Laura Hill · Prevention of Future Deaths report

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Issued 20 Feb 2015•Carmarthenshire & Pembrokeshire

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
7

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

Described in responses

Recipients and published responses

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.

Report evidence summary

Concerns raised7

  1. Insufficient staff training in the section 136 procedure for police handovers
    Part of recurring concern: Failure to ensure custody staff understand and apply detention procedures
  2. Insufficient staff training to recognise absconding and respond after an absconding incident
    Part of recurring concern: Unreliable response to patient absconding
  3. Insufficient staffing resources on the acute ward
    Part of recurring concern: Insufficient qualified healthcare staffing capacity

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.12

  1. Hywel Dda University LHB

    Increase ward staffing to a minimum of four staff per shift, with flexible additional cover and escalation arrangements for increased need.

  2. Hywel Dda University LHB

    Provide Section 136 procedure training to nursing and medical staff through induction, follow-up training and continuing medical education.

  3. Hywel Dda University LHB

    Provide dedicated psychology input to adult mental health wards for patient assessment, intervention and staff support.

  4. Hywel Dda University LHB

    Risk-assess patients and assign observation levels, with continuous review of both.

  5. Hywel Dda University LHB

    Reduce the ward capacity from sixteen to fifteen beds.

  6. Hywel Dda University LHB

    Implement a multi-agency Section 136 protocol defining partner responsibilities, transition points and documentation.

  7. Hywel Dda University LHB

    Enhance personality-disorder training through dialectical behavioural therapy, emotional coping skills and the Knowledge and Understanding Framework.

  8. Hywel Dda University LHB

    Develop the use and range of psychological interventions through a dedicated psychological-therapies committee.

  9. Hywel Dda University LHB

    Maintain an up-to-date door-locking policy covering authorisation and recording requirements.

  10. Hywel Dda University LHB

    Circulate transition guidelines between child and adult mental health services.

  11. Hywel Dda University LHB

    Provide absconding-management guidance to relevant ward staff.

  12. Hywel Dda University LHB

    Provide ongoing Mental Health Act and Mental Capacity Act training to update clinicians on detention powers.

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

  1. Hywel Dda University LHB

    The ward’s current door-locking policy and continuous risk and observation assessments are relied on instead of further door-policy changes.

    Existing 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

Insufficient staff training in the section 136 procedure for police handovers

Wider context from the report

“(3) There was a training need identified in relation to the section 136 procedure when patients are handed over by the Police. ”

Is this part of a recurring concern?

Yes — Failure to ensure custody staff understand and apply detention procedures.

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

Insufficient staff training to recognise absconding and respond after an absconding incident

Wider context from the report

“(4) There was a training need identified in relation to what constitutes ‘absconding’ and what should be done by staff following an incident of absconding. ”

Is this part of a recurring concern?

Yes — Unreliable response to patient absconding.

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

Insufficient staffing resources on the acute ward

Wider context from the report

“(2) Staffing levels on the Ward need to be reviewed as it was felt that staffing resources were stretched at the relevant time (1 nurse and 3 support workers on a 16 bed acute ward). ”

Is this part of a recurring concern?

Yes — Insufficient qualified healthcare staffing capacity.

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

Insufficient staff training in powers of detention and their appropriate use

Wider context from the report

“(7) There was a training need identified in relation to powers of detention and when those powers can and should be used. ”

Is this part of a recurring concern?

Yes — Failure to ensure custody staff understand and apply detention procedures.

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

Insufficient staff training in Personality Disorders

Wider context from the report

“(6) There was a training need identified in relation to Personality Disorders. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Breakdown in information transition and passing between Child/Adolescent and Adult Mental Health Teams

Wider context from the report

“(1) That there appears to be a breakdown in the transition and passing of information between the Child/Adolescent and the Adult Mental Health Teams. ”

Is this part of a recurring concern?

Yes — Unsafe coordination and continuity during mental health service transfers; Unsafe transition and continuity of care from child to adult healthcare.

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 of the ward door policy to prevent or promptly detect patient absconding

Wider context from the report

“(5) The door policy on the Ward needs to be reviewed as a patient was able to abscond without staff noticing. ”

Is this part of a recurring concern?

Yes — Failure to reliably prevent patient escape from wards.

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

Increase ward staffing to a minimum of four staff per shift, with flexible additional cover and escalation arrangements for increased need.

Verbatim wording from the response

“Since the incident occurred, the ward has reviewed (May 2013) the shift pattern and now works on the basis of four staff as a minimum per shift, with an additional staff member on a flexible shift to cover the busier part of the day. This covers 10 nursing staff only. Additionally, the ward would have the manager and other disciplines providing input. Staffing levels have to be flexible and dependant upon patient acuity and complexity. This requires increasing staffing levels at short notice, particularly where one to one observations are required. There are systems in place on a twenty four hour basis to sanction increased staffing levels when they are required.”

Source location

2015-0092-Response-by-University-Health-Board
Page 2 · response
Published 20 February 2015

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

Provide Section 136 procedure training to nursing and medical staff through induction, follow-up training and continuing medical education.

Verbatim wording from the response

“A multi-agency Section 136 Protocol was signed off in November 2014. This Protocol details partner responsibilities in relation to Section 136. There are clear guidelines to be followed and these include points of transition with associated documentation. Nursing staff on St Caradog Ward receive training in respect of their responsibilities as part of their induction. Further follow up training is thereafter provided directly to staff on the ward. Medical staff also receive training on induction as well as on-going through the Post Graduate Medical Training Forum. Medical staff have protected training on a weekly basis.”

Source location

2015-0092-Response-by-University-Health-Board
Page 2 · response
Published 20 February 2015

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

Provide dedicated psychology input to adult mental health wards for patient assessment, intervention and staff support.

Verbatim wording from the response

“Additionally, St Caradog, as well as other adult mental health wards, has dedicated psychology input both to provide patient assessment and intervention as well as supporting ward based staff with guidance in relation to clinical care planning and optimum approaches to patient care.”

Source location

2015-0092-Response-by-University-Health-Board
Page 3 · response
Published 20 February 2015

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

Risk-assess patients and assign observation levels, with continuous review of both.

Verbatim wording from the response

“All patients are risk assessed and assigned observation levels in line with the outcome of the risk assessment. Both risk and observation levels are subject to continuous review.”

Source location

2015-0092-Response-by-University-Health-Board
Page 2 · response
Published 20 February 2015

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

Reduce the ward capacity from sixteen to fifteen beds.

Verbatim wording from the response

“The ward has also reduced to fifteen beds since the incident.”

Source location

2015-0092-Response-by-University-Health-Board
Page 2 · response
Published 20 February 2015

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

Implement a multi-agency Section 136 protocol defining partner responsibilities, transition points and documentation.

Verbatim wording from the response

“A multi-agency Section 136 Protocol was signed off in November 2014. This Protocol details partner responsibilities in relation to Section 136. There are clear guidelines to be followed and these include points of transition with associated documentation. Nursing staff on St Caradog Ward receive training in respect of their responsibilities as part of their induction. Further follow up training is thereafter provided directly to staff on the ward. Medical staff also receive training on induction as well as on-going through the Post Graduate Medical Training Forum. Medical staff have protected training on a weekly basis.”

Source location

2015-0092-Response-by-University-Health-Board
Page 2 · response
Published 20 February 2015

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

Enhance personality-disorder training through dialectical behavioural therapy, emotional coping skills and the Knowledge and Understanding Framework.

Verbatim wording from the response

“Since the incident, there has been an enhancement of training in relation to personality disorder that has taken place within the Mental Health and Learning Disabilities Directorate. These include: Dialectical Behavioural Therapy, Emotional Coping Skills and Knowledge and Understanding Framework for Personality Disorders. The Health Board is committed to developing the use and range of psychological intervention and, in line with Welsh Government guidance, has a Committee dedicated to enhancing the delivery of psychological therapies across the whole service.”

Source location

2015-0092-Response-by-University-Health-Board
Page 3 · response
Published 20 February 2015

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

Develop the use and range of psychological interventions through a dedicated psychological-therapies committee.

Verbatim wording from the response

“Since the incident, there has been an enhancement of training in relation to personality disorder that has taken place within the Mental Health and Learning Disabilities Directorate. These include: Dialectical Behavioural Therapy, Emotional Coping Skills and Knowledge and Understanding Framework for Personality Disorders. The Health Board is committed to developing the use and range of psychological intervention and, in line with Welsh Government guidance, has a Committee dedicated to enhancing the delivery of psychological therapies across the whole service.”

Source location

2015-0092-Response-by-University-Health-Board
Page 3 · response
Published 20 February 2015

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

Maintain an up-to-date door-locking policy covering authorisation and recording requirements.

Verbatim wording from the response

“St Caradog is an open adult admission ward. It is not a secure or locked ward. The ward has the option to lock its door, although this has to be done in line with guidance, as provided by the 1983 Mental Health Act – Code of Practice. An up to date policy is in place to guide staff in relation to the locking of doors on such units as well as the recording of these instances.”

Source location

2015-0092-Response-by-University-Health-Board
Page 2 · response
Published 20 February 2015

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

Circulate transition guidelines between child and adult mental health services.

Verbatim wording from the response

“In January 2013, the Health Board provided transition guidelines in relation to Specialist Child and Adolescent Mental Health Services to Adult Mental Health and Learning Disability Services. The document was circulated across all the relevant teams and provides clear transition guidelines in line with best practice and government guidelines with regards to transitions between services. It is recognised that times of transition can pose potential risks if they are not robustly managed and the guidance enhances the safety of the transition process with clear steps for professionals to follow.”

Source location

2015-0092-Response-by-University-Health-Board
Page 1 · response
Published 20 February 2015

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

Provide absconding-management guidance to relevant ward staff.

Verbatim wording from the response

“Guidance in relation to the management of those patients who abscond from the in-patient ward has been provided to all relevant staff by the Head of Acute Care Services.”

Source location

2015-0092-Response-by-University-Health-Board
Page 2 · response
Published 20 February 2015

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

Provide ongoing Mental Health Act and Mental Capacity Act training to update clinicians on detention powers.

Verbatim wording from the response

“Registered clinical practitioners are aware of the powers of detention which are available to them. On-going Mental Health Act and Mental Capacity Act training (as detailed previously) ensure that clinicians are updated in relation to the application of powers of detention.”

Source location

2015-0092-Response-by-University-Health-Board
Page 3 · response
Published 20 February 2015

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

The ward’s current door-locking policy and continuous risk and observation assessments are relied on instead of further door-policy changes.

Verbatim wording from the response

“5. The Door Policy on the ward needs to be reviewed as a patient was able to abscond without staff noticing.”

Source location

2015-0092-Response-by-University-Health-Board
Page 2 · response
Published 20 February 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

Official responses located
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Data last updated 7 September 2026