PFD report

Gwilym Pugh Jones · Prevention of Future Deaths report

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Issued 25 Sep 2013•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.

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Concerns
1

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

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 conduct tests required by a clinician
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.9

  1. Action

    Deliver Train the Trainer support and ward-level mandatory education on Clostridium difficile management and obtaining specimens.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2014.
  2. Action

    Implement a ward improvement plan with staff training and monitoring of compliance with sample-obtaining responsibilities.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2014.
  3. Action

    Implement a revised Infection Prevention Education Programme covering diarrhoea management and prompt submission of specimens.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 26 January 2014.

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

  1. Position

    The Health Board considers the issues raised adequately addressed by the actions taken and does not identify further responsive work.

    Stated by Betsi Cadwaladr University LHBNo action considered necessaryThe respondent said that 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

Failure to conduct tests required by a clinician

Wider context from the report

“(1) Tests were not conducted despite being required by a clinician and this resulted in a missed opportunity to provide a diagnosis and treatment. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Deliver Train the Trainer support and ward-level mandatory education on Clostridium difficile management and obtaining specimens.

Verbatim wording from the response

“Mandatory training is in place for all staff members on an annual basis. In recent months, the Governance Team in PCSM East have undertaken a “Train the Trainer” programme with the Infection Control Team and are assisting in the training of staff at ward level for times when staff cannot be released from the ward area to attend training sessions. The training which is delivered through the mandatory presentation covers the management of suspected and confirmed cases of Clostridium Difficile and the process of obtaining samples for testing.”

Source location

2013-0239-Response
Page 3 · response
Published 26 January 2014

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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

Implement a ward improvement plan with staff training and monitoring of compliance with sample-obtaining responsibilities.

Verbatim wording from the response

“It therefore appears that the request for a stool sample was an omission on the part of nursing staff. This has been discussed with them, both individually and collectively, and their practice is being monitored by the Ward Sister who has implemented an improvement plan which includes a training programme for all staff. The Ward Sister has provided an assurance to the Matron that staff are now aware of their responsibilities with regards to the obtaining of samples.”

Source location

2013-0239-Response
Page 2 · response
Published 26 January 2014

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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

Implement a revised Infection Prevention Education Programme covering diarrhoea management and prompt submission of specimens.

Verbatim wording from the response

“The Infection Prevention Education Programme within BCUHB was reviewed so as to ensure that education is provided to staff on all key issues. The revised programme includes education on management of patients who present with diarrhoea and the need to ensure specimens are sent to the laboratory. This came into being in January 2014.”

Source location

2013-0239-Response
Page 4 · response
Published 26 January 2014

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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

Run a staff-wide communications and awareness campaign reinforcing immediate actions for diarrhoea, including obtaining and sending specimens for analysis.

Verbatim wording from the response

“As part of actions being introduced to reduce the number of cases of Clostridium Difficile infection, a communications and awareness campaign was introduced in December 2013 which is aimed at all staff. This reinforces key standard required to prevent Clostridium Difficile infection and all the actions that must be taken immediately a patient develops diarrhoea, including obtaining a specimen and sending it for analysis.”

Source location

2013-0239-Response
Page 4 · response
Published 26 January 2014

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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

Include the sample-obtaining issue in ward Safety Briefings for four weeks and circulate a related memo across PCSM East clinical areas.

Verbatim wording from the response

“Matron ████████ has also directed that the issue was to be on every Safety Briefing for a period of four weeks therefore a memo was distributed to all Clinical areas within the PCSM CPG (East), outlining the matter (number 5 on the attached action plan).”

Source location

2013-0239-Response
Page 3 · response
Published 26 January 2014

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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

Disseminate written reminders to Bersham Ward staff about timely investigations and obtaining stool samples, with signed acknowledgement.

Verbatim wording from the response

“The Matron for the relevant area ████████ has written to all staff on Bersham Ward individually outlining the concerns regarding the failure to obtain stool samples for this patient. The letter reminded staff of their duty of care to undertake investigations in a timely manner. A copy of this letter is attached, together with a copy of the signature sheet which staff were required to sign when they had read their letter (items 3 and 4 attached to the action plan).”

Source location

2013-0239-Response
Page 3 · response
Published 26 January 2014

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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

Finalize a ward standards plan using key indicators and increased monitoring to check that specimens are sent promptly when diarrhoea occurs.

Verbatim wording from the response

“A plan to ensure that key standards for the prevention and management of Clostridium Difficile infection are highly visible and clearly understood is in the final stages of development. This work includes the use of key indicators in all wards when a case occurs. As a consequence of this, there will be an increase in the monitoring frequency of key standards and specifically includes a check to ensure that specimens are sent rapidly once diarrhoea occurs. The standards sheet is currently being finalised but a copy of the current version is attached (11) with RAG – red, amber, green status – ratings included as an example.”

Source location

2013-0239-Response
Page 4 · response
Published 26 January 2014

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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

Recirculate the policy for managing suspected and confirmed Clostridium difficile infection to all PCSM clinical areas.

Verbatim wording from the response

“There are also a number of Policies which guide staff on the prevention and control of infection. In these Policies the standard procedures for obtaining samples and managing infectious conditions are clearly set out for staff to follow. As stated above, these are readily available in the ward area and online and staff are expected to adhere to these processes.”

Source location

2013-0239-Response
Page 3 · response
Published 26 January 2014

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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

Conduct an unannounced adult-ward spot check linking diarrhoea cases with laboratory receipt of stool samples and provide immediate staff education where samples were missing.

Verbatim wording from the response

“An unannounced spot check was performed across all adult wards in Wrexham Maelor between 1st and 7th November 2013 to identify patients with diarrhoea and cross check this information with stool samples received in the laboratory. Of the 456 patients reviewed, a total of 17 had diarrhoea and samples from 14 of the 17 had been sent to the laboratory for analysis. The Infection Prevention Nurses provided on the spot education to staff, reinforcing the need for samples to be taken in the 3 cases where a sample had not been sent. A copy of the spot check summary is attached (12).”

Source location

2013-0239-Response
Page 4 · response
Published 26 January 2014

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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

The Health Board considers the issues raised adequately addressed by the actions taken and does not identify further responsive work.

Verbatim wording from the response

“This concludes the actions that have been taken to address the issues raised in your Regulation 28 report and I hope that you feel they have been addressed adequately. However, please do not hesitate to contact me if you require any additional information or if I can be of further assistance.”

Source location

2013-0239-Response
Page 4 · response
Published 26 January 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.3

  1. 1

    Share the incident across all PCSM sites within Betsi Cadwaladr University Health Board to promote learning.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 26 January 2014.
  2. 2

    Assign each site's Governance Lead responsibility for organising future Infection Control meetings.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 26 January 2014.
  3. 3

    Complete mandatory Infection Control training for all staff and monitor training rates monthly through governance meetings.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 26 January 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

Share the incident across all PCSM sites within Betsi Cadwaladr University Health Board to promote learning.

Verbatim wording from the response

“As detailed in the attached action plan, this incident has been shared across the PCSM CPG on all sites within Betsi Cadwaladr University Health Board (BCUHB) i.e. Wrexham Maelor Hospital, Glan Clwyd Hospital and Ysbyty Gwynedd so as to ensure wide awareness and learning.”

Source location

2013-0239-Response
Page 3 · response
Published 26 January 2014

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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

Assign each site's Governance Lead responsibility for organising future Infection Control meetings.

Verbatim wording from the response

“In the past, these meetings have been organised by the Infection Control team who would invite staff from the CPG. However, to ensure ownership by the CPG, the Associate Chief of Staff Nursing for the CPG has instructed that in future the Governance Lead for each site will now be responsible for organising these meetings.”

Source location

2013-0239-Response
Page 2 · response
Published 26 January 2014

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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

Complete mandatory Infection Control training for all staff and monitor training rates monthly through governance meetings.

Verbatim wording from the response

“As a result of the RCA meeting and subsequent discussions, it was identified that some members of staff were not fully up to date with their mandatory Infection Control training. This has now been addressed and all staff received up to date training by 3rd December 2013. Infection Control training rates are now monitored on a monthly basis across the CPG by Matrons and Lead Nurses and scrutinised at the CPG Quality and Governance meeting.”

Source location

2013-0239-Response
Page 2 · response
Published 26 January 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