PFD report

Kyle Nicholas James Hurst · Prevention of Future Deaths report

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Issued 26 Oct 2021•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.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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. Delays in achieving safety changes within self-set timeframes
    Part of recurring concern: Unsafe implementation and oversight of service changes
  2. Failure to adopt accelerated N-acetylcysteine administration into a standard operating protocol
    Part of recurring concern: Unsafe management of operational protocol changesPart of recurring concern: Unsafe updating of clinical policies and guidance
  3. Failure to implement procedures mitigating risks from failure to act on diagnostic results within the stated timeframe
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
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

    Track serious incident investigation actions in the Datix patient safety system and audit completion timeframes and supporting evidence.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 2 November 2021.
  2. Action

    Review historic serious incident action plans and verify evidence for each action through an appointed clinician.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 2 November 2021.
  3. Action

    Implement the ratified procedure defining staff roles and processes for communicating critical and unexpected pathology results.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 2 November 2021.

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

Delays in achieving safety changes within self-set timeframes

Wider context from the report

“3. I am concerned that the Health Board continue to fail to achieve changes in a timely manner, even in circumstances where they have set their own timeframe and that as a result of this lives are being put at risk. ”

Is this part of a recurring concern?

Yes — Unsafe implementation and oversight of service changes.

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 adopt accelerated N-acetylcysteine administration into a standard operating protocol

Wider context from the report

“1. Evidence given at the inquest by the ED Consultant indicated that it has been recognised that the accelerated administration of N-Acetylcysteine may be beneficial in the treatment of a ████████ but this has not yet been adopted into a Standard Operating Protocol despite this having been proposed in August 2021 ”

Is this part of a recurring concern?

Yes — Unsafe management of operational protocol changes; Unsafe updating of clinical policies and guidance.

Open source report

Source evidence

How this individual concern was interpreted

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

PFD Monitor interpretation

Failure to implement procedures mitigating risks from failure to act on diagnostic results within the stated timeframe

Wider context from the report

“2. Following the issue of a regulation 28 report on the 14th of July 2021 in connection with the inquest touching upon the death of Rhian Roberts in similar circumstances, the response from BCUHB indicated by way of a letter dated the 7th of September 2021 that procedures to mitigate risks due to failure to act on diagnostic results would be approved and active by the 1st of October 2021, however at the time of concluding the inquest of Kyle Hurst on the 22nd of October, this had not been accomplished. ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon.

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

Track serious incident investigation actions in the Datix patient safety system and audit completion timeframes and supporting evidence.

Verbatim wording from the response

“In April 2021 we changed our serious incident process and this included all investigation reports going for scrutiny and approval at an Incident Learning Panel. This new step in the process adds an organisational level of scrutiny on all investigations completed by our clinical divisions and we have seen an improvement in the quality of reports and action plans as a result. We are also now tracking actions from these investigation reports through our Datix patient safety system and auditing compliance with action completion timeframes and evidence.”

Source location

2021-0359-Response-from-BCUHB_Published
Page 2 · response
Published 2 November 2021

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 historic serious incident action plans and verify evidence for each action through an appointed clinician.

Verbatim wording from the response

“This process covers incidents from April 2021 onwards, and so for incidents prior to this we have appointed a clinician to undertake a review of historic action plans to ensure evidence is available against each action. This person commenced in post in November, however they have been redeployed to front line services as a result of the current COVID wave, and we hope they will be available to return back to this important work during January 2022.”

Source location

2021-0359-Response-from-BCUHB_Published
Page 2 · response
Published 2 November 2021

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 ratified procedure defining staff roles and processes for communicating critical and unexpected pathology results.

Verbatim wording from the response

“In relation to the procedures to mitigate the risk of not acting upon diagnostic results, we have developed a new Procedure for the Communication of Critical and Unexpected Pathology Results. This document sets out the roles and responsibilities of staff and the process to follow. This new procedure has been ratified.”

Source location

2021-0359-Response-from-BCUHB_Published
Page 2 · response
Published 2 November 2021

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.3

  1. 1

    Begin using the updated paracetamol treatment protocol immediately after approval.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 2 November 2021.
  2. 2

    Require all serious incident investigation reports to undergo scrutiny and approval by an Incident Learning Panel.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 2 November 2021.
  3. 3

    Approve the updated paracetamol treatment protocol through an executive decision outside the usual governance process.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 2 November 2021.

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

Begin using the updated paracetamol treatment protocol immediately after approval.

Verbatim wording from the response

“An updated protocol has been developed and was being formally approved at our Drugs and Therapeutics Group in January. However, due to the unexpected wave of COVID pressures arising from the Omicron variant and the redeployment of staff to vaccination and front line services, this meeting has been cancelled. We therefore intend to take executive decision to approve this procedure outside of the normal governance process and this will be completed no later than the 31 January 2022. Once approved, we will begin use of the protocol immediately.”

Source location

2021-0359-Response-from-BCUHB_Published
Page 2 · response
Published 2 November 2021

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

Require all serious incident investigation reports to undergo scrutiny and approval by an Incident Learning Panel.

Verbatim wording from the response

“In April 2021 we changed our serious incident process and this included all investigation reports going for scrutiny and approval at an Incident Learning Panel. This new step in the process adds an organisational level of scrutiny on all investigations completed by our clinical divisions and we have seen an improvement in the quality of reports and action plans as a result. We are also now tracking actions from these investigation reports through our Datix patient safety system and auditing compliance with action completion timeframes and evidence.”

Source location

2021-0359-Response-from-BCUHB_Published
Page 2 · response
Published 2 November 2021

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

Approve the updated paracetamol treatment protocol through an executive decision outside the usual governance process.

Verbatim wording from the response

“An updated protocol has been developed and was being formally approved at our Drugs and Therapeutics Group in January. However, due to the unexpected wave of COVID pressures arising from the Omicron variant and the redeployment of staff to vaccination and front line services, this meeting has been cancelled. We therefore intend to take executive decision to approve this procedure outside of the normal governance process and this will be completed no later than the 31 January 2022. Once approved, we will begin use of the protocol immediately.”

Source location

2021-0359-Response-from-BCUHB_Published
Page 2 · response
Published 2 November 2021

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