Concerns raised 2 Delays in progressing referrals View source Failure to make additional enquiries to locate missing referral information 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
Caitlin Rachel Imber ("Caiti") · 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
Caitlin Rachel Imber (“Caiti”) died on 13 December 2022; the recorded cause of death was hanging. The report raises concern about a 42-day delay in progressing a CAMHS referral after missing contact information was not followed up, although it states that this was not contributory to Caiti’s death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Delays in progressing referrals
Wider context from the report “On the 9th of May 2022, CAMHS received a referral from a community paediatrician dated the 19th of April 2022. This identified the need for support care and treatment to be provided to a traumatized, vulnerable child, however as the referral did not contain any contact numbers, the referral was closed without any additional enquiries being made to further the matter.
A further referral was received on the 31st of May 2022 and was then accepted by CAMHS, representing a delay of 42 days from the original paediatrician’s referral to any action being taken.
Whilst this was not contributory to Caiti’s death, I am concerned by the apparent lack of effort to locate missing information and progress a referral and I consider that if this situation continues to prevail, then there is a risk that future deaths could occur.
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure to make additional enquiries to locate missing referral information
Wider context from the report “On the 9th of May 2022, CAMHS received a referral from a community paediatrician dated the 19th of April 2022. This identified the need for support care and treatment to be provided to a traumatized, vulnerable child, however as the referral did not contain any contact numbers, the referral was closed without any additional enquiries being made to further the matter .
A further referral was received on the 31st of May 2022 and was then accepted by CAMHS, representing a delay of 42 days from the original paediatrician’s referral to any action being taken.
Whilst this was not contributory to Caiti’s death, I am concerned by the apparent lack of effort to locate missing information and progress a referral and I consider that if this situation continues to prevail, then there is a risk that future deaths could occur.
” Open source report
Concerns raised 1 Failure to complete actions and recommendations within set timeframes 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
Susan Merton · 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
Susan Merton underwent a CT scan whose report did not identify a common bile duct stone. After the stone was recognised and treatment was scheduled, her condition deteriorated acutely and she died at Glan Clwyd Hospital on 23 August 2019. The report raised concerns that the Health Board had not implemented or reviewed actions from its investigation within its own timeframe, potentially putting lives at risk.
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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure to complete actions and recommendations within set timeframes
Wider context from the report “1. Evidence provided to me in the course of the investigation indicated that the Health Board had conducted an investigation and had produced an Action Plan in light of the findings of their investigation. The Action Plan required that the recommendations contained therein be reviewed in a Clinical Governance Meeting on the 5th of August 2021 however for reasons which could not be explained at the inquest, this was not done.
2. On previous occasions I have issued regulation 28 reports expressing concerns that the Health Board continually fail to accomplish actions in circumstances where they have set their own timeframe .
3. I am concerned that as a result of the Health Board failing to follow through with their own actions and recommendations either in a timely manner or in this specific case at all , lives are being put at risk.
” Open source report
Concerns raised 2 Reluctance to supplement locum references with telephone calls to referees View source Lack of a recognised protocol for observing and assessing locum staff in practice 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
Arthur Price Hughes · 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
Arthur Price Hughes underwent emergency surgery on 20 October 2014, during which significant bleeding occurred; despite further surgical interventions, the injury sustained resulted in his subsequent death. The report raised concerns about the lack of a recognised protocol for observing, assessing and mentoring newly appointed locum staff, and about reluctance to supplement references with telephone calls to referees.
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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Reluctance to supplement locum references with telephone calls to referees
Wider context from the report “2. Whilst it would appear that the process by which the taking up of references has improved significantly for the appointment of locums since 2014, evidence provided at the inquest appears to indicate that there is a marked reluctance at a managerial level for references to be supplemented by telephone calls to the referees .
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Lack of a recognised protocol for observing and assessing locum staff in practice
Wider context from the report “1. The appointment of locum staff is a necessary requirement within the Health Board to provide continuity of service and the recruitment process in relation to locums ensures that they have the appropriate qualifications to undertake the roles for which they are appointed. However, there does not appear to a recognised protocol or policy by which their work is initially observed, assessed or evaluated in practice , with the result that locum staff could be required to undertake tasks or roles which are at the limit or beyond their capabilities thus creating a risk to patients which may include a risk to life. A more rigid or defined approach to observing and assessing (and where necessary mentoring) new recruits to ensure that their skills and working practices match their apparent qualifications could be beneficial in ensuring a quality of service.
” Open source report
Concerns raised 4 Delays in ambulance response View source Lack of availability of resources View source Failures in patient flow View source Failures in admission to the emergency department 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
Margaret Megan Evans · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Megan Evans fell outside her home on 22 January 2018 and sustained a fractured hip. Delays in ambulance attendance, admission to the emergency department and being seen by an ED doctor left her lying on a concrete path for more than three hours and delayed medical assessment; the report states that it cannot be said these delays contributed to her death, which was recorded as accidental with hospital-acquired pneumonia and a fractured neck of femur.
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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance response
Wider context from the report “The issues of ambulance delays /admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result .
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Lack of availability of resources
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources /patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result .
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failures in patient flow
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result .
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failures in admission to the emergency department
Wider context from the report “The issues of ambulance delays/admission to ED /availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests.
Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result .
” Open source report
Concerns raised 4 Failure to maintain safe patient flow View source Unavailability of required healthcare resources View source Delays in ambulance response or conveyance View source Failure to ensure timely admission to the emergency department 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
Ester Jane Wood · 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
Ester Jane Wood was taken by ambulance to Maelor Hospital and waited in the ambulance from 20.05hrs until 1am before admission. The report identified concerns about ambulance delays, emergency department admission, resource availability and patient flow, stating that these problems continued and placed patients' lives at risk.
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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain safe patient flow
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of Lilly Baxendall.
Despite the above reports issued to the Health Board and other relevant bodies these problems continue to the present day and patients' lives are being placed at risk as a result .
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Unavailability of required healthcare resources
Wider context from the report “The issues of ambulance delays/admission to ED/availability of resources /patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of Lilly Baxendall.
Despite the above reports issued to the Health Board and other relevant bodies these problems continue to the present day and patients' lives are being placed at risk as a result .
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance response or conveyance
Wider context from the report “The issues of ambulance delays /admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of Lilly Baxendall.
Despite the above reports issued to the Health Board and other relevant bodies these problems continue to the present day and patients' lives are being placed at risk as a result .
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely admission to the emergency department
Wider context from the report “The issues of ambulance delays/admission to ED /availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of Lilly Baxendall.
Despite the above reports issued to the Health Board and other relevant bodies these problems continue to the present day and patients' lives are being placed at risk as a result .
” Open source report
Concerns raised 4 Delays in emergency department patient handover View source Failure to maintain adequate emergency department staffing View source Insufficient hospital bed capacity for admissions View source Failure of hospital patient flow and delayed transfer of care processes 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
Lilly Baxandall · 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
Lilly Baxandall was found collapsed at home after an unwitnessed fall and was taken to hospital by ambulance. Her ambulance handover was delayed for almost four hours amid capacity issues, and a CT scan later showed a large acute subdural haematoma that could not be treated; she died on 5 September 2014. The report raised concerns about continuing ambulance and handover delays, bed shortages, patient flow and delayed transfers of care, placing patients’ lives at risk.
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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Delays in emergency department patient handover
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls" .
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients".
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care.
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays /bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate emergency department staffing
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls".
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients" .
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care.
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Insufficient hospital bed capacity for admissions
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls".
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients".
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care.
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions ”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital patient flow and delayed transfer of care processes
Wider context from the report “Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls".
In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays.
In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients".
In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care .
In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome.
In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”.
In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment ”
Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result.
It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable.
” Open source report
Concerns raised 3 Infrequent consultant psychiatrist review of recently sectioned and treated inpatients View source Delays in completion of Care Treatment Plans after inpatient discharge View source Insufficient staffing cover during sickness and holidays 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
Christopher Glyn Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Glyn Jones died after placing himself into collision with a train while under the care of the Community Mental Health Team. The inquest identified delays in treatment plans and risk assessments, failures in providing intended treatments, and inadequate escalation of concerns during a significant decline in his mental health; it also identified possible service deficiencies in staffing cover.
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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Infrequent consultant psychiatrist review of recently sectioned and treated inpatients
Wider context from the report “1. Evidence at the inquest indicated that the deceased was discharged from inpatient treatment on the 6th of January 2015 but his Care Treatment Plan was not completed until the end of April 2015 and that this would then only require review within a period of twelve months from that date , as a result it could have been the case that a patient who had recently been sectioned and treated as an inpatient may not then be seen by a consultant psychiatrist for a period in the region of sixteen months .
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Delays in completion of Care Treatment Plans after inpatient discharge
Wider context from the report “1. Evidence at the inquest indicated that the deceased was discharged from inpatient treatment on the 6th of January 2015 but his Care Treatment Plan was not completed until the end of April 2015 and that this would then only require review within a period of twelve months from that date, as a result it could have been the case that a patient who had recently been sectioned and treated as an inpatient may not then be seen by a consultant psychiatrist for a period in the region of sixteen months.
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing cover during sickness and holidays
Wider context from the report “2. Furthermore evidence indicated that although additional resources were currently being made available and deployed for Mental Health within BCUHB, there was also an increasing demand on the service and as a result there may still be deficiencies of service , for example in providing acceptable levels of cover for staff at times of sickness/holidays etc.
” Open source report
Concerns raised 2 Lack of a coding system to make injury-identifying radiologist reports easily identifiable for prioritisation View source Failure to reliably deliver and make radiologist reports available in patient context to the Emergency Department 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
Mrs Mary Myfanwy Hollands · 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 Myfanwy Hollands, aged 98, sustained an unwitnessed fall at her nursing home and was later found to have a left hip bony injury that had not been identified on the initial X-ray. She deteriorated and died on 27 July 2015. The principal concern was that the system for conveying radiologists’ reports to the Emergency Department was not sufficiently reliable or safe, including failures in paper-report delivery and the lack of a prioritisation or coding system for reports identifying injuries.
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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Lack of a coding system to make injury-identifying radiologist reports easily identifiable for prioritisation
Wider context from the report “(1) The system currently in place for radiologist’s reports being passed to the Emergency Department is not sufficiently reliable or safe so as to provide effective safety netting for patients.
(2) Under the current system the x ray will be put on the PACS system and any obvious bony injury will have the words “red dot” typed on the area of the injury. The Emergency Department doctor must analyse all X-rays to check for an injury, whether or not marked with “red dot”. This is then followed with a radiologists report within 48 hours. The report is put on the PACS system and a paper copy is despatched to the Emergency Department and attached to the notes. The radiologist will in his report note any injuries which he has seen. This provides a safety net where an Emergency Department doctor may have missed a more subtle injury so that a patient, whom has been discharged can be recalled for future advice and/or treatment.
(3) There is currently no coding system for radiologists to make those reports which identify injuries easily identifiable so that the busy Emergency Department can prioritise the reading of those reports with a view to recalling patients whose injuries have gone undetected. This is in the context of some 50000 patients passing through each Emergency Department each year, an average of one third of whom are x rayed . Time is currently being wasted in an already busy department ploughing through reports which do not need to be considered as no injury is disclosed.
(4) Also the method of passing the paper information to the Emergency Department is flawed. There are regular occasions when the paper report does not arrive, as happened in the case of Mrs Hollands, meaning that some patients are not recalled for necessary advice and treatment, as in the case of Mrs Hollands. Once the paper report arrives in the Emergency Department the paper notes have to be located and the paper report attached before it can be considered in context. On occasion a radiologist will come down and discuss a report. There appears to be a lack of consistency
(5) There needs to be a reliable system for the report of the radiologist to be delivered to the Emergency Department, prioritising patient’s with injuries. An optimum system could be devised between senior Consultant Radiologists and Senior Consultant Emergency doctors. This needs to be considered for use prior to digitalisation of Emergency Department notes and incorporated into the anticipated digitalised system.
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably deliver and make radiologist reports available in patient context to the Emergency Department
Wider context from the report “(1) The system currently in place for radiologist’s reports being passed to the Emergency Department is not sufficiently reliable or safe so as to provide effective safety netting for patients.
(2) Under the current system the x ray will be put on the PACS system and any obvious bony injury will have the words “red dot” typed on the area of the injury. The Emergency Department doctor must analyse all X-rays to check for an injury, whether or not marked with “red dot”. This is then followed with a radiologists report within 48 hours. The report is put on the PACS system and a paper copy is despatched to the Emergency Department and attached to the notes. The radiologist will in his report note any injuries which he has seen. This provides a safety net where an Emergency Department doctor may have missed a more subtle injury so that a patient, whom has been discharged can be recalled for future advice and/or treatment.
(3) There is currently no coding system for radiologists to make those reports which identify injuries easily identifiable so that the busy Emergency Department can prioritise the reading of those reports with a view to recalling patients whose injuries have gone undetected. This is in the context of some 50000 patients passing through each Emergency Department each year, an average of one third of whom are x rayed . Time is currently being wasted in an already busy department ploughing through reports which do not need to be considered as no injury is disclosed.
(4) Also the method of passing the paper information to the Emergency Department is flawed. There are regular occasions when the paper report does not arrive , as happened in the case of Mrs Hollands, meaning that some patients are not recalled for necessary advice and treatment, as in the case of Mrs Hollands. Once the paper report arrives in the Emergency Department the paper notes have to be located and the paper report attached before it can be considered in context. On occasion a radiologist will come down and discuss a report. There appears to be a lack of consistency
(5) There needs to be a reliable system for the report of the radiologist to be delivered to the Emergency Department , prioritising patient’s with injuries. An optimum system could be devised between senior Consultant Radiologists and Senior Consultant Emergency doctors. This needs to be considered for use prior to digitalisation of Emergency Department notes and incorporated into the anticipated digitalised system.
” Open source report
Concerns raised 2 Lack of recording the type of issue in the notes View source Failure to conduct handovers by reference to nursing notes 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
Alan Walker · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alan Walker died after a nasogastric feeding set was connected to an intravenous line, resulting in the infusion of liquid feed. The report raised concern that equipment connectivity issues were not recorded in nursing notes and might not be relayed during staff handovers.
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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Lack of recording the type of issue in the notes
Wider context from the report “That by not recording within the notes the type of issue referred to in paragraph 4 (b) above and then by not conducting handovers by reference to the nursing notes there is a risk that potentially significant information is not relayed to staff who come on duty at a later time.
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct handovers by reference to nursing notes
Wider context from the report “That by not recording within the notes the type of issue referred to in paragraph 4 (b) above and then by not conducting handovers by reference to the nursing notes there is a risk that potentially significant information is not relayed to staff who come on duty at a later time.
” Open source report
Concerns raised 4 Inaccurate information in the Transfer of Care Form View source Failure to provide the Transfer of Care Form to escorting police for immediate availability to the custody nurse View source Failure to ensure completion of the Transfer of Care Form by the examining doctor View source Delays in completing the Transfer of Care Form at the time of examination 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
Andrew Selwyn Roberts · 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
Andrew Selwyn Roberts was arrested on 24 December 2011, after being tasered and having taken an overdose, and was taken to hospital before being assessed as fit to return to custody. The transfer of care form inaccurately stated that he had been assessed by psychiatric liaison, although he had not been seen by that team. The substantive concerns were that the form was completed by a nurse rather than the examining doctor, contained inaccurate information, and was not completed and provided to police at the time of examination.
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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Inaccurate information in the Transfer of Care Form
Wider context from the report “1. That the Transfer of Care Form was not completed by the Doctor who had carried out the examination of the patient and the information contained therein was subsequently found to be inaccurate .
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the Transfer of Care Form to escorting police for immediate availability to the custody nurse
Wider context from the report “2. That the Transfer of Care Form was not completed at the time of examination and provided to the Police Officers escorting the detained person to hospital so that it could be returned with them to custody and made immediately available to the custody nurse .
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure completion of the Transfer of Care Form by the examining doctor
Wider context from the report “1. That the Transfer of Care Form was not completed by the Doctor who had carried out the examination of the patient and the information contained therein was subsequently found to be inaccurate.
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Delays in completing the Transfer of Care Form at the time of examination
Wider context from the report “2. That the Transfer of Care Form was not completed at the time of examination and provided to the Police Officers escorting the detained person to hospital so that it could be returned with them to custody and made immediately available to the custody nurse.
” Open source report
Concerns raised 4 Failure to provide access to mental health information during medical treatment View source Failure to review medication in accordance with accepted medical practice View source Lack of a system to ensure medication review View source Failure to consider care for vulnerable patients requiring additional support 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
Nancy Hughes · 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
Nancy Hughes, who had Alzheimer’s disease and was receiving Risperidone, fell at a care home and later suffered a further unwitnessed fall in hospital before dying on 3 January 2014. The concerns were that her medication was not reviewed as required and that there was insufficient cohesion between mental health and medical treatment, potentially affecting care for vulnerable 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure to provide access to mental health information during medical treatment
Wider context from the report “2. That the evidence given by ████████ Consultant Orthopaedic Surgeon suggested that there was no cohesion between mental health treatment and medical treatment such that whilst receiving medical treatment he would not have access to mental health information relating to a patient and as a result there may be no consideration given to the care given to vulnerable patients requiring additional support.
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure to review medication in accordance with accepted medical practice
Wider context from the report “1. That there was no review of her medication in accordance with accepted medical practice and no system in place to ensure that this was undertaken.
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to ensure medication review
Wider context from the report “1. That there was no review of her medication in accordance with accepted medical practice and no system in place to ensure that this was undertaken .
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure to consider care for vulnerable patients requiring additional support
Wider context from the report “2. That the evidence given by ████████ Consultant Orthopaedic Surgeon suggested that there was no cohesion between mental health treatment and medical treatment such that whilst receiving medical treatment he would not have access to mental health information relating to a patient and as a result there may be no consideration given to the care given to vulnerable patients requiring additional support .
” Open source report
Concerns raised 1 Lack of a documented regime for regular fetal-heart auscultation after maternal opiate administration 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
Elouise Winship · 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
Elouise Winship was delivered unresponsive on 11 March 2011, was resuscitated, and died 13 hours later. Concerns included the absence of a documented standard regime for fetal heart auscultation after maternal opiates and the need for further maternal examination and fresh observations following a recognisable change in condition during labour.
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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Lack of a documented regime for regular fetal-heart auscultation after maternal opiate administration
Wider context from the report “1. That although a Local Serious Review was undertaken following Elouise’s death in which it was agreed that the fetal heart should have been auscultated on a regular basis following administration of opiates to the mother, there is no documented regime by which this has been adopted into standard practice .
” Open source report
Concerns raised 6 Delays in the provision of ambulance assistance View source Failure of Emergency Department patient handover practices to prevent prolonged ambulance waits and resource unavailability View source Failure to ensure emergency clinicians know what pain relief has already been provided View source Unavailability of senior clinicians for overnight second opinions View source Failure to rectify previously identified patient handover delays View source Lack of emergency clinicians’ awareness of overnight patient-discharge policies 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
Clive Harold Turner · 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 Harold Turner was taken to hospital after delays in the response to a call for medical assistance and was discharged after being incorrectly diagnosed as constipated. He was later found deceased at home from a gastrointestinal haemorrhage due to ischaemic bowel resulting from atherosclerosis. Concerns included uncertainty about pain relief provided by the ambulance service, lack of awareness of overnight discharge policies, and the absence of senior clinicians available for a second opinion.
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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Delays in the provision of ambulance assistance
Wider context from the report “1. That there were significant delays in the provision of assistance to Mr Turner by the Welsh Ambulance Service
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure of Emergency Department patient handover practices to prevent prolonged ambulance waits and resource unavailability
Wider context from the report “2. That the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls . Whilst this is a multi-factorial problem, improvements must be made so as to reduce the risk of future deaths.
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure emergency clinicians know what pain relief has already been provided
Wider context from the report “That ████████SHO in Emergency Medicine indicated in her evidence as follows :-
1. that she did not know what pain relief had been provided to Mr Turner by the Welsh Ambulance Service
2. that she was not aware of any policies within BCUHB relating to the discharge of patients overnight.
3. that there were no senior clinicians on duty from whom she could seek a second opinion due to the lateness of the hour when she was attending to Mr Turner.
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Unavailability of senior clinicians for overnight second opinions
Wider context from the report “That ████████SHO in Emergency Medicine indicated in her evidence as follows :-
1. that she did not know what pain relief had been provided to Mr Turner by the Welsh Ambulance Service
2. that she was not aware of any policies within BCUHB relating to the discharge of patients overnight.
3. that there were no senior clinicians on duty from whom she could seek a second opinion due to the lateness of the hour when she was attending to Mr Turner .
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Failure to rectify previously identified patient handover delays
Wider context from the report “3. It is of considerable concern to me that item 2 above is a direct repeat of a concern which I raised in a previous Regulation 28 report following the death of Mr Frederick Pring in March 2013, twelve months before that of Mr Turner, the joint response of WAST and BCUHB being received exactly one week before Mr Turner's death.
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Lack of emergency clinicians’ awareness of overnight patient-discharge policies
Wider context from the report “That ████████SHO in Emergency Medicine indicated in her evidence as follows :-
1. that she did not know what pain relief had been provided to Mr Turner by the Welsh Ambulance Service
2. that she was not aware of any policies within BCUHB relating to the discharge of patients overnight .
3. that there were no senior clinicians on duty from whom she could seek a second opinion due to the lateness of the hour when she was attending to Mr Turner.
” Open source report
Concerns raised 2 Inconsistent criteria for requesting CT scans outside standard hours and at weekends View source Inconsistent levels of care provided to patients across the 24-hour period 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
Ronald Perry · 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 Perry attended Glan Clwyd Hospital on 17 January 2014, was discharged after examination, then collapsed several hours later and could not be resuscitated after readmission. Evidence at the inquest indicated that a CT scan might probably have detected his aneurysm, and raised concern about inconsistent criteria for requesting CT scans outside normal hours and at weekends, creating continuing risks to 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Inconsistent criteria for requesting CT scans outside standard hours and at weekends
Wider context from the report “During the course of the inquest, evidence given by ████████
████████ indicated that had the Deceased undergone a CT scan then it is probable that his aneurysm would have been detected and that he would have undergone surgery. However different criteria exist within BCUHB by which CT scans can be requested by clinicians dependent upon the time of day (before or after 5.00 pm) or whether such a request is made at a weekend.
That unless steps are taken to provide consistency within the levels of care provided to patients on a 24 hour basis then there will be continuing risks to patients "out of hours" and may lead to future deaths.
” 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 Ysbyty Gwynedd; that does not assign responsibility.
PFD Monitor interpretation Inconsistent levels of care provided to patients across the 24-hour period
Wider context from the report “During the course of the inquest, evidence given by ████████
████████ indicated that had the Deceased undergone a CT scan then it is probable that his aneurysm would have been detected and that he would have undergone surgery. However different criteria exist within BCUHB by which CT scans can be requested by clinicians dependent upon the time of day (before or after 5.00 pm) or whether such a request is made at a weekend.
That unless steps are taken to provide consistency within the levels of care provided to patients on a 24 hour basis then there will be continuing risks to patients "out of hours" and may lead to future deaths.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations