clear responsibility for the environment and resident safety control measures
Wider context from the report “(2) It was unclear from the evidence who had the responsibility for the environment and control measures to ensure residents safety at the property .
” 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 of care and risk assessments to consider stair-gate and locking-mechanism risks
Wider context from the report “(1) The evidence revealed that the care and risk assessments did not appear to consider the impact of the gate being left open by other residents, the type of stair-gate and the suitability of the locking mechanism .
” Open source report
Concerns raised 2 Lack of legal duty for landlords to fit smoke alarms in let properties View source Lack of legal duty for landlords to ensure smoke alarms are working at tenancy commencement View source
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.
×
AI-generated summary
Jac Evan Davies · 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
Jac Evan Davies, aged four, died from smoke inhalation after a house fire at his home on 27 July 2016. The report raised concerns that, unlike in England, landlords in Wales were under no legal duty to install smoke alarms in rented properties or ensure they were working when a tenancy began.
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 legal duty for landlords to fit smoke alarms in let properties
Wider context from the report “During the course of the inquest it became apparent there was no duty in Wales for landlords to install smoke alarms in properties let out to tenants. In England this duty is set out in the Smoke and Carbon Monoxide Alarm (England) Regulations 2015. These regulations require a landlord to have at least one smoke alarm installed on every storey of their properties and a carbon monoxide alarm in any room containing a solid fuel burning appliance (eg a coal fire, wood burning stove). The landlord must make sure the alarms are in working order at the start of each new tenancy.
In Wales the fitting of smoke alarms is covered by the Code of Practice for Landlords and Agents licensed under Part 1 of the Housing (Wales) Act 2016. In that code of practice there is a requirement for landlords to fit carbon monoxide alarms in every room where there is a solid fuel appliance. Failure to do so can result in a landlord registered with the Rent Smart Wales scheme losing their licence.
The fitting of smoke alarms is covered under “best practice” and recommends what landlords can do to raise standards above the minimum level required by law. There is no sanction for not complying with best practice.
1. Landlords in Wales are under no legal duty to fit smoke alarms to properties they let out , and are under no legal duty to ensure they are working when a tenancy is initially entered into.
2. There is no reciprocal legislation in Wales to the Smoke and Carbon Monoxide Alarm (England) Regulation 2015 that enforces the above obligations on landlords
” 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 legal duty for landlords to ensure smoke alarms are working at tenancy commencement
Wider context from the report “During the course of the inquest it became apparent there was no duty in Wales for landlords to install smoke alarms in properties let out to tenants. In England this duty is set out in the Smoke and Carbon Monoxide Alarm (England) Regulations 2015. These regulations require a landlord to have at least one smoke alarm installed on every storey of their properties and a carbon monoxide alarm in any room containing a solid fuel burning appliance (eg a coal fire, wood burning stove). The landlord must make sure the alarms are in working order at the start of each new tenancy.
In Wales the fitting of smoke alarms is covered by the Code of Practice for Landlords and Agents licensed under Part 1 of the Housing (Wales) Act 2016. In that code of practice there is a requirement for landlords to fit carbon monoxide alarms in every room where there is a solid fuel appliance. Failure to do so can result in a landlord registered with the Rent Smart Wales scheme losing their licence.
The fitting of smoke alarms is covered under “best practice” and recommends what landlords can do to raise standards above the minimum level required by law. There is no sanction for not complying with best practice.
1. Landlords in Wales are under no legal duty to fit smoke alarms to properties they let out, and are under no legal duty to ensure they are working when a tenancy is initially entered into.
2. There is no reciprocal legislation in Wales to the Smoke and Carbon Monoxide Alarm (England) Regulation 2015 that enforces the above obligations on landlords
” Open source report
8 Aug 2017 Deidre Harvey · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 9 Lack of effective tracking of items taken from and returned to patients View source Lack of routine clinical monitoring of Hydroxychloroquine levels View source Lack of active input from outside consultants into mental health unit patient care View source Failure of liaison between dermatologists and other consultants about Hydroxychloroquine toxicity View source Lack of awareness of Hydroxychloroquine toxic accumulation at recommended doses View source Delays in rectifying obvious ligature points on mental health units View source Incomplete description of the risk of combining Lamotrigine or similar drugs with Hydroxychloroquine View source Lack of awareness among psychiatrists of Hydroxychloroquine mental and toxic side-effects View source Failure to disseminate risk management policies clearly to frontline staff View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Deidre Harvey · 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
Deidre Harvey died on 19 April 2017 after attaching a dressing gown cord to her neck in a mental health unit bathroom; the cause of death was recorded as hanging. The report raised concerns about coordination between mental-health and outside consultants, management of ligature risks and dangerous items, risk-assessment communication, and the potential toxicity and monitoring of hydroxychloroquine.
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 effective tracking of items taken from and returned to patients
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” 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 routine clinical monitoring of Hydroxychloroquine levels
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” 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 active input from outside consultants into mental health unit patient care
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” 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 of liaison between dermatologists and other consultants about Hydroxychloroquine toxicity
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” 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 awareness of Hydroxychloroquine toxic accumulation at recommended doses
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” 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 Delays in rectifying obvious ligature points on mental health units
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” 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 Incomplete description of the risk of combining Lamotrigine or similar drugs with Hydroxychloroquine
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” 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 awareness among psychiatrists of Hydroxychloroquine mental and toxic side-effects
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” 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 disseminate risk management policies clearly to frontline staff
Wider context from the report “Secretary of State for Health
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Minister for Health, Welsh Assembly Government
1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk.
The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units
Chief Executive – Cwm Taf University Health Board
1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when.
The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient.
2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus.
The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist.
3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised.
The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion
Editor British National Formulary
Hydroxychloroquine
1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic.
The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine.
Royal College of Psychiatrists
Hydroxychloroquine
1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis.
The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects.
In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition
British Association of Dermatologists
Hydroxychloroquine
1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L.
The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose.
The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared.
CEO Alerts NHS
Hydroxychloroquine
1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important.
The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers.
” Open source report
×
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 NHS organisations, professionals and health boards are responsible for assessing ligature risks and implementing mitigation where risks cannot be immediately addressed.
Verbatim wording from the response “NHS organisations are expected to ensure that units / wards are safe for the patients being cared within them. Fixtures and fittings should therefore be assessed to ensure they are anti-ligature. Where ligature risk points are identified but cannot be immediately addressed, it is the responsibility of the professionals caring for people on such a unit and the health board generally to put robust measures in place to mitigate the risks.” Source location 2018-0266-Response-by-Welsh-Government
Open published response
27 Jul 2017 Percy Jacks · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Reliance of GP prescribing on receipt of hospital scan-result notification View source Haphazard DVT management system View source Failure of the hospital-to-GP DVT result communication system View source Failure to reliably communicate medication and clinical plans from hospital to care home View source Lack of medication review for correct Rivaroxaban dosage and duration View source Fragile communication system between GP, hospital and care home View source See 3 more concerns
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.
×
AI-generated summary
Percy Jacks · 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
Percy Jacks died from a pulmonary embolus after being found unresponsive the morning following treatment for chest pain. The report identified failings in the management of his anticoagulation medication, including poor communication between the hospital, GP surgery and care home, and inadequate systems for ensuring the medication continued for the intended period.
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 Reliance of GP prescribing on receipt of hospital scan-result notification
Wider context from the report “(2) The system within the GP surgery for prescribing Rivaroxaban was poor and relied solely on receiving the notification of the results of the scan from the hospital . There was no facility to review the medication to ensure that the correct dosage for the correct period of time continued to be prescribed.
” 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 Haphazard DVT management system
Wider context from the report “(3) The evidence revealed a view from one of the hospital doctors to the effect that DVT management should be undertaken within the hospital setting rather than by the GP’s to ensure that a comprehensive and failsafe system operated rather than the somewhat haphazard one revealed by the evidence .
” 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 of the hospital-to-GP DVT result communication system
Wider context from the report “(1) The investigation revealed that the system for the Bronglais Hospital contacting the GP was poor. The result of the DVT scan which took place on 6 February was sent to the incorrect GP surgery and despite an explanation as to why that happened no satisfactory explanation could be found.
” 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 reliably communicate medication and clinical plans from hospital to care home
Wider context from the report “(4) The evidence further revealed a practice of sending details of the medication and clinical plan back with the driver of the patient who had taken the patient back from hospital to the care home.
” 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 review for correct Rivaroxaban dosage and duration
Wider context from the report “(2) The system within the GP surgery for prescribing Rivaroxaban was poor and relied solely on receiving the notification of the results of the scan from the hospital. There was no facility to review the medication to ensure that the correct dosage for the correct period of time continued to be prescribed .
” 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 Fragile communication system between GP, hospital and care home
Wider context from the report “(5) Overall the evidence revealed a very fragile system of communication between GP hospital and care home in circumstances in which the deceased had moved between three care homes in a short period of time.
” Open source report
27 Jul 2017 Sheila Margaret Gaskin · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Failure to prohibit carers assisting the service user to smoke in bed View source Lack of effective day-to-day oversight of care provision View source
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.
×
AI-generated summary
Sheila Margaret Gaskin · 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
Sheila Margaret Gaskin was bedbound and living at home with support from carers. After a carer assisted her to light a cigarette in bed on the evening of 20 March 2017, she was found the following morning with burns and soot markings after a fire; concerns included the absence of a prohibition on carers assisting her to smoke in bed and ineffective day-to-day oversight by care management.
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 prohibit carers assisting the service user to smoke in bed
Wider context from the report “(1) The evidence revealed that there was an identified risk in the deceased's Care Plan of her smoking in bed. The Fire Service had been involved in risk assessing the situation and have provided flame retardant bedding and linen. Despite this obvious risk having been identified and implemented into the Care Plan there was nothing prohibiting carers assisting the deceased to smoke in bed which, the evidence revealed, was a regular occurrence.
(2) Management of the care provided accepted that there was no effective oversight by them on a day-to-day basis and they were unaware that carers were assisting the deceased in this way . They agreed that what was required was a blanket prohibition on carers assisting the service user in smoking which would have given greater degree of clarity.
” 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 effective day-to-day oversight of care provision
Wider context from the report “(1) The evidence revealed that there was an identified risk in the deceased's Care Plan of her smoking in bed. The Fire Service had been involved in risk assessing the situation and have provided flame retardant bedding and linen. Despite this obvious risk having been identified and implemented into the Care Plan there was nothing prohibiting carers assisting the deceased to smoke in bed which, the evidence revealed, was a regular occurrence.
(2) Management of the care provided accepted that there was no effective oversight by them on a day-to-day basis and they were unaware that carers were assisting the deceased in this way . They agreed that what was required was a blanket prohibition on carers assisting the service user in smoking which would have given greater degree of clarity.
” Open source report
Concerns raised 4 Failure to inform the responsible clinician of ward transfers View source Failure to determine the number of escorts required for Section 17 leave View source Lack of guidance for review or revocation of Section 17 leave on transfer View source Failure to review Section 17 leave on transfer View source See 1 more concern
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.
×
AI-generated summary
Khuong Lam · 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
Khuong Lam, a 42-year-old man with schizophrenia, died after absconding while on Section 17 leave, following a struggle involving pressure to the neck. The concerns included the lack of review or revocation of Section 17 leave when he was transferred to the Psychiatric Intensive Care Ward, the arrangements for escorts during leave, and the need to share related learning across 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 inform the responsible clinician of ward transfers
Wider context from the report “(3) ████████ the RC told the inquest that if he had been made aware of Khuong Lam’s transfer to PICU he could have reviewed him and decided whether Section 17 leave was still appropriate. The Coroner is concerned that the good practice now adopted by Cardiff Health Board should be replicated across Wales i.e. that the RC be informed of any transfer between wards ; that Section 17 leave is reviewed on a transfer (and especially to PICU); and to consider further the number of escorts required for any Section 17 leave.
” 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 determine the number of escorts required for Section 17 leave
Wider context from the report “(2) The inquest heard evidence that two escorts can provide a deterrent effect against absconsion, and are better able to deal with absconsions . Cardiff and Vale Health Board have now concluded a two month study of the efficacy of having two escorts to a patient on Section 17 leave and the lessons of this study should be applied across 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 guidance for review or revocation of Section 17 leave on transfer
Wider context from the report “(1) The issue of Section 17 leave is covered in the Guidance issued in 2016. There is no section in this guidance covering the issue of review or revocation of Section 17 leave on transfer to another ward or to the PICU. It is the concern of the coroner that such guidance should be given across Wales in the next edition of the guidance.
” 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 review Section 17 leave on transfer
Wider context from the report “(3) ████████ the RC told the inquest that if he had been made aware of Khuong Lam’s transfer to PICU he could have reviewed him and decided whether Section 17 leave was still appropriate . The Coroner is concerned that the good practice now adopted by Cardiff Health Board should be replicated across Wales i.e. that the RC be informed of any transfer between wards; that Section 17 leave is reviewed on a transfer (and especially to PICU) ; and to consider further the number of escorts required for any Section 17 leave.
” Open source report
16 Mar 2017 Clive Davies · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Failure to conduct scheduled neuro observations View source Failure to accurately calculate NEWS scores and trigger required medical review View source Failure to continue NEWS observations View source
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.
×
AI-generated summary
Clive Davies · 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
Clive Davies, who was generally in poor health and had a history of falls, fell down the stairs at home on 22 August 2016 and sustained serious head and neck injuries. He died in hospital on 30 August 2016; concerns included failures in routine NEWS and neurological observations, including an incorrectly calculated NEWS score and missed observations.
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 conduct scheduled neuro observations
Wider context from the report “(1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations . On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM . The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter. Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been. It was accepted at the inquest that this was a failure for which no explanation was forthcoming.
” 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 accurately calculate NEWS scores and trigger required medical review
Wider context from the report “(1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations. On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM. The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter. Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been . It was accepted at the inquest that this was a failure for which no explanation was forthcoming.
” 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 continue NEWS observations
Wider context from the report “(1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations. On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM. The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter . Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been. It was accepted at the inquest that this was a failure for which no explanation was forthcoming.
” Open source report
1 Mar 2017 Ceriann Richards · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Delays in ambulance-to-hospital handover View source
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.
×
AI-generated summary
Ceriann Richards · 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
Ceriann Richards was found acutely unwell and suffering seizures at home on 14 August 2016. An ambulance took approximately three hours to convey her to hospital, where she died later that morning. A post-mortem found very high, toxic levels of Venlafaxine, while the principal concern was delay in ambulance despatch linked to hospital handover delays.
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 Delays in ambulance-to-hospital handover
Wider context from the report “(1) The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures. The evidence showed that the main reason for the delay was the significant hand over delays being experienced at the 2 district general hospitals within the Aneurin Bevan University Health Board Areas which on that day for the Royal Gwent Hospital were of an average of 107 minutes up to a maximum of 279 minutes and for the Neville Hall Hospital with an average delay of 43 minutes and the longest delay of 93 minutes. The evidence revealed that the agreed “handover time” is 15 minutes. The evidence further revealed that since guidance was issued in the spring of 2016 in relation to the handover from ambulance crews to hospital staff the position has worsened and in the order of 140 to 200 hours are lost each day equating to 10 to 20 vehicles being off road for the whole day across the Welsh Ambulance Trusts Area .
” Open source report
22 Dec 2016 Edwina Rose Moses · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Unavailability of additional nursing cover for one-to-one support View source Failure to clearly allocate responsibility for requesting and securing additional nursing cover for one-to-one support View source Inadequate ward staffing levels for safely caring for patients View source
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.
×
AI-generated summary
Edwina Rose Moses · 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
Edwina Rose Moses was admitted to hospital after a fall at home that fractured her left hip. While in hospital, she fell from her bed at a time when she should have been receiving one-to-one nursing care, fractured her right hip, and later died following an upper gastrointestinal bleed; concerns included poor systems for arranging additional nursing cover and inadequate staffing when such cover was unavailable.
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 Unavailability of additional nursing cover for one-to-one support
Wider context from the report “2. The evidence showed that it was common place for additional nursing cover not to attend and staff were then left to provide one to one cover alongside their main stream duties – which was wholly unrealistic. Given the apparent frequency in which additional nursing cover is “unavailable” , often in the context of dealing with patients suffering with dementia, the issue of appropriate staffing levels on wards and the ability of staff to safely look after patients must be a concern.
” 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 clearly allocate responsibility for requesting and securing additional nursing cover for one-to-one support
Wider context from the report “1. The evidence revealed that there was a poor system in place for requesting additional nursing cover to provide one to one support . There was confusion by front line staff as to who was responsible for identifying, booking and ensuring that such help was provided .
” 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 Inadequate ward staffing levels for safely caring for patients
Wider context from the report “2. The evidence showed that it was common place for additional nursing cover not to attend and staff were then left to provide one to one cover alongside their main stream duties – which was wholly unrealistic . Given the apparent frequency in which additional nursing cover is “unavailable”, often in the context of dealing with patients suffering with dementia, the issue of appropriate staffing levels on wards and the ability of staff to safely look after patients must be a concern .
” Open source report
21 Dec 2016 David Bassett COOPER · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Lack of comprehensive transfer handover of falls risk View source Shortcomings in booking additional staff for 1:1 care View source Failure to integrate and respond to the whole picture of ongoing falls risk View source Inaccurate and incomplete nursing notes and falls records View source See 1 more concern
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.
×
AI-generated summary
David Bassett COOPER · 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
David Bassett Cooper was admitted to hospital after a serious head injury caused by a fall in the community and sustained nine further falls while being transferred between wards. He died from a subdural haematoma caused by the final fall on 5 March 2016. The concerns included inadequate handovers about falls risk, incomplete nursing records, a failure to see the overall pattern of falls, and shortcomings in arranging additional one-to-one nursing care.
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 comprehensive transfer handover of falls risk
Wider context from the report “1. When transfers between wards took place, the evidence revealed that there was a lack of comprehensive hand-over by the transferring ward to the receiving ward especially in terms of identifying the patient’s risk of falls . For example, on ward 18 Mr Cooper was in receipt of ‘1:1’ nursing care, but on transfer to ward 21, not only was that never given, but the evidence suggested it was not considered.
” 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 Shortcomings in booking additional staff for 1:1 care
Wider context from the report “4. As with many other cases involving patients at high risk of falls, the evidence revealed shortcomings in the system used for booking additional staff to provide ‘1:1’ care , revealing a system which left front line nursing staff unable to cope with the challenges in looking after the most vulnerable.
” 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 integrate and respond to the whole picture of ongoing falls risk
Wider context from the report “3. The evidence revealed that there was a distinct lack of “joined up” thinking and a failure to see the “whole picture” . Mr Cooper’s risk of falling was as high when he was admitted in October 2015 as it was when he died in March 2016, but still he sustained 9 falls.
” 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 Inaccurate and incomplete nursing notes and falls records
Wider context from the report “2. The accuracy and completeness of nursing notes and records left much to be desired . For example, on Ward 21 when he fell three times, there was no entry made in the Falls Diary – a document which was supposed to act as a tool for nursing staff to assess whether there was a pattern to the numerous falls being sustained – save for the last fall on 5th March. This deprived staff of the opportunity to see the ‘whole picture’ and to take into consideration the eight falls which he had sustained up to that point.
” Open source report
7 Nov 2016 Maurice ISAACS · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Failure to comprehensively assess and record falls risk and implement a clear care plan View source Failure to ensure trained staff carry out neuro observations in line with policy View source Failure of qualified nurse oversight to identify omitted neuro observations View source Failure to complete all components of neuro observations at the required frequency View source Insufficient ward staffing to manage care demands View source Failure to provide indicated continuous 1:1 supervision for a high falls-risk patient View source See 3 more concerns
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.
×
AI-generated summary
Maurice ISAACS · 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
Maurice ISAACS, who had dementia and other chronic health conditions, was admitted to hospital after deteriorating and suffered multiple falls. He fell from his bed on 12 June 2016, sustained a head injury and died two days later. Concerns included shortcomings in falls-risk assessment, care planning and supervision, as well as failures in carrying out and overseeing neurological observations after the final fall.
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 comprehensively assess and record falls risk and implement a clear care plan
Wider context from the report “(1) The investigation into his death revealed shortcomings in the way in which his risk of falls were assessed and recorded . For example, no clear care plan was introduced until after the fourth fall . Although there were some occasions when he was given 1:1 care that was not consistent and despite the increasing number of falls, he was never given true 1:1 supervision / observation. Despite the medical notes showing that this should have been in place at the time of his final fall, the reality on the ward was that he was being observed by a nurse on a 1:4 basis. Despite the ward being staffed to "agreed staffing levels" the evidence showed that on the ground, on occasions, this was simply not enough staff to manage the demands of the ward.
His condition was so variable and unpredictable, and against a background of so many falls, 1:1 care was indicated. The evidence showed that whilst there was a review of his situation after each fall, a more 'holistic' approach, recognising the dangers posed by his unpredictable behaviour, and the causes of that , might have prevented so many falls.
” 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 ensure trained staff carry out neuro observations in line with policy
Wider context from the report “(2) After the final fall, shortcomings were identified in the way that the standard "Neuro Observations" were carried out. They were not carried out in line with Trust Policy . They were conducted by a Health Care Assistant, who had not been trained and who failed to conduct one part of the test for a period of six hours. The omission was not spotted by the qualified nurse whose duty it was to oversee the work of the Healthcare Assistant.
” 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 of qualified nurse oversight to identify omitted neuro observations
Wider context from the report “(2) After the final fall, shortcomings were identified in the way that the standard "Neuro Observations" were carried out. They were not carried out in line with Trust Policy. They were conducted by a Health Care Assistant, who had not been trained and who failed to conduct one part of the test for a period of six hours. The omission was not spotted by the qualified nurse whose duty it was to oversee the work of the Healthcare Assistant .
” 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 components of neuro observations at the required frequency
Wider context from the report “(2) After the final fall, shortcomings were identified in the way that the standard "Neuro Observations" were carried out. They were not carried out in line with Trust Policy. They were conducted by a Health Care Assistant, who had not been trained and who failed to conduct one part of the test for a period of six hours . The omission was not spotted by the qualified nurse whose duty it was to oversee the work of the Healthcare Assistant.
” 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 Insufficient ward staffing to manage care demands
Wider context from the report “(1) The investigation into his death revealed shortcomings in the way in which his risk of falls were assessed and recorded. For example, no clear care plan was introduced until after the fourth fall. Although there were some occasions when he was given 1:1 care that was not consistent and despite the increasing number of falls, he was never given true 1:1 supervision / observation. Despite the medical notes showing that this should have been in place at the time of his final fall, the reality on the ward was that he was being observed by a nurse on a 1:4 basis. Despite the ward being staffed to "agreed staffing levels" the evidence showed that on the ground, on occasions, this was simply not enough staff to manage the demands of the ward .
His condition was so variable and unpredictable, and against a background of so many falls, 1:1 care was indicated. The evidence showed that whilst there was a review of his situation after each fall, a more 'holistic' approach, recognising the dangers posed by his unpredictable behaviour, and the causes of that, might have prevented so many falls.
” 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 provide indicated continuous 1:1 supervision for a high falls-risk patient
Wider context from the report “(1) The investigation into his death revealed shortcomings in the way in which his risk of falls were assessed and recorded. For example, no clear care plan was introduced until after the fourth fall. Although there were some occasions when he was given 1:1 care that was not consistent and despite the increasing number of falls, he was never given true 1:1 supervision / observation . Despite the medical notes showing that this should have been in place at the time of his final fall, the reality on the ward was that he was being observed by a nurse on a 1:4 basis . Despite the ward being staffed to "agreed staffing levels" the evidence showed that on the ground, on occasions, this was simply not enough staff to manage the demands of the ward.
His condition was so variable and unpredictable, and against a background of so many falls, 1:1 care was indicated . The evidence showed that whilst there was a review of his situation after each fall, a more 'holistic' approach, recognising the dangers posed by his unpredictable behaviour, and the causes of that, might have prevented so many falls.
” Open source report
5 Sep 2016 Dr Imad Hassan · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Lack of a bed management pathway View source Lack of an agreed tertiary-services pathway for unconscious STEMI patients requiring PCI View source Insufficient capacity for admission to designated hospitals for PCI View source Lack of capacity for rescue PCI at designated hospitals View source Lack of an agreed pathway to access adult critical care beds outside Wales View source Lack of a formal backup plan for PCI when designated hospitals cannot accept a patient View source See 3 more concerns
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.
×
AI-generated summary
Dr Imad Hassan · 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
On 17 April 2016, Dr Imad Hassan suffered an out-of-hospital heart attack and cardiac arrest, was resuscitated, and taken to Prince Charles Hospital. He suffered a further cardiac arrest and died at 04:35 on 18 April 2016. The report raised concerns about the lack of a formal backup and transfer pathway for patients requiring PCI when capacity was unavailable at the relevant hospitals, including for unconscious STEMI patients.
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 a bed management pathway
Wider context from the report “3) As per the evidence of ████████ given at inquest, an agreed short term pathway needs to be put in place to access adult critical care beds outside Wales and a bed management pathway put in place .
” 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 an agreed tertiary-services pathway for unconscious STEMI patients requiring PCI
Wider context from the report “4) There is currently no agreed pathway for an unconscious STEMI patient requiring PCI in tertiary services as there is currently for conscious patients with STEMI. Although in the case of Dr Hassan transfer to another hospital for a rescue PCI was not clinically indicated, that may not necessarily be the case in the future, particularly in a patient who has had a short period of unconsciousness and a PCI is clinically indicated.
” 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 Insufficient capacity for admission to designated hospitals for PCI
Wider context from the report “2) In such circumstances, a patient meeting the criteria for PCI is unable to undergo that procedure, increasing the risk of his/her death, until there is such capacity for that patient to be admitted to UHW or Morriston Hospitals for PCI .
” 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 capacity for rescue PCI at designated hospitals
Wider context from the report “5) In similar circumstances as pertained on the evening prior to / the morning of Dr Hassan's death such a patient (as described in 4)) may be deprived the opportunity of undergoing rescue PCI due to lack of capacity at either UHW in Cardiff or Morriston in Swansea .
” 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 an agreed pathway to access adult critical care beds outside Wales
Wider context from the report “3) As per the evidence of ████████ given at inquest, an agreed short term pathway needs to be put in place to access adult critical care beds outside Wales and a bed management pathway put in place.
” 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 a formal backup plan for PCI when designated hospitals cannot accept a patient
Wider context from the report “1) In the event that a patient at Prince Charles Hospital is deemed suitable for PCI there is currently no formal back up plan in place , to enable the PCI to proceed, should UHW in Cardiff or Morriston Hospital in Swansea be unable to accept that patient.
” Open source report
20 Apr 2016 Ronald Hamer · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 4 Failure to provide timely ambulance responses to Amber 2 calls View source Failure to make timely follow-up calls to update, advise and reassess emergency callers View source Lack of clear planning and direction for maintaining and delivering ambulance services View source Failure to maintain ambulance service delivery during significant call volumes View source See 1 more concern
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.
×
AI-generated summary
Ronald Hamer · 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
Ronald Hamer, an elderly man living independently at home, fell in his bathroom on 8 February 2016 and remained immobilised on the floor for over 13½ hours before being found. He was taken to hospital after a delayed ambulance response and died there on the morning of 10 February 2016. Concerns included the ambulance response time, the lack of timely follow-up contact with the family, and inadequate planning and direction during periods of very high call volumes.
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 provide timely ambulance responses to Amber 2 calls
Wider context from the report “1) As against an internal Welsh Ambulance Services Trust response target time for an Amber 2 call of 20 minutes, an ambulance did not arrive at the scene for nearly 2 hours and 40 minutes . It was accepted in evidence on behalf of the Welsh Ambulance Services Trust that this response time was unacceptable and that the situation could happen again .
” 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 make timely follow-up calls to update, advise and reassess emergency callers
Wider context from the report “2) Cognisant of the delay in responding to the original call to the emergency services, good practice of the Welsh Ambulance Services Trust would have been to have made a phone call(s) to seek an update on the condition of the patient, to provide further advice and to ascertain whether it would have been appropriate to re-categorise the call . A call was not made to the family of the deceased (and this was disputed in evidence in any event) until just before 8:25pm, 1½ hours after the original call had been made .
” 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 clear planning and direction for maintaining and delivering ambulance services
Wider context from the report “3) The evidence suggested that at or around the time of the first call being made to the Welsh Ambulance Services Trust at around 6:50pm on the 8th February 2016 there was an extremely high number of calls being polled. The evidence suggested that there was an absence of clear planning and direction as to the maintenance and delivery of the Trust's services and that in repeat circumstances of such significant polling the same circumstances as found at the inquest of Mr Hamer could repeat themselves .
” 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 ambulance service delivery during significant call volumes
Wider context from the report “3) The evidence suggested that at or around the time of the first call being made to the Welsh Ambulance Services Trust at around 6:50pm on the 8th February 2016 there was an extremely high number of calls being polled . The evidence suggested that there was an absence of clear planning and direction as to the maintenance and delivery of the Trust's services and that in repeat circumstances of such significant polling the same circumstances as found at the inquest of Mr Hamer could repeat themselves .
” Open source report
15 Feb 2016 Eileen Annie Thompson · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 2 Inaccessibility of inner-wheel locking mechanisms when beds are placed against walls View source Failure to lock the inner wheels of beds View source
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.
×
AI-generated summary
Eileen Annie Thompson · 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
Eileen Annie Thompson, who had dementia, fell between her bed and a wall after the bed moved and sustained serious head injuries. She died shortly after admission to hospital. The concerns were that the bed’s inner wheels were not locked because their locking mechanisms were inaccessible against the wall, creating a risk of recurrence for other service users.
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 Inaccessibility of inner-wheel locking mechanisms when beds are placed against walls
Wider context from the report “(1) The bed was able to move from the wall because the two inner wheels were not locked.
(2) The locking mechanism for the inner wheels was not easily accessible when the bed was placed against a wall .
(3) There is risk of recurrence in respect of service users who are provided with this type of bed when the bed is placed against a wall.
” 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 lock the inner wheels of beds
Wider context from the report “(1) The bed was able to move from the wall because the two inner wheels were not locked .
(2) The locking mechanism for the inner wheels was not easily accessible when the bed was placed against a wall.
(3) There is risk of recurrence in respect of service users who are provided with this type of bed when the bed is placed against a wall.
” Open source report
15 Jan 2016 Jasmine Ruby Lapsley · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 5 Lack of an effective rota system for consistent Community First Responder cover View source Failure to provide increased resources during the July and August population increase View source Unavailability of reliable air support in North West Wales during overnight hours View source Insufficient planning for recruitment and retention of local Community First Responders View source Unreliable communication for contacting Community First Responders in remote and/or rural areas View source See 2 more concerns
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.
×
AI-generated summary
Jasmine Ruby Lapsley · 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
On 19 August 2016, six-year-old Jasmine Lapsley choked on a grape while on holiday in Morfa Nefyn and died at 23.58 hours despite resuscitation efforts. The report identified concerns about gaps in overnight air support, the lack of a reliable Community First Responder rota and communication system, the need for sufficient local responders, and resource planning during seasonal population increases in rural and remote areas.
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 an effective rota system for consistent Community First Responder cover
Wider context from the report “(2) There is no effective rota system for Community First Responders to ensure consistent cover these local volunteers who provide essential support for patients in remote and/or rural locations in North West Wales. The method of communicating Community First Responders to attend is mobile telephone although this is by mobile telephone although this is fraught with difficulties in remote and/or rural areas where network coverage can be patchy at best and frequently non existent. WAST should review the systems in place for rostering and contacting Community First Responders to ensure more consistent cover and more reliable communication.
” 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 provide increased resources during the July and August population increase
Wider context from the report “(4) The population of many rural and remote areas of North West Wales increases significantly during the months of July and August. WAST currently do not provide increased resources during these two months to cope with this increase in population . WAST should review their planning for effective allocation of resources to ensure the safety of this population during the months of July and August.
” 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 reliable air support in North West Wales during overnight hours
Wider context from the report “(1) There is no reliable WAST Air Support in North West Wales during the hours of 20.00 hours and 07.00 hours , those being the hours not covered by Wales Air Ambulance or the recently introduced Emergency Medical Retrieval Teams. WAST should review this gap in air support which is an essential asset in accessing, treating and retrieving critically ill or injured patients, particularly in remote and/or rural areas .
” 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 Insufficient planning for recruitment and retention of local Community First Responders
Wider context from the report “(3) Given the difficulties in ambulances arriving at many rural and/or remote areas in North West Wales it is essential that there are sufficient local Community First Responders to arrive promptly at the casualty and provide essential treatment preserving life until an ambulance arrives . WAST should review the planning for the recruitment and retention of Community First Responders .
” 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 communication for contacting Community First Responders in remote and/or rural areas
Wider context from the report “(2) There is no effective rota system for Community First Responders to ensure consistent cover these local volunteers who provide essential support for patients in remote and/or rural locations in North West Wales. The method of communicating Community First Responders to attend is mobile telephone although this is by mobile telephone although this is fraught with difficulties in remote and/or rural areas where network coverage can be patchy at best and frequently non existent . WAST should review the systems in place for rostering and contacting Community First Responders to ensure more consistent cover and more reliable communication.
” Open source report
Concerns raised 3 Unmonitored over-anticoagulation following omitted delegated INR testing View source Non-uniform implementation of monitoring practices for delegated INR testing View source Risk of unmonitored or unactioned failure to complete delegated INR testing View source
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.
×
AI-generated summary
Mr Ronald Francis Bonfield · 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 Ronald Francis Bonfield sustained a head injury at home on 29 September 2014, was admitted to Prince Charles Hospital on 1 October, and died there on 2 October 2014. The inquest recorded that he was taking Warfarin, was over-anticoagulated, and that his INR levels were not being monitored as required. The substantive concerns related to inconsistent procedures for monitoring delegated INR testing and the risk of unmonitored over-anticoagulation.
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 Unmonitored over-anticoagulation following omitted delegated INR testing
Wider context from the report “(3) Until such action is taken there remains a risk that a future death(s) could occur in similar circumstances to Mr Bonfield’s, where delegated INR testing has not been done leading to unmonitored over anti-coagulation
” 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 Non-uniform implementation of monitoring practices for delegated INR testing
Wider context from the report “(1) The practices and procedures implemented by the Practice 1, Keir Hardie Health Park, GP Surgery following Mr Bonfield’s death (with regard to monitoring the compliance of the Health Boards District Nurse Teams following delegation to undertake a patient’s INR testing) is not uniform and/or implemented across all of the Health Boards Level 4 Accredited GP practices .
” 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 Risk of unmonitored or unactioned failure to complete delegated INR testing
Wider context from the report “(2) The practices and procedures implemented by Practice 1, Keir Hardie Health Park Surgery act as a check and balance to reduce the risk of an unmonitored/unactioned failure on the part of the District Nurse service to undertake the task(testing the patients INR level) delegated to them by the GP practice concerned.
” Open source report
Concerns raised 4 Inadequate monitoring of INR levels View source Inadequate communication about anticoagulation monitoring and potential therapy adjustment View source Lack of certainty whether Warfarin was being taken View source Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment View source See 1 more concern
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.
×
AI-generated summary
Mrs. Mary Patricia 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
Mrs. Mary Patricia James had a prosthetic heart valve requiring anticoagulation, but INR monitoring was inadequate and there was uncertainty about whether she was taking Warfarin. Concerns included failures in communication between the INR Unit, care home and GP, and that she was not admitted to hospital on 15 May 2015 despite concern about a possible ischaemic leg. The inquest concluded: “Ischaemic leg contributed to by inadequate Warfarin monitoring and dosing”.
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 Inadequate monitoring of INR levels
Wider context from the report “(1) Inadequate monitoring of INR levels in a patient suffering from dementia;
” 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 Inadequate communication about anticoagulation monitoring and potential therapy adjustment
Wider context from the report “(3) Inadequate communication between the INR Unit, the Care Home and the GP regarding this patient’s anticoagulation monitoring and the potential need for therapy adjustment ;
” 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 certainty whether Warfarin was being taken
Wider context from the report “(2) Lack of certainty whether Warfarin was being taken by the patient ;
” 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 a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment
Wider context from the report “(4) That against this background and the Care Home’s concern about a possible ischaemic leg , Mrs. James was not admitted to hospital on the 15th May, 2015 when there may have been a window of opportunity to have adjusted the anticoagulation therapy .
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations