PFD report

Mrs Ruth Ellen Edwards · Prevention of Future Deaths report

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Issued 18 Dec 2018•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
5

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
5

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 raised5

  1. Failure to communicate accurate overdose information to liaison psychiatry
    Part of recurring concern: Unreliable communication of patient-care information between clinical staff
  2. Failure to arrange psychiatric liaison assessment and professional follow-up after overdose
    Part of recurring concern: Failure to provide timely and adequate follow-up after dischargePart of recurring concern: Failure to provide timely continuing mental health reviews and follow-up
  3. Inadequate risk history-taking during clinical consultation
    Part of recurring concern: Incomplete clinical history-takingPart of recurring concern: Unreliable assessment of suicide and self-harm risk
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

    Discuss the report’s medication-review and high-risk-patient learning at the monthly significant-events meeting with clinical staff.

    Stated by West Quay Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 17 May 2019.
  2. Action

    Employ a full-time clinical pharmacist to oversee and improve prescribing governance and patient monitoring.

    Stated by West Quay Medical CentreStated completedThe respondent said that this action was complete when they made their response on 17 May 2019.
  3. Action

    Remind staff through Clinical Board quality, safety and experience structures to take complete, diligent mental-health histories using all available information.

    Stated by Cardiff & Vale University LHBStated plannedThe respondent said that this action was planned when they made their response on 17 May 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Existing Bristol Matrix procedures and established training are considered sufficient to identify patients requiring immediate psychiatric assessment.

    Stated by Cardiff & Vale 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

Failure to communicate accurate overdose information to liaison psychiatry

Wider context from the report

“(2) The consultation at the UHW on 23rd August was poor. The history-taking was inadequate, as it did not reveal the true extent of Mrs Edwards’ risk in terms of previous suicide attempts and deep-seated mental health problems. Furthermore, inaccurate information was communicated to liaison psychiatry: they were told that Mrs Edwards had taken 2 tablets, when she had taken 20. ”

Is this part of a recurring concern?

Yes — Unreliable communication of patient-care information between clinical staff.

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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

Failure to arrange psychiatric liaison assessment and professional follow-up after overdose

Wider context from the report

“(1) Mrs Edwards’ discharge from hospital following overdose on 23rd August to see GP was surprising. It was expected in these circumstances that Mrs Edwards would have been transferred to Llandough Hospital for a psychiatric liaison assessment. Instead, responsibility for any further assessment and treatment of Mrs Edwards was passed entirely to Mrs Edwards and her family. A less capable family/individual may not have pursued help and fallen through the cracks. Furthermore, had Mrs Edwards been hospitalised, her treatment may have been different. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate follow-up after discharge; Failure to provide timely continuing mental health reviews and follow-up.

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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

Inadequate risk history-taking during clinical consultation

Wider context from the report

“(2) The consultation at the UHW on 23rd August was poor. The history-taking was inadequate, as it did not reveal the true extent of Mrs Edwards’ risk in terms of previous suicide attempts and deep-seated mental health problems. Furthermore, inaccurate information was communicated to liaison psychiatry: they were told that Mrs Edwards had taken 2 tablets, when she had taken 20. ”

Is this part of a recurring concern?

Yes — Incomplete clinical history-taking; Unreliable assessment of suicide and self-harm risk.

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 to perform suitably frequent medication reviews

Wider context from the report

“(3) The GP practice may not have performed suitably frequent medication reviews with Mrs Edwards. Many boxes of different tablets were found at the family home, many on repeat prescription, posing an overdose risk. ”

Is this part of a recurring concern?

Yes — Failure to reliably conduct clinically required medication reviews.

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

Availability of many boxes of different repeat-prescribed tablets posing an overdose risk

Wider context from the report

“(3) The GP practice may not have performed suitably frequent medication reviews with Mrs Edwards. Many boxes of different tablets were found at the family home, many on repeat prescription, posing an overdose risk. ”

Is this part of a recurring concern?

Yes — Medication quantity controls failing to prevent unsafe access to excessive amounts.

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

Discuss the report’s medication-review and high-risk-patient learning at the monthly significant-events meeting with clinical staff.

Verbatim wording from the response

“That said, we would also bring these comments to our monthly significant events meeting to highlight the importance of medication reviews and high risk patients to all of our clinical staff.”

Source location

2018-0395-Response-by-West-Quay-Centre
Page 1 · response
Published 17 May 2019

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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

Employ a full-time clinical pharmacist to oversee and improve prescribing governance and patient monitoring.

Verbatim wording from the response

“Specifically with relation to the comments regarding medication reviews with ourselves as General Practitioners, we would recognise that this presents a particular challenge to us and safe prescribing of medicine requires a great deal of resource. In the last 12 months we have taken on a Clinical Pharmacist within the Practice Team on a full time basis whose responsibility it has been to oversee and improve the governance regarding repeat prescribing and acute prescribing of medications plus patient monitoring. We have in fact achieved an NHS award for quality improvement in this area and although this may have come too late for Mrs Edwards in order to reduce her risk, I would be confident that we have made great strides over and above that we would expect to meet standards of our General Practice.”

Source location

2018-0395-Response-by-West-Quay-Centre
Page 1 · response
Published 17 May 2019

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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

Remind staff through Clinical Board quality, safety and experience structures to take complete, diligent mental-health histories using all available information.

Verbatim wording from the response

“The care and attention to detail taken by doctors and other healthcare professionals when taking histories and information from mental health patients.”

Source location

2018-0395-Response-by-University-Health-Board
Page 3 · response
Published 17 May 2019

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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

Use the Bristol Matrix to identify patients requiring psychiatric assessment, supported by established staff training.

Verbatim wording from the response

“The identification of patients who require immediate psychiatric assessments and review by specialist teams.”

Source location

2018-0395-Response-by-University-Health-Board
Page 3 · response
Published 17 May 2019

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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

Raise medication-review frequency as a practice issue with the Primary, Community and Intermediate Care Clinical Board for consideration.

Verbatim wording from the response

“The GP practice may not have performed suitable frequent medication reviews with Mrs Edwards. Many boxes of different tablets were found at the family home. Many on repeat prescription posing an overdose risk.”

Source location

2018-0395-Response-by-University-Health-Board
Page 3 · response
Published 17 May 2019

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

Existing Bristol Matrix procedures and established training are considered sufficient to identify patients requiring immediate psychiatric assessment.

Verbatim wording from the response

“The identification of patients who require immediate psychiatric assessments and review by specialist teams.”

Source location

2018-0395-Response-by-University-Health-Board
Page 3 · response
Published 17 May 2019

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

Home treatment with frequent specialist input was considered appropriate, balancing admission risks and the patient's unwillingness to be admitted.

Verbatim wording from the response

“The UHB would absolutely concur that some families may not have been in a position to provide ongoing support, but the judgement that Mrs Edwards might remain at home with regular and frequent input from the REACT team was made with the conscious participation and agreement of all, including the team, the patient and the family.”

Source location

2018-0395-Response-by-University-Health-Board
Page 2 · response
Published 17 May 2019

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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 documentation error stating two tablets were taken did not influence the clinical decision because clinicians knew twenty tablets had been taken.

Verbatim wording from the response

“The consultation at the UHW on 23 August was poor. The history taking was inadequate as it did not reveal the true extent of Mrs Edwards risk in terms of previous suicide attempts and deep seated mental health problems. Furthermore, inaccurate information was communicated to liaison psychiatry; they were told that Mrs Edwards had taken 2 tablets when she had taken 20.”

Source location

2018-0395-Response-by-University-Health-Board
Page 2 · response
Published 17 May 2019

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

Medication review for patients managed in primary care is a matter for the GP practice and Primary, Community and Intermediate Care Clinical Board.

Verbatim wording from the response

“The GP practice may not have performed suitable frequent medication reviews with Mrs Edwards. Many boxes of different tablets were found at the family home. Many on repeat prescription posing an overdose risk.”

Source location

2018-0395-Response-by-University-Health-Board
Page 3 · response
Published 17 May 2019

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 positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The general standard of documentation was considered satisfactory, despite the identified typographical error.

    Stated by Cardiff & Vale University LHBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 general standard of documentation was considered satisfactory, despite the identified typographical error.

Verbatim wording from the response

“Our review has identified that, although there was a typographical error in the documentation stating that only two tablets of Sertraline had been taken when in fact the true figure was twenty, this error was rectified on the night in question; when ████████ had his discussion with Mark Bates (the night site coordinator for mental health services), both individuals knew that twenty tablets had been taken and made their clinical decision on that basis. This is borne out by the notes taken by ████████ at the time, and also I can confirm that the night site coordinator in mental health services has located his own personal notes from that night, in which he has written that Mrs Edwards took twenty tablets, not two. The typographical error was therefore not a factor in the decision making process on that night.”

Source location

2018-0395-Response-by-University-Health-Board
Page 2 · response
Published 17 May 2019

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