PFD report

Kaye McCoy · Prevention of Future Deaths report

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Issued 30 Jun 2023•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.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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. Failure to fully incorporate suicide-prevention guidelines into policy and practice
    Part of recurring concern: Inconsistent implementation of suicide-prevention systems
  2. Unavailability of 24-hour crisis support
    Part of recurring concern: Inadequate 24-hour mental health crisis support
  3. Lack of a strategy for engagement with the family
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.8

  1. Action

    Explore alternative crisis-service models, review other Welsh Health Boards’ provision, and develop associated standards for ongoing audit.

    Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 7 July 2023.
  2. Action

    Produce staff guidance on principles for family and supporter involvement in care and care planning, including confidentiality and inclusion.

    Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
  3. Action

    Make Tŷ Cynnаl crisis-sanctuary support available to older people known to the mental health service.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.

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 fully incorporate suicide-prevention guidelines into policy and practice

Wider context from the report

“At the inquest I was referred to the National Confidential Enquiry into Suicides. I was informed that the Enquiry identified key factors that should be adopted by Health Organisations to reduce the incidence of suicides, including: • That there should be a strategy for engagement with the family. • That every patient should have access to 24-hour Crisis Support Neither of these key components of care were available to Kaye. Whilst I was informed that there were steps being taken to address these I was not persuaded that these guidelines had been fully inculcated into policy and practice at Aneurin Bevan University Health Board. ”

Is this part of a recurring concern?

Yes — Inconsistent implementation of suicide-prevention systems.

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

Unavailability of 24-hour crisis support

Wider context from the report

“At the inquest I was referred to the National Confidential Enquiry into Suicides. I was informed that the Enquiry identified key factors that should be adopted by Health Organisations to reduce the incidence of suicides, including: • That there should be a strategy for engagement with the family. • That every patient should have access to 24-hour Crisis Support Neither of these key components of care were available to Kaye. Whilst I was informed that there were steps being taken to address these I was not persuaded that these guidelines had been fully inculcated into policy and practice at Aneurin Bevan University Health Board. ”

Is this part of a recurring concern?

Yes — Inadequate 24-hour mental health crisis support.

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

Lack of a strategy for engagement with the family

Wider context from the report

“At the inquest I was referred to the National Confidential Enquiry into Suicides. I was informed that the Enquiry identified key factors that should be adopted by Health Organisations to reduce the incidence of suicides, including: • That there should be a strategy for engagement with the family. • That every patient should have access to 24-hour Crisis Support Neither of these key components of care were available to Kaye. Whilst I was informed that there were steps being taken to address these I was not persuaded that these guidelines had been fully inculcated into policy and practice at Aneurin Bevan University Health Board. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Explore alternative crisis-service models, review other Welsh Health Boards’ provision, and develop associated standards for ongoing audit.

Verbatim wording from the response

“In addition to the pathways described above, the Health Board is exploring other alternatives including understanding the offers of other Health Boards in Wales from a future review of crisis provision for this group, with associated standards for ongoing audit. In the interim, the Health Board will continue to audit use of the current pathway by the older adult population to continue to inform service development.”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 7 July 2023

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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

Produce staff guidance on principles for family and supporter involvement in care and care planning, including confidentiality and inclusion.

Verbatim wording from the response

“This year’s National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) Annual Report also provides data and evidence relating to family and supporter involvement in patient care. This is discussed during the Division’s awareness-raising training to registrants about NCISH findings which highlights and promotes helpful and inclusive dialogue with patients and their families/supporters. The Division will be producing a guidance document – ‘Principles for family/supporter involvement in care and care planning’ for staff which will also include advice and principles in relation to confidentiality and inclusion. This will be drafted by the end of October 2023.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 7 July 2023

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

Make Tŷ Cynnаl crisis-sanctuary support available to older people known to the mental health service.

Verbatim wording from the response

“e. Tŷ Cynnаl is a house provided in partnership with ‘Platform’, a third sector organisation that supports people with mental health issues when housing. The house is available to support people experiencing mental health crisis who do not require medical/hospital support but require a safe sanctuary for support to manage their distress. People are referred to Tŷ Cynnаl by the mental health service. This option has only recently become available to older people experiencing crisis who are already known to the mental health service.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 7 July 2023

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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

Strengthen family-engagement content in Care and Treatment Planning and WARRN risk-formulation training.

Verbatim wording from the response

“With regard to the first point, the Division of Mental Health and Learning Disabilities has a number of processes currently in place to support family engagement, for example, training in both Care and Treatment Planning and in Wales Applied Risk Research Network (WARRN) risk formulation, which emphasises the importance of family involvement and engagement, particularly in the recognition and management of relapse indicators and contingency”

Source location

Response from Aneurin Bevan University Health Board
Page 1 · response
Published 7 July 2023

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

Consider the completed pilot’s findings and recommendations for future crisis-service provision.

Verbatim wording from the response

“Additionally, the Older Adult Mental Health service has completed a 6-month pilot extending the hours of the Community Mental Health Team in Caerphilly, to include evenings and weekends. The pilot funded extra clinical staff to support this function and Caerphilly was chosen as the pilot area as the highest populated borough within Gwent to establish need and demand. One of the terms of reference of the Health Board’s incident review into Mrs McCoy’s death was whether her needs would have met the criteria for inclusion in this pilot. The Investigating Officer found that she would have been offered this service if she lived in Caerphilly at that time.”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 7 July 2023

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 auditing older adults’ use of current crisis pathways to inform service development.

Verbatim wording from the response

“In addition to the pathways described above, the Health Board is exploring other alternatives including understanding the offers of other Health Boards in Wales from a future review of crisis provision for this group, with associated standards for ongoing audit. In the interim, the Health Board will continue to audit use of the current pathway by the older adult population to continue to inform service development.”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 7 July 2023

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

Extend the Shared Lives crisis-support project to include older people.

Verbatim wording from the response

“d. The ‘Shared Lives’ project, previously available to younger adults, has recently been extended to include older people in crisis. The schemes match someone who needs care with an approved carer. The carer shares their family and community life, and gives care and support to the person with care needs. (This service was not available at the time that Mrs McCoy was experiencing crisis.)”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 7 July 2023

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

Extend Community Mental Health Team operating hours into evenings and weekends through a six-month pilot funded with additional clinical staff.

Verbatim wording from the response

“Additionally, the Older Adult Mental Health service has completed a 6-month pilot extending the hours of the Community Mental Health Team in Caerphilly, to include evenings and weekends. The pilot funded extra clinical staff to support this function and Caerphilly was chosen as the pilot area as the highest populated borough within Gwent to establish need and demand. One of the terms of reference of the Health Board’s incident review into Mrs McCoy’s death was whether her needs would have met the criteria for inclusion in this pilot. The Investigating Officer found that she would have been offered this service if she lived in Caerphilly at that time.”

Source location

Response from Aneurin Bevan University Health Board
Page 3 · response
Published 7 July 2023

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