PFD report

Isaac Arlan Ingle-Gillis · Prevention of Future Deaths report

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Issued 22 Jul 2025•Gwent

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
2

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 CRHTT access to GP records
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.2

  1. Action

    Make summary GP records available to all secondary-care clinicians, including Crisis Resolution and Home Treatment Team staff.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 28 July 2025.
  2. Action

    Provide staff training on accessing and using summary GP records, initially prioritising crisis and emergency mental-health clinics.

    Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 28 July 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Routine full GP-record access for external clinicians is constrained by legal, data-controller and logistical barriers.

    Stated by Aneurin Bevan 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 CRHTT access to GP records

Wider context from the report

“During the inquest I heard evidence that the CRHTT do not have access to the GP records. I could not determine on balance of probabilities that access to additional information recorded by the GP in their consultation with Isaac on 9/2/2025 would have changed the assessment made by the CRHTT on this occasion. However, I am concerned that in future this information (or lack of it) may be vital. ”

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

Make summary GP records available to all secondary-care clinicians, including Crisis Resolution and Home Treatment Team staff.

Verbatim wording from the response

“A summary/precis version of the GP record is available to clinicians working in secondary care via the Welsh Clinical Portal, until now that availability has been restricted to the medical staff in the Mental Health and Learning Disability Division. Work has commenced to broaden that access to other clinicians including those who work in the CRHTT. This information is a summary/precis record and it is a high-level summary of key diagnoses, medications, allergies and other selected coded information. It may not convey all of the information that could be potentially useful to clinicians from outside the practice.”

Source location

Response from Bwrdd Lechyd Prifysgol Aneurin Bevan University Health Board
Page 1 · response
Published 28 July 2025

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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

Provide staff training on accessing and using summary GP records, initially prioritising crisis and emergency mental-health clinics.

Verbatim wording from the response

“Notwithstanding that the Health Board has made the summary GP record available to all clinicians working in secondary care in the Health Board. Training will be provided to staff, with initial priority given to those in the Mental Health and Learning Disability Division who work in crisis and emergency clinics.”

Source location

Response from Bwrdd Lechyd Prifysgol Aneurin Bevan University Health Board
Page 2 · response
Published 28 July 2025

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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

Routine full GP-record access for external clinicians is constrained by legal, data-controller and logistical barriers.

Verbatim wording from the response

“The availability of the summary GP record cannot substitute for the full detail available in the GP record. Unfortunately, there are barriers to making this routinely available for clinicians working outside a GP practice. These include legal and practical barriers.”

Source location

Response from Bwrdd Lechyd Prifysgol Aneurin Bevan University Health Board
Page 2 · response
Published 28 July 2025

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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

National bodies control integration and scope of cross-agency GP-record access, including Welsh Clinical Portal data sharing.

Verbatim wording from the response

“The integration of records across the architecture of clinical IT systems in Wales, including the scope of shared data, is centrally co-ordinated by Digital Health and Care Wales. We are not aware of any immediate plans to allow full access to systems to users across different agencies with the emphasis being on ensuring that key information can be shared without the need for all clinicians to have individual user access across multiple platforms. The scope of which data is shared via the Welsh Clinical Portal is also determined nationally.”

Source location

Response from Bwrdd Lechyd Prifysgol Aneurin Bevan University Health Board
Page 2 · response
Published 28 July 2025

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