PFD report

Margaret Joy Daly · Prevention of Future Deaths report

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Issued 28 Oct 2024•North Wales (East and 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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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. Failure to access and consider full medical records and risk assessments when prescribing medication changes
    Part of recurring concern: Unsafe medication prescribing
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.3

  1. Action

    Progress development of integrated electronic health records through business cases, Welsh Government-supported mental health work, and collaboration with early implementers and other Welsh organisations.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.
  2. Action

    Establish a prescribing safety process requiring access to patient notes, communication of falls risk, and escalation or assessment when safe prescribing is uncertain.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.
  3. Action

    Roll out the electronic Prescribing and Medication Administration System across most acute and community specialties, including staff training and access to medication information.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.

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 access and consider full medical records and risk assessments when prescribing medication changes

Wider context from the report

“The clinician who prescribed a sedative, did so, without reference to any of Mrs Daly’s notes other than her prescription chart and as a result was unaware of her enhanced falls risk or any other behavioural issues. Whilst I recognise that medication changes may be necessary without the doctor being able to review a patient in person, I am concerned that this may occur without the doctor having access to and considering her full medical records and risk assessments. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

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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

Progress development of integrated electronic health records through business cases, Welsh Government-supported mental health work, and collaboration with early implementers and other Welsh organisations.

Verbatim wording from the response

“The longer term, and more sustainable solution is the development of an integrated electronic health record and I know our Chief Executive has discussed these developments with you.”

Source location

Response from BCUHB
Page 2 · response
Published 27 December 2024

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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

Establish a prescribing safety process requiring access to patient notes, communication of falls risk, and escalation or assessment when safe prescribing is uncertain.

Verbatim wording from the response

“Having considered the learning, a new process is being established by the East Medical Director to improve safety whilst recognising medication changes may be necessary without the doctor being able to review a patient in person.”

Source location

Response from BCUHB
Page 1 · response
Published 27 December 2024

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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

Roll out the electronic Prescribing and Medication Administration System across most acute and community specialties, including staff training and access to medication information.

Verbatim wording from the response

“The Health Board is also working to roll out an Electronic Prescribing and Medication Administration System (ePMA).”

Source location

Response from BCUHB
Page 2 · response
Published 27 December 2024

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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.2

  1. 1

    Maintain a dedicated multidisciplinary ePMA implementation team with clinical champions and expert trainers.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 27 December 2024.
  2. 2

    Share the East team’s learning and actions with central and west teams for wider learning.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 December 2024.

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 dedicated multidisciplinary ePMA implementation team with clinical champions and expert trainers.

Verbatim wording from the response

“This is the Health Board’s largest-ever transformation project and we are committed to making it a success. We have taken a user-centred approach with a dedicated multi-disciplinary team of nurses, pharmacists, doctors, and IT professionals, plus Clinical Champions and expert trainers to ensure ePMA works effectively. We aim for the pilot sites to go-live in March 2025.”

Source location

Response from BCUHB
Page 2 · response
Published 27 December 2024

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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

Share the East team’s learning and actions with central and west teams for wider learning.

Verbatim wording from the response

“The learning and actions from our East team will also be shared with our teams in central and west for wider learning.”

Source location

Response from BCUHB
Page 1 · response
Published 27 December 2024

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