PFD report

Jean THOMAS · Prevention of Future Deaths report

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Issued 23 Oct 2024•Gwent

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
13

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 monitor fluid balance
    Part of recurring concern: Failure to ensure reliable renal monitoring for patients with renal diseasePart of recurring concern: Failure to reliably monitor patient fluid balance
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.11

  1. Action

    Use the AMAT tool to standardise fluid-balance compliance audits, conduct audits through ward accreditation and report results to the Nutrition and Hydration Committee.

    Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 3 February 2025.
  2. Action

    Deliver strengthened multidisciplinary education and training on fluid-balance roles, responsibilities and best practice.

    Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 3 February 2025.
  3. Action

    Complete the review of Health Board documentation, monitoring tools and relevant national guidelines to establish an evidence base for best practice.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 3 February 2025.

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 monitor fluid balance

Wider context from the report

“Jean was known to have significant cardiovascular problems and from her admission there were signs this was worsening. Her blood pressure was low, which would normally be treated with intravenous fluids, but excess fluids would put more pressure on her heart, and thus she was also treated with a low dose of furosemide. The management of Jean’s fluid balance was important for the following reasons; she had heart failure, she had chronic renal failure, she had signs of a superimposing acute kidney injury and she was scoring on the NEWS chart from admission, such that the algorithm required the fluid balance to be monitored. Jean had signs of sepsis. I find at inquest that Jean’s fluid balance was not monitored, which I determined to be a failure in care. It was not monitored by the nursing or the medical staff. Whilst I could not find that knowledge of Jean’s fluid balance would have altered the outcome, it is a matter of grave concern that this basic nursing care was ignored, and these important clinical indicators not monitored by the medical staff. ”

Is this part of a recurring concern?

Yes — Failure to ensure reliable renal monitoring for patients with renal disease; Failure to reliably monitor patient fluid balance.

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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 AMAT tool to standardise fluid-balance compliance audits, conduct audits through ward accreditation and report results to the Nutrition and Hydration Committee.

Verbatim wording from the response

“The AMAT tool will be used to standardise the audit process for fluid balance compliance across the health board. Audits will be carried out in accordance with the Ward / Team Accreditation process and will be reported to the Nutrition & Hydration Committee.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 3 February 2025

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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 strengthened multidisciplinary education and training on fluid-balance roles, responsibilities and best practice.

Verbatim wording from the response

“(1) Standardisation of Fluid Balance monitoring documentation across the organisation. (2) Exploration of the possibility of utilising a digital observation platform to record fluid balance. (3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure. (4) Increase awareness about the expected standards for fluid balance monitoring across the Health Board through various communication methods, such as feedback sessions, posters, emails, ward meetings, weekly cross-divisional ward meetings, and learning events. (5) Identification and delivery of the multidisciplinary training requirements to ensure sustainable improvement in fluid balance monitoring.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 3 February 2025

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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 the review of Health Board documentation, monitoring tools and relevant national guidelines to establish an evidence base for best practice.

Verbatim wording from the response

“A review of current Health Board documentation and monitoring tools across the Region, alongside a review of recommended National Guidelines has taken place to provide the evidence base that will lead to best practice.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 3 February 2025

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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

Incorporate Medical Examiner and Quality Safety Learning Forum learning into the fluid-balance improvement plan.

Verbatim wording from the response

“Compliance with fluid balance monitoring and subsequent improvements will be incorporated into the work of the Nutritional and Hydration Committee. Senior medical staff will be engaged clinically to support education and establish clinical expectations. Learning from Medical Examiner feedback and the Quality Safety Learning Forum will be incorporated into the improvement plan.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 3 February 2025

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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

Explore using a digital observation platform to record fluid balance.

Verbatim wording from the response

“(1) Standardisation of Fluid Balance monitoring documentation across the organisation. (2) Exploration of the possibility of utilising a digital observation platform to record fluid balance. (3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure. (4) Increase awareness about the expected standards for fluid balance monitoring across the Health Board through various communication methods, such as feedback sessions, posters, emails, ward meetings, weekly cross-divisional ward meetings, and learning events. (5) Identification and delivery of the multidisciplinary training requirements to ensure sustainable improvement in fluid balance monitoring.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 3 February 2025

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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

Establish and operate a multidisciplinary Fluid Balance Task and Finish Group with defined improvement objectives.

Verbatim wording from the response

“A Health Board Multidisciplinary Fluid Balance Task & Finish Group has formed with key objectives set which include:”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 3 February 2025

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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

Develop a multidisciplinary fluid-balance standard operating procedure.

Verbatim wording from the response

“(1) Standardisation of Fluid Balance monitoring documentation across the organisation. (2) Exploration of the possibility of utilising a digital observation platform to record fluid balance. (3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure. (4) Increase awareness about the expected standards for fluid balance monitoring across the Health Board through various communication methods, such as feedback sessions, posters, emails, ward meetings, weekly cross-divisional ward meetings, and learning events. (5) Identification and delivery of the multidisciplinary training requirements to ensure sustainable improvement in fluid balance monitoring.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 3 February 2025

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

Disseminate expected fluid-balance monitoring standards through feedback sessions, posters, emails, ward meetings and learning events.

Verbatim wording from the response

“(1) Standardisation of Fluid Balance monitoring documentation across the organisation. (2) Exploration of the possibility of utilising a digital observation platform to record fluid balance. (3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure. (4) Increase awareness about the expected standards for fluid balance monitoring across the Health Board through various communication methods, such as feedback sessions, posters, emails, ward meetings, weekly cross-divisional ward meetings, and learning events. (5) Identification and delivery of the multidisciplinary training requirements to ensure sustainable improvement in fluid balance monitoring.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 3 February 2025

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

Standardise fluid-balance monitoring documentation across the organisation.

Verbatim wording from the response

“(1) Standardisation of Fluid Balance monitoring documentation across the organisation. (2) Exploration of the possibility of utilising a digital observation platform to record fluid balance. (3) Development of a multidisciplinary Fluid Balance Standard Operating Procedure. (4) Increase awareness about the expected standards for fluid balance monitoring across the Health Board through various communication methods, such as feedback sessions, posters, emails, ward meetings, weekly cross-divisional ward meetings, and learning events. (5) Identification and delivery of the multidisciplinary training requirements to ensure sustainable improvement in fluid balance monitoring.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 3 February 2025

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

Initiate a surgical-ward fluid-balance monitoring pilot incorporating staff education, information boards, data sharing and auditing.

Verbatim wording from the response

“A pilot project on fluid balance monitoring will be initiated on a surgical ward, incorporating education, information boards, and sharing and auditing of data. The pilot will evolve into a broader implementation project once the PDSA improvement tools demonstrate progress in the pilot area.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 3 February 2025

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

Engage senior medical staff to support education and establish clinical expectations for fluid-balance monitoring.

Verbatim wording from the response

“Compliance with fluid balance monitoring and subsequent improvements will be incorporated into the work of the Nutritional and Hydration Committee. Senior medical staff will be engaged clinically to support education and establish clinical expectations. Learning from Medical Examiner feedback and the Quality Safety Learning Forum will be incorporated into the improvement plan.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 3 February 2025

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.2

  1. 1

    Add fluid-balance monitoring to the Nutrition and Hydration Committee risk register and keep it under review until standards consistently improve.

    Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 3 February 2025.
  2. 2

    Incorporate fluid-balance compliance and improvement work into the Nutritional and Hydration Committee’s activities.

    Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 3 February 2025.

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

Add fluid-balance monitoring to the Nutrition and Hydration Committee risk register and keep it under review until standards consistently improve.

Verbatim wording from the response

“Fluid balance monitoring will be added to the Nutrition and Hydration Committee risk register and will be kept under review until improvements in standards are consistently achieved.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 3 February 2025

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

Incorporate fluid-balance compliance and improvement work into the Nutritional and Hydration Committee’s activities.

Verbatim wording from the response

“Compliance with fluid balance monitoring and subsequent improvements will be incorporated into the work of the Nutritional and Hydration Committee. Senior medical staff will be engaged clinically to support education and establish clinical expectations. Learning from Medical Examiner feedback and the Quality Safety Learning Forum will be incorporated into the improvement plan.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 3 February 2025

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