PFD report

Richard Geraint Griffiths · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 14 Sep 2023•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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to provide a finalised and widely shared transfer-of-care process
    Part of recurring concern: Unreliable healthcare patient transfer processes
  2. Failure of investigations to address how transfer of care did not occur
    Part of recurring concern: Inadequate safety incident investigations
  3. Unavailability of electronic mental-health patient notes
    Part of recurring concern: Unreliable access to relevant clinical records for safe care
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.8

  1. Action

    Share the addendum investigation report when completed.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 18 September 2023.
  2. Action

    Require investigating officers to meet involved staff and share investigation outcomes with them.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 18 September 2023.
  3. Action

    Develop a Health Board-wide Strategic Outline Case for electronic patient records addressing fragmented care records.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 18 September 2023.

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

  1. Position

    National digital patient-record implementation depends on decisions about the national system made by Welsh Government.

    Stated by Betsi Cadwaladr University LHBRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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 provide a finalised and widely shared transfer-of-care process

Wider context from the report

“b. The Health Board’s Transfer of Care document at the time the transfer occurred did not include any detail or process as to how the transfer should occur. The amended policy has still not been finalised and there remains a concern that deaths will continue to occur if the process is not finalised and shared widely within the Health Board to staff. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes.

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 investigations to address how transfer of care did not occur

Wider context from the report

“a. The Investigation undertaken by the Health Board was deficient in that it did not contain pertinent points relating to how the transfer of care did not occur. I have previously issued a number of Prevention of Future Death Reports relating to quality and timeliness of investigation. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident 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

Unavailability of electronic mental-health patient notes

Wider context from the report

“c. Patient notes for mental health are still not electronic; they are paper based. I have issued several Prevention of Future Death Reports specifically relating to this. There has been considerable delay in actioning this and yet there is still not anticipated timescale for this to occur. As such, deaths will continue to occur or may occur into the future with the risk that notes are paper based only. The risk relates to only one department or individual having access to them at once when there is wider support for the patient. ”

Is this part of a recurring concern?

Yes — Unreliable access to relevant clinical records for safe care.

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

Share the addendum investigation report when completed.

Verbatim wording from the response

“The investigation is underway, and the investigating officer (IO) has undertaken interviews with staff directly and indirectly involved in Mr Griffiths’ care and treatment. The IO has considered the transfer process that was in place at the time Mr Griffiths was receiving care, the improvements that have been made since, and the review of the Transfer and Discharge of Care Protocol. The addendum report is currently progressing through the Health Board’s approval process and I will be happy to share this with you on its completion in the coming weeks.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 18 September 2023

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

Require investigating officers to meet involved staff and share investigation outcomes with them.

Verbatim wording from the response

“On the 15th September 2023, the Quality Governance team contacted the Heads of Operations and Heads of Nursing throughout MH&LD to share the concerns you raised about the quality of the investigation report. The Quality Governance team requested that in future, IOs meet with the staff involved in the delivery of care and treatment to explore in detail the decision-making and actions taken when delivering care and that the”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 18 September 2023

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 a Health Board-wide Strategic Outline Case for electronic patient records addressing fragmented care records.

Verbatim wording from the response

“In addition I am pleased to report that a Strategic Outline Case for an Electronic Patient Record system(s) is being developed on a Health Board wide level to address the issue of fragmented care records; the deadline for the strategic outline case is the end of January 2024. MH&LD are taking a key role in shaping the outline case to ensure that the Division’s needs are considered as part of the Health Board wide proposal.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 18 September 2023

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

Complete the addendum investigation and progress its report through Health Board approval.

Verbatim wording from the response

“████████, the Director of MH&LD Division, reported to you on the 14th September 2023 that an addendum investigation would be undertaken to expand on the pertinent points relating to how the transfer of care of Mr Griffiths did not happen.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 18 September 2023

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

Progress the revised Transfer and Discharge of Care Protocol through Health Board ratification.

Verbatim wording from the response

“The Transfer and Discharge of Care Protocol has been revised to include explicit guidance relating to transfers of care between community teams. This includes the steps to be taken by the care coordinator, supporting administrative staff and the single point of access service (SPOA). Progression of this protocol through the Health Board ratification process is being led by the MH&LD Deputy Director of Nursing and progress is overseen by the MH&LD Policy and Procedure Group. The revised protocol is due at MH&LD Policy and Procedure Group in December 2023 after which it will progress through the Health Board’s revised ratification process. I anticipate that the protocol will be ratified by the end of January 2024.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 18 September 2023

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

Work with the Chief Information Officer to consider options for a more timely MH&LD digital-records solution.

Verbatim wording from the response

“Whilst MH&LD are keen to support and progress the processes outlined above, we are mindful of the scale of the task for agreeing a national solution and are therefore working with BCUHBs Chief Information Officer to consider options which may bring MH&LD a more timely solution. This remains a major priority for the Division and is supported by the Health Board.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 18 September 2023

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

Engage in regional and local-authority discussions to agree a preferred digital patient-records option for North Wales.

Verbatim wording from the response

“Regional meetings are now taking place across Wales to discuss the options that have been presented to them by WG as alternative to WCCIS Care Direct Version 5. BCUHB has met with Local Authorities to discuss implications across health and social care services in order to come to an agreement on the preferred option for North Wales.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 18 September 2023

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

Check during report quality assurance whether investigating officers have explored staff decision-making and actions.

Verbatim wording from the response

“outcome of reports are shared with the staff involved. The Quality Governance team now also check for this aspect during the quality assurance of reports. This will ensure more detailed investigations that get to heart of the contributory factors and the root causes of incidents.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 18 September 2023

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

National digital patient-record implementation depends on decisions about the national system made by Welsh Government.

Verbatim wording from the response

“Within the notice, you also raised your continued concerns about the implementation of digital patient records for MH&LD. In previous correspondence with you, the Health Board has reported significant delays with the development and implementation of a suitable system at a national level. I understand that you have raised your concerns about the delays with the Health Minister directly. We now know that following a decision made by WG the national system will not be progressing in the way that was previously expected. This has significantly altered MH&LD divisional plans for digital transformation as these were dependent upon the use of the WCCIS Care Director Version 5 product, with a pilot having been due to start in September 2023, and the expectation that a wider adoption across all applicable MH&LD services would follow.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 18 September 2023

Open published response
Back to top

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