PFD report

SUMMER RAE MANT · Prevention of Future Deaths report

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Issued 27 Feb 2026•South Wales Central

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.

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Concerns
1

Raised in this report

Recipients
10

Named on the report

Responses found
3

Of 10 recipients

Stated actions
17

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 raised1

  1. Lack of standardised crash trolleys across hospital settings
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

    Review resuscitation trolley arrangements across acute hospital sites to identify layout, presentation and human-factors risks.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
  2. Action

    Introduce interim resuscitation trolley orientation arrangements for medical staff unfamiliar with the standardised layout.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
  3. Action

    Embed resuscitation trolley orientation in formal induction for incoming medical staff and develop supporting visual and instructional resources.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Full standardisation of resuscitation trolley configuration across all settings is difficult in practice and may not address all identified contributory factors.

    Stated by Betsi Cadwaladr University LHBUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Lack of standardised crash trolleys across hospital settings

Wider context from the report

“During the resuscitation of Summer at Prince Charles Hospital in the theatre following intubation, there was a delay in obtaining adrenaline. The incident occurred at night and it involved a skeleton staff including some junior doctors, fairly new to the hospital. The delay in finding adrenaline, was likely due to the fact that there is no standardised crash trolley, and junior doctors frequently rotate between hospitals and health boards and encounter different set-ups. Paediatric crash trolleys are necessarily different to adult crash trolleys, but there was consensus in evidence that it would be safer if there was a single standardised version of each type across every hospital setting in which junior doctors rotate, to minimise confusion at a time critical moment. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 resuscitation trolley arrangements across acute hospital sites to identify layout, presentation and human-factors risks.

Verbatim wording from the response

“The Health Board has undertaken a comprehensive review of resuscitation trolley arrangements across all acute hospital sites. This confirmed that whilst the contents of cardiac arrest drug trays are standardised in line with Resuscitation Council guidance, there remained variation in visual layout and presentation, particularly at Princess of Wales Hospital (POW), which presents a recognised human factors risk in time-critical situations. In response, immediate action has been taken to align POW paediatric resuscitation trolleys with the established model used at Prince Charles Hospital and Royal Glamorgan Hospital. This includes the removal of red paediatric drug boxes and the introduction of a clear tray system to improve visibility and rapid access to emergency medication.”

Source location

Response from Cwm Taf Morgannwg University Health
Page 2 · response
Published 3 March 2026

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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

Introduce interim resuscitation trolley orientation arrangements for medical staff unfamiliar with the standardised layout.

Verbatim wording from the response

“The Health Board has also strengthened training and induction arrangements to address human factors risks associated with staff unfamiliarity. Whilst nursing staff already receive resuscitation trolley orientation as part of induction and mandatory training, gaps were identified within medical induction, particularly for rotational and out-of-hours staff. In response, work is underway with Medical Education to embed resuscitation trolley orientation within formal induction programmes for all incoming medical staff. Interim arrangements have been introduced to provide immediate assurance, alongside the development of updated training resources, including visual guides and instructional materials, to support consistent staff familiarisation with the standardised trolley layout.”

Source location

Response from Cwm Taf Morgannwg University Health
Page 3 · response
Published 3 March 2026

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

Embed resuscitation trolley orientation in formal induction for incoming medical staff and develop supporting visual and instructional resources.

Verbatim wording from the response

“The Health Board has also strengthened training and induction arrangements to address human factors risks associated with staff unfamiliarity. Whilst nursing staff already receive resuscitation trolley orientation as part of induction and mandatory training, gaps were identified within medical induction, particularly for rotational and out-of-hours staff. In response, work is underway with Medical Education to embed resuscitation trolley orientation within formal induction programmes for all incoming medical staff. Interim arrangements have been introduced to provide immediate assurance, alongside the development of updated training resources, including visual guides and instructional materials, to support consistent staff familiarisation with the standardised trolley layout.”

Source location

Response from Cwm Taf Morgannwg University Health
Page 3 · response
Published 3 March 2026

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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

Standardise resuscitation trolley layouts and visual guidance across paediatric, neonatal and other clinical environments through a phased rollout.

Verbatim wording from the response

“The Health Board has undertaken a comprehensive review of resuscitation trolley arrangements across all acute hospital sites. This confirmed that whilst the contents of cardiac arrest drug trays are standardised in line with Resuscitation Council guidance, there remained variation in visual layout and presentation, particularly at Princess of Wales Hospital (POW), which presents a recognised human factors risk in time-critical situations. In response, immediate action has been taken to align POW paediatric resuscitation trolleys with the established model used at Prince Charles Hospital and Royal Glamorgan Hospital. This includes the removal of red paediatric drug boxes and the introduction of a clear tray system to improve visibility and rapid access to emergency medication.”

Source location

Response from Cwm Taf Morgannwg University Health
Page 2 · response
Published 3 March 2026

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

Reduce variation in adult and paediatric crash trolley layouts while ensuring adherence to Resuscitation Council UK guidelines.

Verbatim wording from the response

“The Welsh Government will require NHSP&I to convene a group of resuscitation experts from Wales to review whether any medicines other than those on the Resuscitation Council UK’s standard list should be available on all crash trolleys in hospitals. The group will undertake work to reduce variation in crash trolley layout for both adults and paediatrics, ensuring adherence to Resuscitation Council UK guidelines.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 3 March 2026

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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

Select standard medicine preparations and establish a single all-Wales supplier contract to ensure availability, standardised packaging and branding on crash trolleys.

Verbatim wording from the response

“This group will also work with the All Wales Drug Contracting Committee to select the most appropriate preparation of each of these medicines to be stocked on crash trolleys and ensure they are all available to all health boards and trusts through a single all-Wales contract with suppliers. This will ensure standardised packaging and branding of products on crash trolleys for any products where this is not already the case. This approach will ensure that procurement decisions take account not only of cost but also human factors that may influence usability in emergency situations, alongside safety, standardisation, and supply chain resilience.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 3 March 2026

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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 boards and trusts to use only nationally procured standardised crash-trolley products and follow the agreed layout.

Verbatim wording from the response

“The Welsh Government will direct health boards and trusts to only use nationally procured standardised products on crash trolleys and follow the agreed layout.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 3 March 2026

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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

Maintain standardised resuscitation trolleys and drug provision across acute sites in line with national standards.

Verbatim wording from the response

“• A standardised approach to resuscitation trolleys and drug provision is in place across our acute sites, aligned to national standards;”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 3 March 2026

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

Update the Resuscitation Policy to strengthen expectations for checking, stocking and laying out resuscitation equipment.

Verbatim wording from the response

“• The Health Board has recently updated its Resuscitation Policy, which includes strengthened expectations in relation to the checking, stocking and layout of resuscitation equipment; and”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 3 March 2026

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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 local resuscitation trolley and drug arrangements against the concerns identified.

Verbatim wording from the response

“• Local arrangements have been reviewed by our Resuscitation Service and relevant clinical leads in light of the issues identified;”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 3 March 2026

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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

Full standardisation of resuscitation trolley configuration across all settings is difficult in practice and may not address all identified contributory factors.

Verbatim wording from the response

“In considering further action, the Health Board supports the principle of improving consistency in the availability and location of key resuscitation drugs. However, consistent with the national work undertaken to date, we consider that full standardisation of resuscitation trolley configuration across all settings will be difficult in practice and may not address all of the contributory factors identified particularly given our need to work the NHS in north-west England.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 3 March 2026

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.7

  1. 1

    Develop and oversee delivery of a comprehensive Action Plan through coordinated clinical and governance arrangements.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2026.
  2. 2

    Rationalise and align medicines governance policies and procedures under a single controlled set of guidance.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2026.
  3. 3

    Establish a multidisciplinary Task and Finish Group to oversee the local patient-safety response.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
  4. 4

    Clarify nursing and Pharmacy responsibilities for trolley checks, replenishment and expiry control.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
  5. 5

    Convene Welsh resuscitation experts to review whether additional medicines should be stocked on all hospital crash trolleys.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 3 March 2026.
  6. 6

    Promote staff familiarity with trolley equipment through visual guidance, local induction, training and clinical-area checking processes.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
  7. 7

    Contribute to the national programme identifying evidence-based approaches to improve consistency in access to essential resuscitation drugs.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2026.

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 oversee delivery of a comprehensive Action Plan through coordinated clinical and governance arrangements.

Verbatim wording from the response

“• Developed and is overseeing delivery of a comprehensive Action Plan”

Source location

Response from Cwm Taf Morgannwg University Health
Page 2 · response
Published 3 March 2026

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

Rationalise and align medicines governance policies and procedures under a single controlled set of guidance.

Verbatim wording from the response

“These risks have been addressed through clear delineation of responsibilities, with nursing teams responsible for daily checks of resuscitation trolleys and Pharmacy responsible for ongoing stock management and expiry control. Work is underway to rationalise and align all relevant policies and SOPs, ensuring that a single, current and consistent set of guidance is available across the organisation, supported by appropriate document control arrangements.”

Source location

Response from Cwm Taf Morgannwg University Health
Page 3 · response
Published 3 March 2026

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 a multidisciplinary Task and Finish Group to oversee the local patient-safety response.

Verbatim wording from the response

“In addition, following receipt of the Regulation 28 report, the Health Board established a multidisciplinary Task and Finish Group to oversee the local response and provide assurance of delivery. This group includes representation from resuscitation services, pharmacy, clinical services and clinical education.”

Source location

Response from Cwm Taf Morgannwg University Health
Page 2 · response
Published 3 March 2026

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

Clarify nursing and Pharmacy responsibilities for trolley checks, replenishment and expiry control.

Verbatim wording from the response

“In parallel, a review of medicines governance identified inconsistencies between Pharmacy Standard Operating Procedures and the overarching Resuscitation Policy, particularly in relation to roles and responsibilities for checking, replenishment and expiry monitoring.”

Source location

Response from Cwm Taf Morgannwg University Health
Page 2 · response
Published 3 March 2026

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

Convene Welsh resuscitation experts to review whether additional medicines should be stocked on all hospital crash trolleys.

Verbatim wording from the response

“The Welsh Government will require NHSP&I to convene a group of resuscitation experts from Wales to review whether any medicines other than those on the Resuscitation Council UK’s standard list should be available on all crash trolleys in hospitals. The group will undertake work to reduce variation in crash trolley layout for both adults and paediatrics, ensuring adherence to Resuscitation Council UK guidelines.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 3 March 2026

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

Promote staff familiarity with trolley equipment through visual guidance, local induction, training and clinical-area checking processes.

Verbatim wording from the response

“• Supporting practical measures are in place to promote staff familiarity with equipment, including visual guidance tools (“My Kit Check”) to assist staff in understanding the contents and layout of resuscitation trolleys, alongside local induction, training and checking processes within clinical areas.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 3 March 2026

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

Contribute to the national programme identifying evidence-based approaches to improve consistency in access to essential resuscitation drugs.

Verbatim wording from the response

“• The Health Board is engaged in national work to explore opportunities for greater consistency, particularly in relation to the availability and presentation of core resuscitation drugs;”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 3 March 2026

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