PFD report

Connor William DAVIES · Prevention of Future Deaths report

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Issued 29 Nov 2019•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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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 clinically review the urgency of patients when appointments are cancelled
    Part of recurring concern: Unreliable safety review and escalation when clinical appointments are delayed or cancelled
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.1

  1. Action

    Review appointment-cancellation processes to ensure urgent referral needs receive appropriate clinical input.

    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 29 December 2019.

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 clinically review the urgency of patients when appointments are cancelled

Wider context from the report

“(1) Mr Davies was seen by a consultant psychiatrist in November 2018 and a follow up appointment made for January 2019. That appointment was cancelled and another made for March 2019. That too was cancelled and a further appointment made for June 2019 but before he could attend Mr Davies killed himself. ████████ who gave evidence confirmed that when appointments are cancelled there is no clinical input as to the need of individual patients for more urgent referrals and thus a patient who is in serious need of an appointment may ‘fall through the net’ as may have been the case here. ████████ told me that he had endeavoured to put in place a system whereby this could be avoided but, to his knowledge, it is not yet operating. ”

Is this part of a recurring concern?

Yes — Unreliable safety review and escalation when clinical appointments are delayed or cancelled.

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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

Review appointment-cancellation processes to ensure urgent referral needs receive appropriate clinical input.

Verbatim wording from the response

“Synopsis of Concern: To review the existing processes that determine the appropriate priority for booking of appointments, to ensure allocation of clinics across the appropriate level of clinicians.”

Source location

2019-0412-Response-by-University-Health-Board
Page 2 · response
Published 29 December 2019

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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

    Audit the new appointment process at agreed checkpoints to determine compliance.

    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 29 December 2019.
  2. 2

    Ensure clinical and administrative staff understand cancellation and rebooking processes and maintain an audit trail.

    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 29 December 2019.

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

Audit the new appointment process at agreed checkpoints to determine compliance.

Verbatim wording from the response

“Action Needed: Audit the new process to determine compliance at specific check points as agreed.”

Source location

2019-0412-Response-by-University-Health-Board
Page 2 · response
Published 29 December 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

Ensure clinical and administrative staff understand cancellation and rebooking processes and maintain an audit trail.

Verbatim wording from the response

“Action Needed: Ensure all clinical and administrative staff who are involved in cancelling and rebooking of appointments are fully aware of the process and that there is an audit trail to demonstrate this.”

Source location

2019-0412-Response-by-University-Health-Board
Page 2 · response
Published 29 December 2019

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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