PFD report

Elsie May Hayward · Prevention of Future Deaths report

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Issued 19 Mar 2015•Cardiff and Vale of Glamorgan

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
20

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Insufficient staffing capacity for safe patient oversight
    Part of recurring concern: Insufficient qualified healthcare staffing capacity
  2. Failure to maintain complete and consistent nursing and clinical records
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  3. Failure to undertake nursing observations in accordance with required procedures and guidance
    Part of recurring concern: Failure to carry out required neurological observations
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. Action

    Remove real-time documentation so that one clinical note is used.

    Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 19 March 2015.
  2. Action

    Maintain a process for covering short-term sickness and absence vacancies to protect staffing levels.

    Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 19 March 2015.
  3. Action

    Use cross-Clinical-Board medical staffing during extreme pressure to increase capacity in pressured areas.

    Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2015.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient staffing capacity for safe patient oversight

Wider context from the report

“1. On the 7th January 2015 medical staff were having to care for 50% more patients over what is generally considered to be safe staffed patient ratio. The evidence showed that the team was significantly overstretched and as a result were not able to oversee the care to this lady. Because of the pressures on the team it is likely that there were deficiencies in the care afforded to her which may have contributed to her repeated falls. ”

Is this part of a recurring concern?

Yes — Insufficient qualified healthcare staffing capacity.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain complete and consistent nursing and clinical records

Wider context from the report

“3. There were extensive omissions in the note taking and a clear inconsistency between the “nursing notes” and “clinical notes” resulting in confusion and breakdown of communication between the nursing staff and the medical team. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to undertake nursing observations in accordance with required procedures and guidance

Wider context from the report

“2. Despite clear guidance and directive the nursing observations on the deceased following her head injury were not undertaken in accordance with the Health Boards procedure and the N.I.C.E. national guidance. ”

Is this part of a recurring concern?

Yes — Failure to carry out required neurological observations.

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

Remove real-time documentation so that one clinical note is used.

Verbatim wording from the response

“The omissions and inconsistencies in notetaking has been recognised and immediate action has been taken to remove the “core-care plan” and staff will now write individualized care plans for all patients. Further checks have been made in all other areas within Medicine to ensure the core care plan is not being used. The “real time” documentation has also been removed so that only one clinical note is in use.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 4 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain a process for covering short-term sickness and absence vacancies to protect staffing levels.

Verbatim wording from the response

“• The Clinical Director for Internal Medicine has worked with the junior doctors, led by the Chief Resident (SpR) to agree a process for covering vacancies due to short term sickness/absence to ensure that staffing is not compromised”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 3 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Use cross-Clinical-Board medical staffing during extreme pressure to increase capacity in pressured areas.

Verbatim wording from the response

“• In times of extreme pressure, the Medical Director makes representation to all Clinical Boards to make sure that as many medical staff are undertaking generic medical duties as possible to increase capacity in areas which are under more pressure.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 3 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Work with the Royal College of Physicians to agree staffing requirements and standards for managing medical outlier patients.

Verbatim wording from the response

“Currently there are no national recognised standards for medical staffing levels although this is currently being considered by the Royal College of Physicians (RCP) and the UHB will work with the RCP to agree staff requirements and standards for the medical management of patients who are outliers.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 2 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Audit known fallers with head injuries for compliance with NICE guidance and UHB falls-management policies.

Verbatim wording from the response

“There will be a planned audit by the end of July 2015 of any known patient fallers with a head injury to give assurance that staff are complying with the requirements of the NICE Guidance and relevant UHB policies for the management of patients following falls.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 3 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Disseminate head-injury NICE guidance to ward sisters across the Medicine Clinical Board.

Verbatim wording from the response

“More recently, Welsh Government has issued Patient Safety Notice PSN/009/April 2015 - Awareness of NICE Clinical Guidelines on head injuries - and this has been issued to all Clinical Boards to remind them of the importance of this particular guidance. Within the medicine Clinical Board, Lead and senior nurses will ensure further dissemination of this information to ward sisters by the end of May 2015.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 3 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Remove the core care plan and require individualised care plans for all patients.

Verbatim wording from the response

“The omissions and inconsistencies in notetaking has been recognised and immediate action has been taken to remove the “core-care plan” and staff will now write individualized care plans for all patients. Further checks have been made in all other areas within Medicine to ensure the core care plan is not being used. The “real time” documentation has also been removed so that only one clinical note is in use.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 4 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue participating in the all-Wales programme to progress a single electronic patient record.

Verbatim wording from the response

“The UHB, in line with all other Health Boards in Wales does not have a single electronic patient record in place but will continue with all Wales work to progress this agenda which would inevitably bring significant patient safety benefits. The continuous improvement plan has been presented and discussed at the Medicine Clinical Board formal Board meeting and has also been shared at the UHB Quality, Safety and Patient Experience Committee meeting. The Directorate is required to regularly review the improvement plan and provide assurance to the various quality and safety monitoring mechanisms. An update on progress will be presented at the September 2015 Quality, Safety and Patient Experience Committee.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 4 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue prioritising patient flow and monitoring multidisciplinary workload pressures, managing identified risks through the Risk Register.

Verbatim wording from the response

“Additionally the UHB continues to prioritise issues of patient flow and monitors workload pressures for the multi-disciplinary team and recognises associated risks. The Medicine Clinical Board (MCB) will continue to work with the UHB patient flow work stream in order to safely manage patient flow through the organisation. Risks identified will be managed via the Risk Register and acted upon accordingly.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 3 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and disseminate a new care plan across clinical areas using Falls Focus Group champions as required.

Verbatim wording from the response

“The Medicine Clinical Board representatives at the Vulnerable Adult Risk Management Group (VARMG) will support the development and dissemination of a new care plan to all clinical areas, utilising champions from the newly formed Falls Focus Group as required.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 4 · response
Published 19 March 2015

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. 1

    Present an update on continuous improvement plan progress to the Quality, Safety and Patient Experience Committee in September 2015.

    Stated by Cardiff & Vale University LHBStated plannedThe respondent said that this action was planned when they made their response on 19 March 2015.
  2. 2

    Hold ward safety briefings, board rounds and multidisciplinary meetings to discuss falls risks, actions and anti-coagulation risks.

    Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 19 March 2015.
  3. 3

    Incorporate additional winter medical-bed requirements and lessons learned into Winter 2015 planning.

    Stated by Cardiff & Vale University LHBStated plannedThe respondent said that this action was planned when they made their response on 19 March 2015.
  4. 4

    Establish revised nursing establishments to provide clinical nurse attendance at board rounds, ward rounds and multidisciplinary meetings.

    Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2015.
  5. 5

    Review the continuous improvement plan regularly and provide assurance through quality and safety monitoring mechanisms.

    Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2015.
  6. 6

    Retrain general staff in the clinical area on relevant falls prevention and care procedures.

    Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2015.
  7. 7

    Issue the falls-learning SBAR report across all Clinical Boards to support organisation-wide improvement.

    Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 19 March 2015.
  8. 8

    Maintain local compliance audits of relevant clinical practice.

    Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2015.
  9. 9

    Revise medical staff and student induction to cover ward-based falls assessment tools and bedrail use.

    Stated by Cardiff & Vale University LHBStated plannedThe respondent said that this action was planned when they made their response on 19 March 2015.
  10. 10

    Implement the developed staff training strategy.

    Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 19 March 2015.

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

Present an update on continuous improvement plan progress to the Quality, Safety and Patient Experience Committee in September 2015.

Verbatim wording from the response

“The UHB, in line with all other Health Boards in Wales does not have a single electronic patient record in place but will continue with all Wales work to progress this agenda which would inevitably bring significant patient safety benefits. The continuous improvement plan has been presented and discussed at the Medicine Clinical Board formal Board meeting and has also been shared at the UHB Quality, Safety and Patient Experience Committee meeting. The Directorate is required to regularly review the improvement plan and provide assurance to the various quality and safety monitoring mechanisms. An update on progress will be presented at the September 2015 Quality, Safety and Patient Experience Committee.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 4 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Hold ward safety briefings, board rounds and multidisciplinary meetings to discuss falls risks, actions and anti-coagulation risks.

Verbatim wording from the response

“• At Ward level: ◦ Board rounds, safety briefings and MDT meetings are held to discuss risks, actions and raise awareness of the risks of Falls for patients on anti-coagulation. ◦ A Disciplinary investigation into the practice of an individual nurse is to commence due to repeated failures to follow UHB policies and procedures following a patient fall ◦ General staff in this clinical area are being retrained”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 1 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Incorporate additional winter medical-bed requirements and lessons learned into Winter 2015 planning.

Verbatim wording from the response

“• Annual winter planning incorporates the need for additional medical beds over the winter months to accommodate the anticipated additional demand. Planning for Winter 2015 will incorporate the lessons learned from last year to ensure that there are sufficient beds on each hospital site and ensure that as far as reasonably possible there are no medical outliers.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 3 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish revised nursing establishments to provide clinical nurse attendance at board rounds, ward rounds and multidisciplinary meetings.

Verbatim wording from the response

“The revised nursing establishments will facilitate a clinical nurse being present at Board rounds, ward rounds and Multi-disciplinary Team meetings so that communication can be improved. There is a recognition that this will not be fully effective until all the nurse recruitment has been completed but is imminent.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 4 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review the continuous improvement plan regularly and provide assurance through quality and safety monitoring mechanisms.

Verbatim wording from the response

“The UHB, in line with all other Health Boards in Wales does not have a single electronic patient record in place but will continue with all Wales work to progress this agenda which would inevitably bring significant patient safety benefits. The continuous improvement plan has been presented and discussed at the Medicine Clinical Board formal Board meeting and has also been shared at the UHB Quality, Safety and Patient Experience Committee meeting. The Directorate is required to regularly review the improvement plan and provide assurance to the various quality and safety monitoring mechanisms. An update on progress will be presented at the September 2015 Quality, Safety and Patient Experience Committee.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 4 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Retrain general staff in the clinical area on relevant falls prevention and care procedures.

Verbatim wording from the response

“• At Ward level: ◦ Board rounds, safety briefings and MDT meetings are held to discuss risks, actions and raise awareness of the risks of Falls for patients on anti-coagulation. ◦ A Disciplinary investigation into the practice of an individual nurse is to commence due to repeated failures to follow UHB policies and procedures following a patient fall ◦ General staff in this clinical area are being retrained”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 1 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Issue the falls-learning SBAR report across all Clinical Boards to support organisation-wide improvement.

Verbatim wording from the response

“In addition to the measures being taken forward by the Medicine Clinical Board to address the local issues identified, the Executive Nurse Director and Medical Director have issued a Situation, Background, Assessment and Recommendation (SBAR) report across all Clinical Boards within the UHB to ensure that the learning from this case is shared and leads to improvements across the whole organisation.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 2 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain local compliance audits of relevant clinical practice.

Verbatim wording from the response

“◦ Local compliance audits are to be maintained ◦ A Training strategy has been developed and implemented ◦ Medical staff (including medical students) induction will be revised to include the practical aspects of ward based falls assessment tools/use of bedrails.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 2 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Revise medical staff and student induction to cover ward-based falls assessment tools and bedrail use.

Verbatim wording from the response

“◦ Local compliance audits are to be maintained ◦ A Training strategy has been developed and implemented ◦ Medical staff (including medical students) induction will be revised to include the practical aspects of ward based falls assessment tools/use of bedrails.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 2 · response
Published 19 March 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement the developed staff training strategy.

Verbatim wording from the response

“◦ Local compliance audits are to be maintained ◦ A Training strategy has been developed and implemented ◦ Medical staff (including medical students) induction will be revised to include the practical aspects of ward based falls assessment tools/use of bedrails.”

Source location

2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 2 · response
Published 19 March 2015

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026