PFD report

Patricia Ann Catterall · Prevention of Future Deaths report

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Issued 11 Apr 2025•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
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
7

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 raised2

  1. Failure to assess relevant patient-care information before accepting transfer
    Part of recurring concern: Inadequate assessment of care needs before accepting patients into care
  2. Failure to ensure receipt of all relevant patient-care information before transfer
    Part of recurring concern: Inadequate assessment of care needs before accepting patients into carePart of recurring concern: Unreliable healthcare patient transfer processesPart of recurring concern: Unreliable safety assessment of new care-home residents on admission
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.7

  1. Action

    Update the pre-admission assessment document with prompts to obtain all required information, including diabetes information.

    Stated by Highfield Care Home, WrexhamStated completedThe respondent said that this action was complete when they made their response on 17 April 2025.
  2. Action

    Conduct all pre-admission assessments in person, except for emergency admissions.

    Stated by Highfield Care Home, WrexhamStated completedThe respondent said that this action was complete when they made their response on 17 April 2025.
  3. Action

    Review the care-home discharge plan form to define observation and medication frequencies clearly.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2025.

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 assess relevant patient-care information before accepting transfer

Wider context from the report

“That the process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had been received and assessed prior to the patient being received into their care. Evidence was received that in the majority of cases (post Covid) there are no face to face assessments prior to patient transfer and that the assessment is therefore dependent on the documentation supplied to the Nursing Home by the Health Board which in some cases may result in not all relevant information being provided. In this instance evidence was given that the Nursing Home did not know that the deceased’s blood sugar levels were monitored three times per days whilst in the care of Health Board. ”

Is this part of a recurring concern?

Yes — Inadequate assessment of care needs before accepting patients into care.

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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 ensure receipt of all relevant patient-care information before transfer

Wider context from the report

“That the process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had been received and assessed prior to the patient being received into their care. Evidence was received that in the majority of cases (post Covid) there are no face to face assessments prior to patient transfer and that the assessment is therefore dependent on the documentation supplied to the Nursing Home by the Health Board which in some cases may result in not all relevant information being provided. In this instance evidence was given that the Nursing Home did not know that the deceased’s blood sugar levels were monitored three times per days whilst in the care of Health Board. ”

Is this part of a recurring concern?

Yes — Inadequate assessment of care needs before accepting patients into care; Unreliable healthcare patient transfer processes; Unreliable safety assessment of new care-home residents on admission.

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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

Update the pre-admission assessment document with prompts to obtain all required information, including diabetes information.

Verbatim wording from the response

“2. Our pre-admission assessment document has been updated and includes prompts to ensure all information is requested prior to admission, this includes a section for diabetes, see attached pre-admission assessment document.”

Source location

Response from Pendine Park Care Organisation
Page 1 · response
Published 17 April 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

Conduct all pre-admission assessments in person, except for emergency admissions.

Verbatim wording from the response

“1. All pre-admission assessments are now being conducted in person except for emergency admissions.”

Source location

Response from Pendine Park Care Organisation
Page 1 · response
Published 17 April 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

Review the care-home discharge plan form to define observation and medication frequencies clearly.

Verbatim wording from the response

“In response to the notice, our senior nursing team in the East Integrated Health Community have led work to understand the issue across the Health Board. This work has identified that whilst there is a standardised form for discharge plans into care homes, the level of detail is varied.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 17 April 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

Develop audit questions, complete peer-review monitoring, and report findings through monthly Matron Reports to local quality groups.

Verbatim wording from the response

“Audit questions will be developed to monitor these changes which will be completed by Ward Managers and Matrons and included in the peer reviews across our services. The audit findings will be included in the monthly Matron Reports into local quality groups for assurance.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 17 April 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

Establish a Task and Finish Group of Community Hospital Matrons and Discharge Nurses to review the care-home discharge plan form.

Verbatim wording from the response

“A Task and Finish Group has been set up (consisting of Community Hospital Matrons and Discharge Nurses) to review the current form for suitability, and this work will specifically ensure that frequency of observations and medication is clearly defined within the document.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 17 April 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

Share the finalized and approved form changes with the North Wales Care Home Forum.

Verbatim wording from the response

“Changes to the form, once finalised and approved, will be shared with the North Wales Care Home Forum, with support from the Quality Development Team (this team supports improvements in quality across commissioned care home services).”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 17 April 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

Share the new form and supporting examples with teams through Team Meeting Safety Briefs.

Verbatim wording from the response

“The new form, and examples to support learning, will be shared with teams and will be included on Team Meeting Safety Briefs.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 17 April 2025

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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