PFD report

Isobel Lilian Stapleton · Prevention of Future Deaths report

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Issued 25 Jun 2024•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.

View original report
Concerns
6

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
20

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 raised6

  1. Delays in access to necessary psychotherapy
    Part of recurring concern: Excessive waiting times for NHS mental health services
  2. Failure to provide mental health practitioners with easy access to all relevant clinical records
    Part of recurring concern: Unreliable access to relevant clinical records for safe care
  3. Unavailability of clinical psychologist access for direct inpatient assessment and treatment at Royal Glamorgan Hospital
    Part of recurring concern: Unreliable access to specialist mental health treatment for serious mental illnessPart of recurring concern: Unreliable specialist mental health support in hospital 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.9

  1. Action

    Work with Cwm Taf Morgannwg University Health Board to accelerate implementation of electronic mental health patient records.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024.
  2. Action

    Develop the business case for introducing and deploying mental health systems across NHS Wales.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024.
  3. Action

    Develop a contingency business case with implementation timescales and deployment plans for procuring a mental-health information solution.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024.

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

Delays in access to necessary psychotherapy

Wider context from the report

“(5) The Home treatment team covering Merthyr Tydfil does not have access to a clinical psychologist to provide direct assessment and treatment of a patient. The waiting list for any necessary psychotherapy is months in length. ”

Is this part of a recurring concern?

Yes — Excessive waiting times for NHS mental health services.

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 provide mental health practitioners with easy access to all relevant clinical records

Wider context from the report

“(1) Mental health practitioners are not easily able to access all of a patient's relevant clinical records pending the introduction of a “Once for Wales” solution, for which there is currently no timetable for implementation. ”

Is this part of a recurring concern?

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

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 clinical psychologist access for direct inpatient assessment and treatment at Royal Glamorgan Hospital

Wider context from the report

“(4) The inpatient hospital team at the Royal Glamorgan Hospital did and does not have access to a clinical psychologist to provide direct assessment and treatment of a patient. ”

Is this part of a recurring concern?

Yes — Unreliable access to specialist mental health treatment for serious mental illness; Unreliable specialist mental health support in hospital care.

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 easy access for Welsh mental health practitioners to NHS England clinical records

Wider context from the report

“(3) Mental health practitioners in Wales currently have no way easily to access NHS England clinical records. ”

Is this part of a recurring concern?

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

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 clinical psychologist access for direct home treatment assessment and treatment in Merthyr Tydfil

Wider context from the report

“(5) The Home treatment team covering Merthyr Tydfil does not have access to a clinical psychologist to provide direct assessment and treatment of a patient. The waiting list for any necessary psychotherapy is months in length. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 ensure mental health practitioners are aware of all relevant clinical records

Wider context from the report

“(2) Mental health practitioners may not be aware of the existence of all such records, some of which may be in paper. ”

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

Work with Cwm Taf Morgannwg University Health Board to accelerate implementation of electronic mental health patient records.

Verbatim wording from the response

“In relation to the first three matters of concern in your report, I wish to highlight that a business case is being developed by Digital Health and Care Wales for the introduction and deployment of mental health systems across health boards in NHS Wales. Once a timetable for deployment has been agreed, this will be communicated. However, it is anticipated that this will be a phased approach over a number of years. This work will improve digital and data service provision in mental health. It will be based on the principle of parity with physical health and will deliver on key areas including electronic records, data sharing, use of digital across services, and improved mental health data. Officials are working with Cwm Taf Morgannwg University Health Board to accelerate the implementation of electronic patient records for mental health, ahead of the all-Wales system.”

Source location

Response from Welsh Government
Page 1 · response
Published 27 June 2024

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 the business case for introducing and deploying mental health systems across NHS Wales.

Verbatim wording from the response

“In relation to the first three matters of concern in your report, I wish to highlight that a business case is being developed by Digital Health and Care Wales for the introduction and deployment of mental health systems across health boards in NHS Wales. Once a timetable for deployment has been agreed, this will be communicated. However, it is anticipated that this will be a phased approach over a number of years. This work will improve digital and data service provision in mental health. It will be based on the principle of parity with physical health and will deliver on key areas including electronic records, data sharing, use of digital across services, and improved mental health data. Officials are working with Cwm Taf Morgannwg University Health Board to accelerate the implementation of electronic patient records for mental health, ahead of the all-Wales system.”

Source location

Response from Welsh Government
Page 1 · response
Published 27 June 2024

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 contingency business case with implementation timescales and deployment plans for procuring a mental-health information solution.

Verbatim wording from the response

“As a contingency measure we are also working with colleagues in another Health Board to accelerate the procurement and implementation of a Mental Health solution should the Connecting Care business case not be approved in the near future. CTMUHB are working on a business case for this which will include timescales and deployments plans, it is expected that we will be ready to procure in the Autumn of 2024.”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 3 · response
Published 27 June 2024

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

Implement and disseminate the Clinical Information Access and Recording Matrix and accompanying procedure across mental-health and learning-disability services.

Verbatim wording from the response

“As a mitigation for the multiple record system that are still in place across the Mental Health and Learning Disability (MHLD) Care Group the Health Board developed a Clinical Information Access and Recording Matrix (CIARM) in August 2023 for clinical team/staff access for all systems across the MHLD Care Group. This informs all clinical staff of how to access patient clinical risk and discharge planning information both in and out of hours and is the primary tool by which the MHLD Care Group mitigates the potential risks inherent with our present multiple systems.”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 3 · response
Published 27 June 2024

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

Continue working with the national Connecting Care programme to deliver an integrated mental-health information solution as a priority.

Verbatim wording from the response

“The Health Board has continued to work with the National programme for Connecting Care, with an aim to deliver a fully integrated Mental Health solution as a priority. A Business Case was due to be submitted at the end of July 2024 for an alternative national solution but at the time of writing this response it has not been received by Welsh Government.”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 3 · response
Published 27 June 2024

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

Provide psychological-professional sessions to the Royal Glamorgan Hospital mental-health unit.

Verbatim wording from the response

“There is no designated clinical psychology provision for the Royal Glamorgan Hospital Mental health Unit (RGH MHU). In an attempt to mitigate this, the following has been put in place:”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 4 · response
Published 27 June 2024

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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

Prioritise and plan implementation of a national integrated mental-health records solution through workshops and related planning exercises.

Verbatim wording from the response

“I can report that the Health Board had approved prioritisation of the implementation of the national Care Director solution under the Welsh Community Care Information System (WCCIS) programme. As a result, throughout Spring and Summer 2023 the Health Board commenced a series of workshops and planning exercises, supported by local authority colleagues and the national team within Digital Health Care Wales (DHCW). However, during this time, significant operational issues with the Care Director system identified by an early implementing neighbouring Health Board raised questions about future implementation. In addition, we noted that Care Director as a national solution will be withdrawn in January 2026, so all organisations are reviewing”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 2 · response
Published 27 June 2024

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

Provide a dedicated psychological professional for direct assessment and treatment across all three crisis-resolution home-treatment teams.

Verbatim wording from the response

“Since June 2024, there is a dedicated psychological professional available for direct assessment and treatment into all three of the CRHTTs. There is no”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 4 · response
Published 27 June 2024

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

Invest resources to address the psychological-therapy waiting-list backlog across primary and secondary mental-health services.

Verbatim wording from the response

“waiting list in these services, and the Psychologists and Psychological Therapists work closely with the team as soon as a need for input is identified. There has been significant investment of resource to address the backlog of people waiting for psychological therapies in both Primary and Secondary mental health services. This has reduced the number of people waiting over 52 weeks from 221 in May 2023 to 109 in May 2024.”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 5 · response
Published 27 June 2024

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.11

  1. 1

    Deliver rapid prevention, intervention and support for people vulnerable to suicide and self-harm through the settings they use, including mental health services.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 27 June 2024.
  2. 2

    Increase public, professional and agency skills, awareness, knowledge and understanding of suicide and self-harm.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 27 June 2024.
  3. 3

    Improve discharge arrangements through the Strategic Mental Health Programme and Mental Health Patient Safety Programme.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 27 June 2024.
  4. 4

    Provide dedicated NHS Wales Executive support through strategic and patient safety programmes to improve mental health service quality and safety.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
  5. 5

    Drive improvements in the quality of care and treatment planning through the Strategic Mental Health Programme and Mental Health Patient Safety Programme.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 27 June 2024.
  6. 6

    Provide ward-based assessment, formulation and CBT interventions through the trainee Clinical Associate in Applied Psychology placement.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024.
  7. 7

    Establish acute mental-health psychological staffing at full establishment across acute adult services.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
  8. 8

    Contact people waiting for primary mental-health psychological therapies at two weeks and six months, using CORE-10 assessments to monitor and escalate changes in presentation or risk.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
  9. 9

    Upskill ward staff to deliver psychologically informed low-level interventions as part of inpatient-service improvement work.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024.
  10. 10

    Provide supervised skills-development, emotional-regulation and psychoeducation placements through University of Bath undergraduate students.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
  11. 11

    Finalise routine documentation, information-sharing and communication audits through the Health Board’s audit management and tracking platform.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.

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 rapid prevention, intervention and support for people vulnerable to suicide and self-harm through the settings they use, including mental health services.

Verbatim wording from the response

“Alongside this, the draft Suicide and Self-harm Prevention Strategy includes commitments to deliver rapid and impactful prevention, intervention, and support to those in society who are the most vulnerable to suicide and self-harm through the settings with which they are most engaged. This includes those in contact with mental health services. It also includes an objective to increase skills, awareness, knowledge and understanding of suicide and self-harm amongst the public, professionals and agencies who may come into contact with those at risk of suicide and self-harm.”

Source location

Response from Welsh Government
Page 2 · response
Published 27 June 2024

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

Increase public, professional and agency skills, awareness, knowledge and understanding of suicide and self-harm.

Verbatim wording from the response

“Alongside this, the draft Suicide and Self-harm Prevention Strategy includes commitments to deliver rapid and impactful prevention, intervention, and support to those in society who are the most vulnerable to suicide and self-harm through the settings with which they are most engaged. This includes those in contact with mental health services. It also includes an objective to increase skills, awareness, knowledge and understanding of suicide and self-harm amongst the public, professionals and agencies who may come into contact with those at risk of suicide and self-harm.”

Source location

Response from Welsh Government
Page 2 · response
Published 27 June 2024

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

Improve discharge arrangements through the Strategic Mental Health Programme and Mental Health Patient Safety Programme.

Verbatim wording from the response

“We have also provided dedicated support in the NHS Wales Executive to support health boards to improve the quality and safety of mental health services. This includes through a Strategic Mental Health Programme and a Mental Health Patient Safety Programme. A key focus of this work will be to improve discharge arrangements and to drive improvements in the quality of care and treatment planning. I am committed to ensuring a person-centred”

Source location

Response from Welsh Government
Page 1 · response
Published 27 June 2024

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

Provide dedicated NHS Wales Executive support through strategic and patient safety programmes to improve mental health service quality and safety.

Verbatim wording from the response

“We have also provided dedicated support in the NHS Wales Executive to support health boards to improve the quality and safety of mental health services. This includes through a Strategic Mental Health Programme and a Mental Health Patient Safety Programme. A key focus of this work will be to improve discharge arrangements and to drive improvements in the quality of care and treatment planning. I am committed to ensuring a person-centred”

Source location

Response from Welsh Government
Page 1 · response
Published 27 June 2024

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

Drive improvements in the quality of care and treatment planning through the Strategic Mental Health Programme and Mental Health Patient Safety Programme.

Verbatim wording from the response

“We have also provided dedicated support in the NHS Wales Executive to support health boards to improve the quality and safety of mental health services. This includes through a Strategic Mental Health Programme and a Mental Health Patient Safety Programme. A key focus of this work will be to improve discharge arrangements and to drive improvements in the quality of care and treatment planning. I am committed to ensuring a person-centred”

Source location

Response from Welsh Government
Page 1 · response
Published 27 June 2024

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

Provide ward-based assessment, formulation and CBT interventions through the trainee Clinical Associate in Applied Psychology placement.

Verbatim wording from the response

“• The trainee CAAP provides assessment, formulation and CBT-based interventions for individual patients on the ward. However, the Trainee CAAP has only recently started their training placement (January, 2024) so the level of complexity of input they are able to provide is therefore limited at this point.”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 4 · response
Published 27 June 2024

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

Establish acute mental-health psychological staffing at full establishment across acute adult services.

Verbatim wording from the response

“The acute mental health psychological team has been at full establishment since June 2024. This consists of a total 4.3 whole time equivalent staff (WTE) across CTMUHB acute adult mental health services:”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 4 · response
Published 27 June 2024

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

Contact people waiting for primary mental-health psychological therapies at two weeks and six months, using CORE-10 assessments to monitor and escalate changes in presentation or risk.

Verbatim wording from the response

“In addition, people on the waiting list for psychological therapies in Local Primary Mental Health Support Services receive a contact phone call after two weeks and 6 months of waiting. The service uses CORE-10, a standardised assessment of common presentations of psychological distress to monitor and escalate any significant changes in clinical presentation or risk, at both of these contact points.”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 5 · response
Published 27 June 2024

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

Upskill ward staff to deliver psychologically informed low-level interventions as part of inpatient-service improvement work.

Verbatim wording from the response

“• As part of the broader improvement work to the inpatient service, workforce development is aimed at upskilling ward staff to be able to offer psychologically informed low-level interventions.”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 4 · response
Published 27 June 2024

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

Provide supervised skills-development, emotional-regulation and psychoeducation placements through University of Bath undergraduate students.

Verbatim wording from the response

“• Skills development/ emotional regulation and psychoeducation work is provided by undergraduate students on nine-month clinical placements from the University of Bath. This work is closely supervised by the Consultant Clinical Psychologist.”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 4 · response
Published 27 June 2024

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

Finalise routine documentation, information-sharing and communication audits through the Health Board’s audit management and tracking platform.

Verbatim wording from the response

“With CIARM now in place practitioners report that patient information is shared more effectively between staff across multiple sites (in and outside of normal working hours) which allows more time to be spent on patient care, and that clinical staff now have the right information and the right time to inform Multidisciplinary decision making. The MHLD Care Group has finalised a range of routine audits of documentation, information sharing and communication”

Source location

Response from Cwm Taf Morgannwg University Health Board
Page 3 · response
Published 27 June 2024

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