PFD report

Susan Merton · Prevention of Future Deaths report

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Issued 9 Nov 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.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
4

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 complete actions and recommendations within set timeframes
    Part of recurring concern: Failure to implement identified safety actions
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.4

  1. Action

    Require serious incident investigation reports to undergo Incident Learning Panel scrutiny and approval, with an action plan on the required template.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 11 November 2021.
  2. Action

    Track 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 11 November 2021.
  3. Action

    Appoint a clinician to review historic action plans and verify action completion and available evidence.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 11 November 2021.

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

  1. Position

    Historic action-plan review was temporarily interrupted because the appointed clinician was redeployed to frontline services during the COVID wave.

    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

Failure to complete actions and recommendations within set timeframes

Wider context from the report

“1. Evidence provided to me in the course of the investigation indicated that the Health Board had conducted an investigation and had produced an Action Plan in light of the findings of their investigation. The Action Plan required that the recommendations contained therein be reviewed in a Clinical Governance Meeting on the 5th of August 2021 however for reasons which could not be explained at the inquest, this was not done. 2. On previous occasions I have issued regulation 28 reports expressing concerns that the Health Board continually fail to accomplish actions in circumstances where they have set their own timeframe. 3. I am concerned that as a result of the Health Board failing to follow through with their own actions and recommendations either in a timely manner or in this specific case at all, lives are being put at risk. ”

Is this part of a recurring concern?

Yes — Failure to implement identified safety actions.

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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

Require serious incident investigation reports to undergo Incident Learning Panel scrutiny and approval, with an action plan on the required template.

Verbatim wording from the response

“As outlined in my response to the Regulation 28 regarding Mr Hurst, we changed our serious incident process in April 2021. From this date all investigation reports are submitted 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. A report without an action plan would not be accepted. I am very disappointed that our service did not complete an action plan when they should have done, nor was it completed on the right template when it was. Our new process ensures this cannot happen.”

Source location

2021-0375-Response-from-BCUHB_Published
Page 1 · response
Published 11 November 2021

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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

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

Verbatim wording from the response

“We are also now tracking actions from these investigation reports and action plans through our Datix patient safety system and auditing compliance with action completion timeframes and evidence.”

Source location

2021-0375-Response-from-BCUHB_Published
Page 1 · response
Published 11 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

Appoint a clinician to review historic action plans and verify action completion and available evidence.

Verbatim wording from the response

“This new process covers incidents from April 2021 onwards. We recognise the case of Ms Merton, and Mr Hurst, occurred prior to this, so we have appointed a clinician to undertake a review of historic action plans to ensure actions are completed and evidence is available. This person commenced in post in November 2021, 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. This work will continue until we are assured of prior action plan completion.”

Source location

2021-0375-Response-from-BCUHB_Published
Page 2 · response
Published 11 November 2021

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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

Continue reviewing historic action plans until prior actions are confirmed complete.

Verbatim wording from the response

“This new process covers incidents from April 2021 onwards. We recognise the case of Ms Merton, and Mr Hurst, occurred prior to this, so we have appointed a clinician to undertake a review of historic action plans to ensure actions are completed and evidence is available. This person commenced in post in November 2021, 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. This work will continue until we are assured of prior action plan completion.”

Source location

2021-0375-Response-from-BCUHB_Published
Page 2 · response
Published 11 November 2021

Open published response

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

Historic action-plan review was temporarily interrupted because the appointed clinician was redeployed to frontline services during the COVID wave.

Verbatim wording from the response

“This new process covers incidents from April 2021 onwards. We recognise the case of Ms Merton, and Mr Hurst, occurred prior to this, so we have appointed a clinician to undertake a review of historic action plans to ensure actions are completed and evidence is available. This person commenced in post in November 2021, 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. This work will continue until we are assured of prior action plan completion.”

Source location

2021-0375-Response-from-BCUHB_Published
Page 2 · response
Published 11 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