PFD report

Ronald Perry · Prevention of Future Deaths report

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Issued 2 Jul 2014•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
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
1

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. Inconsistent criteria for requesting CT scans outside standard hours and at weekends
    Part of recurring concern: Inadequate safety guidance for CT scanning and reportingPart of recurring concern: Unreliable CT scan request and escalation processes
  2. Inconsistent levels of care provided to patients across the 24-hour period
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Position

    Existing emergency on-call arrangements ensure life-threatening CT referrals receive urgent scanning at any time, regardless of whether it is within normal working hours.

    Stated by Betsi Cadwaladr University LHBExisting 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

Inconsistent criteria for requesting CT scans outside standard hours and at weekends

Wider context from the report

“During the course of the inquest, evidence given by ████████ ████████ indicated that had the Deceased undergone a CT scan then it is probable that his aneurysm would have been detected and that he would have undergone surgery. However different criteria exist within BCUHB by which CT scans can be requested by clinicians dependent upon the time of day (before or after 5.00 pm) or whether such a request is made at a weekend. That unless steps are taken to provide consistency within the levels of care provided to patients on a 24 hour basis then there will be continuing risks to patients "out of hours" and may lead to future deaths. ”

Is this part of a recurring concern?

Yes — Inadequate safety guidance for CT scanning and reporting; Unreliable CT scan request and escalation processes.

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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

Inconsistent levels of care provided to patients across the 24-hour period

Wider context from the report

“During the course of the inquest, evidence given by ████████ ████████ indicated that had the Deceased undergone a CT scan then it is probable that his aneurysm would have been detected and that he would have undergone surgery. However different criteria exist within BCUHB by which CT scans can be requested by clinicians dependent upon the time of day (before or after 5.00 pm) or whether such a request is made at a weekend. That unless steps are taken to provide consistency within the levels of care provided to patients on a 24 hour basis then there will be continuing risks to patients "out of hours" and may lead to future deaths. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Existing emergency on-call arrangements ensure life-threatening CT referrals receive urgent scanning at any time, regardless of whether it is within normal working hours.

Verbatim wording from the response

“The Radiology service at all three district general hospital’s in North Wales operates a full service Monday to Friday 8.30 am to 5.30pm with some scanning lists being extended into the evenings. This comprises of lists with booked outpatients, urgent suspected cancer patients, inpatients and clinical emergencies. At all other times a general X-ray service is offered alongside an emergency on call service for CT and ultrasound scanning. The emergency on call service is provided on a consultant to consultant basis for all cases where scanning is required to diagnose an emergency or life threatening condition.”

Source location

2014-0302-Response-by-University-Health-Board
Page 1 · response
Published 2 July 2014

Open published response

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.1

  1. 1

    Develop increased access to radiology scanning outside normal office hours.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 2 July 2014.

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 increased access to radiology scanning outside normal office hours.

Verbatim wording from the response

“As part of continued improvements to the service the Radiology Clinical Programme Group is working to develop increased access outside of normal office hours. However, in this particular case had a referral been made with a clinical indication of possible dissecting or ruptured abdominal aortic aneurysm the level of urgency would have resulted in an urgent scan being performed, whether in or out of normal working hours.”

Source location

2014-0302-Response-by-University-Health-Board
Page 1 · response
Published 2 July 2014

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