PFD report

Eric Thompson · Prevention of Future Deaths report

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Issued 14 Jun 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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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. Lack of an electronic laboratory-to-emergency-department alert system for abnormal results
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
  2. Failure to act on abnormal blood results
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
  3. Failure to document abnormal blood results in emergency department records
    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.2

  1. Action

    Review, revise and update telephone-alert procedures across all three emergency departments, establishing a clear mechanism for receiving and acting on abnormal laboratory results.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 25 June 2024.
  2. Action

    Cascade learning from the case across all three emergency departments and ensure staff are aware of the updated telephone-alert procedures.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 25 June 2024.

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

  1. Position

    Telephone alerts remain an adequate safety arrangement and are unlikely to be replaced by a future electronic alert system.

    Stated by Betsi Cadwaladr University LHBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 an electronic laboratory-to-emergency-department alert system for abnormal results

Wider context from the report

“The abnormal blood results were telephoned through to the emergency department as required by the current system within an hour of the blood being taken to highlight the abnormal results. The results were available on the system; but they were not initially documented by the emergency department following the telephone call. They were not actioned, nor were they noted until many hours later until a clinician actively considered the electronic emergency department medical records for Mr Thompson. There is no electronic or IT method or system by which the laboratory can send the results to the emergency department quickly and efficiently with an alert to indicate abnormal results. Instead, the system relies on person-to-person discussions and for this to then be escalated, as necessary. ”

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 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 act on abnormal blood results

Wider context from the report

“The abnormal blood results were telephoned through to the emergency department as required by the current system within an hour of the blood being taken to highlight the abnormal results. The results were available on the system; but they were not initially documented by the emergency department following the telephone call. They were not actioned, nor were they noted until many hours later until a clinician actively considered the electronic emergency department medical records for Mr Thompson. There is no electronic or IT method or system by which the laboratory can send the results to the emergency department quickly and efficiently with an alert to indicate abnormal results. Instead, the system relies on person-to-person discussions and for this to then be escalated, as necessary. ”

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 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 document abnormal blood results in emergency department records

Wider context from the report

“The abnormal blood results were telephoned through to the emergency department as required by the current system within an hour of the blood being taken to highlight the abnormal results. The results were available on the system; but they were not initially documented by the emergency department following the telephone call. They were not actioned, nor were they noted until many hours later until a clinician actively considered the electronic emergency department medical records for Mr Thompson. There is no electronic or IT method or system by which the laboratory can send the results to the emergency department quickly and efficiently with an alert to indicate abnormal results. Instead, the system relies on person-to-person discussions and for this to then be escalated, as necessary. ”

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

Review, revise and update telephone-alert procedures across all three emergency departments, establishing a clear mechanism for receiving and acting on abnormal laboratory results.

Verbatim wording from the response

“To that end, our three hospital Medical Directors will work with all of our three ED teams to review, revise and update the processes in place to ensure there is a clear mechanism for telephone alerts to be received and acted upon. That work will include ensuring the learning from this case is cascaded, that procedures are considered and updated, and importantly that staff are aware of those procedures.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 25 June 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

Cascade learning from the case across all three emergency departments and ensure staff are aware of the updated telephone-alert procedures.

Verbatim wording from the response

“To that end, our three hospital Medical Directors will work with all of our three ED teams to review, revise and update the processes in place to ensure there is a clear mechanism for telephone alerts to be received and acted upon. That work will include ensuring the learning from this case is cascaded, that procedures are considered and updated, and importantly that staff are aware of those procedures.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 25 June 2024

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

Telephone alerts remain an adequate safety arrangement and are unlikely to be replaced by a future electronic alert system.

Verbatim wording from the response

“In specific relation to the issue of abnormal results being communicated to the emergency department (ED) quickly, our Medical Directors have discussed this with senior clinicians and they have identified the telephone alert process is standard in most EDs. This method of alert is more likely to bring the abnormal result to the attention of the department than an IT related alert, due to the dynamic nature of the ED and the fact that most clinicians will be working agile and with patients rather than by a computer. Therefore, the arrangement of phone alerts would still have a valuable role in safety and is not likely to be replaced by any future electronic system (although we acknowledge such systems may provide improved access to information).”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 25 June 2024

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.1

  1. 1

    Continue working with national Welsh partners to develop improved and integrated digital records.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 25 June 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Improved integrated digital records depend on national Welsh partners delivering the necessary system and funding arrangements.

    Stated by Betsi Cadwaladr University LHBRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 working with national Welsh partners to develop improved and integrated digital records.

Verbatim wording from the response

“As you will know from our responses to other notices, the Health Board is committed to improved and integrated digital records and we will continue to work with national partners across Wales whom we rely upon to deliver this. The Health Board continues to do all it can on the issue of digital records, and the Board approved an outline business case for an All Age Mental Health Digital Solution at its meeting on 25 July 2024. This case will now be reviewed at the Welsh Government investment panel prior to a recommendation being made to the Cabinet Secretary for Health and Social Care. Whilst this of course would not be ████████ ████████ ████████ ████████”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 25 June 2024

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

Improved integrated digital records depend on national Welsh partners delivering the necessary system and funding arrangements.

Verbatim wording from the response

“As you will know from our responses to other notices, the Health Board is committed to improved and integrated digital records and we will continue to work with national partners across Wales whom we rely upon to deliver this. The Health Board continues to do all it can on the issue of digital records, and the Board approved an outline business case for an All Age Mental Health Digital Solution at its meeting on 25 July 2024. This case will now be reviewed at the Welsh Government investment panel prior to a recommendation being made to the Cabinet Secretary for Health and Social Care. Whilst this of course would not be ████████ ████████ ████████ ████████”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 25 June 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