PFD report

Yvonne Rankin · Prevention of Future Deaths report

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Issued 13 Dec 2022•South Wales 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
1

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 raised1

  1. Failure to ensure that patients and carers understand the specific signs of sepsis
    Part of recurring concern: Failure to reliably recognise and respond promptly to sepsis
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.5

  1. Action

    Ensure new patients seen by the ANA team receive updated sepsis-sign information, supplying the literature when patients do not have it.

    Stated by Abbott Laboratories LimitedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2022.
  2. Action

    Carry and share Adult and Paediatric Symptom Cards with patients showing infection signs and their relevant family members or carers.

    Stated by Abbott Laboratories LimitedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2022.
  3. Action

    Provide sepsis symptom cards to children and their parents to promote awareness of childhood sepsis signs and symptoms.

    Stated by Cardiff & Vale University LHBStated plannedThe respondent said that this action was planned when they made their response on 19 December 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Cardiff and Vale UHB is responsible for updating patient information and purchasing symptom cards addressing sepsis signs.

    Stated by Abbott Laboratories LimitedRedirects 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 ensure that patients and carers understand the specific signs of sepsis

Wider context from the report

“(1) although family and Yvonne were told that they could refer any concerns to various professionals including the Abbott nurse, they did not understand the specific signs of sepsis to watch out for; (2) had family understood the signs of sepsis, it is likely that they would have rung 999 much sooner; and (3) It may be that patient/carer information cards setting out the common signs of sepsis already exists. Would it be possible to give out such information cards to patients/carers with PEGs and/or those who are at known risk of infection who are in the community? ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond promptly to sepsis.

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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

Ensure new patients seen by the ANA team receive updated sepsis-sign information, supplying the literature when patients do not have it.

Verbatim wording from the response

“For clarity, the Abbott Nurse Advisor team is employed by CHASE and, on behalf of Abbott Laboratories Limited (Abbott), their role is to fulfil an enteral feeding nursing service, as part of an NHS Contract Specification. Abbott currently holds an enteral feeding contract with Cardiff and Vale University Health Board (Cardiff and Vale UHB).”

Source location

Response from Abbott Nutrition
Page 1 · response
Published 19 December 2022

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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

Carry and share Adult and Paediatric Symptom Cards with patients showing infection signs and their relevant family members or carers.

Verbatim wording from the response

“For clarity, the Abbott Nurse Advisor team is employed by CHASE and, on behalf of Abbott Laboratories Limited (Abbott), their role is to fulfil an enteral feeding nursing service, as part of an NHS Contract Specification. Abbott currently holds an enteral feeding contract with Cardiff and Vale University Health Board (Cardiff and Vale UHB).”

Source location

Response from Abbott Nutrition
Page 1 · response
Published 19 December 2022

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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

Provide sepsis symptom cards to children and their parents to promote awareness of childhood sepsis signs and symptoms.

Verbatim wording from the response

“We will in addition ensure a sepsis card is also given to children and their parents. We will use the Paediatric Symptom Cards | The UK Sepsis Trust to promote awareness of the signs and symptoms of children who are developing sepsis. We will commence use of the cards as soon as possible.”

Source location

Response from Cardiff and Vale University Health Board
Page 2 · response
Published 19 December 2022

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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 PEG patient and family information to include sepsis signs and symptoms, and provide it to new patients.

Verbatim wording from the response

“The eCORFLO booklet (Information for patients, relatives and carers, Gastrostomy feeding tube, Percutaneous Endoscopic Gastrostomy) the patient is given at time of the procedure has been updated to reference to sepsis (attached as Appendix One).”

Source location

Response from Cardiff and Vale University Health Board
Page 1 · response
Published 19 December 2022

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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

Consider suitable generic sepsis information for use at the procedure and later in the community, including a credit-card-sized symptom card.

Verbatim wording from the response

“In addition, we are considering suitable generic information to be given both at time of procedure and later in the community we are considering the SEPSIS awareness credit card size information. This will then be able to be used across wider areas, it gives simple clear information and is a highly visible card. We care for approximately 450 enterally fed patients within the UHB (not all with gastrostomies) so dietetics would purchase these so they could be issued at initial discharge as well as in the community when needed.”

Source location

Response from Cardiff and Vale University Health Board
Page 2 · response
Published 19 December 2022

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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

Cardiff and Vale UHB is responsible for updating patient information and purchasing symptom cards addressing sepsis signs.

Verbatim wording from the response

“Abbott and Cardiff and Vale UHB have reviewed how the requirements of the Regulation 28 Report can be met and the following has been agreed between the parties on 3 February 2023:”

Source location

Response from Abbott Nutrition
Page 1 · response
Published 19 December 2022

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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

Patient information may only be issued when authorised by Cardiff and Vale UHB under the existing contract specification.

Verbatim wording from the response

“For clarity, the Abbott Nurse Advisor team is employed by CHASE and, on behalf of Abbott Laboratories Limited (Abbott), their role is to fulfil an enteral feeding nursing service, as part of an NHS Contract Specification. Abbott currently holds an enteral feeding contract with Cardiff and Vale University Health Board (Cardiff and Vale UHB).”

Source location

Response from Abbott Nutrition
Page 1 · response
Published 19 December 2022

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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.2

  1. 1

    Advise other Welsh health board dietetic teams about the actions taken for consideration of an all-Wales approach.

    Stated by Cardiff & Vale University LHBStated plannedThe respondent said that this action was planned when they made their response on 19 December 2022.
  2. 2

    Provide an additional information sheet to patients and families when early discharge occurs.

    Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 19 December 2022.

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

Advise other Welsh health board dietetic teams about the actions taken for consideration of an all-Wales approach.

Verbatim wording from the response

“We will advise the other Welsh health board dietetic teams of actions taken in response to the Regulation 28 for their consideration as an all Wales approach would be helpful.”

Source location

Response from Cardiff and Vale University Health Board
Page 2 · response
Published 19 December 2022

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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

Provide an additional information sheet to patients and families when early discharge occurs.

Verbatim wording from the response

“People will also be given an additional information sheet if an early discharge occurs (attached as Appendix Two). The booklet and information sheet are in use.”

Source location

Response from Cardiff and Vale University Health Board
Page 1 · response
Published 19 December 2022

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