PFD report

Sally Ellison · Prevention of Future Deaths report

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Issued 27 Apr 2015•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.

View original report
Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

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 raised3

  1. Unavailability of a rapid testing and reporting service for legionella
    Part of recurring concern: Unreliable Legionella infection detection and investigation
  2. Failure to expedite urgent blood test samples for laboratory analysis
    Part of recurring concern: Failure to provide timely clinically required blood testsPart of recurring concern: Failure to provide timely urgent diagnostic investigations
  3. Failure to undertake timely urine testing for legionella
    Part of recurring concern: Failure to obtain clinically indicated microbiological samplesPart of recurring concern: Unreliable Legionella infection detection and investigation
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 primary-care urgent-sample requesting processes and prepare a memorandum covering sample labelling, transport and laboratory notification.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 27 April 2015.
  2. Action

    Distribute the urgent-sample process memorandum electronically to all BCUHB-supported GPs and practice managers.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 April 2015.

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 a rapid testing and reporting service for legionella

Wider context from the report

“2. Not only should consideration therefore be given to undertaking tests at an earlier stage but there should also be available to the hospital a rapid testing and reporting service, either preferably a service within North Wales or utilising options within organisations geographically closer and more accessible than those in Cardiff. ”

Is this part of a recurring concern?

Yes — Unreliable Legionella infection detection and investigation.

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 expedite urgent blood test samples for laboratory analysis

Wider context from the report

“1. That urgent blood tests were requested By ████████ (GP) at lunchtime on the 28th of April 2012, yet, despite these being noted as urgent, the samples were not conveyed to the laboratory for analysis after collection by the district nurse, until a routine collection of samples was undertaken from Colwyn Bay Community Hospital later that afternoon. As a result the delay in an analysis meant that results were not provided to surgery until the following morning. Whilst the evidence indicates that changes have been made within the laboratory at Glan Clwyd to enable the immediate reporting of all cases where the CRP is greater than 300, there was no evidence available to confirm that all urgent tests could be expedited by district nurses thus alleviating potentially life threatening delays in treatment. ”

Is this part of a recurring concern?

Yes — Failure to provide timely clinically required blood tests; Failure to provide timely urgent diagnostic investigations.

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 undertake timely urine testing for legionella

Wider context from the report

“1. That although it was clear upon her admission to Glan Clwyd on the 29th of May 2012 at around 16.00 hours, that she was suffering from a severe form of Community Acquired Pneumonia, and that this was recognised as being an atypical pneumonia that same evening, no urine sample was sent for analysis until overnight on the 31st of May with the confirmation of it being positive for legionella coming on the morning of the 1st of June. It is the case that treatment was already being given for the possibility of legionella from the 30th of May, but this was not against a confirmed diagnosis and therefore optimal treatment may have been delayed. ”

Is this part of a recurring concern?

Yes — Failure to obtain clinically indicated microbiological samples; Unreliable Legionella infection detection and investigation.

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 primary-care urgent-sample requesting processes and prepare a memorandum covering sample labelling, transport and laboratory notification.

Verbatim wording from the response

“From this, you have requested that actions should be taken to prevent future deaths. Because of this, the Pathology Clinical Programme Group (CPG), and in particular the Governance section of the CPG, has reviewed the process for the requesting of urgent samples from primary care across BCUHB. This process has been explained in a memorandum ████████ that will be distributed electronically to all GPs and Practice Managers supported by BCUHB. The memorandum includes the correct process for the labeling of samples and its transportation to minimise delay. It also includes the relevant departmental telephone numbers for the laboratories across North Wales to ensure that the sample requester can warn the relevant department of the samples imminent arrival.”

Source location

2015-0163-Response-by-NHS-Wales
Page 1 · response
Published 27 April 2015

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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

Distribute the urgent-sample process memorandum electronically to all BCUHB-supported GPs and practice managers.

Verbatim wording from the response

“From this, you have requested that actions should be taken to prevent future deaths. Because of this, the Pathology Clinical Programme Group (CPG), and in particular the Governance section of the CPG, has reviewed the process for the requesting of urgent samples from primary care across BCUHB. This process has been explained in a memorandum ████████ that will be distributed electronically to all GPs and Practice Managers supported by BCUHB. The memorandum includes the correct process for the labeling of samples and its transportation to minimise delay. It also includes the relevant departmental telephone numbers for the laboratories across North Wales to ensure that the sample requester can warn the relevant department of the samples imminent arrival.”

Source location

2015-0163-Response-by-NHS-Wales
Page 1 · response
Published 27 April 2015

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