PFD report

David Robert Griffiths · Prevention of Future Deaths report

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Issued 3 Feb 2017•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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

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 raised3

  1. Lack of specific training for new medical and nursing staff in intercostal drain insertion
    Part of recurring concern: Unreliable chest drain insertion and management
  2. Unavailability of real-time ultrasound guidance for fluid chest drain insertion
    Part of recurring concern: Unreliable chest drain insertion and management
  3. Lack of local cardiothoracic department protocols for intercostal drain insertion
    Part of recurring concern: Unreliable chest drain insertion and management
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.6

  1. Action

    Explore implementing a safety checklist for chest drain insertion.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
  2. Action

    Implement and oversee ongoing ultrasound training and competence assessment across the Health Board.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
  3. Action

    Purchase two additional ultrasound machines suitable for chest drain and pleural procedures.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.

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

Lack of specific training for new medical and nursing staff in intercostal drain insertion

Wider context from the report

“(1) The evidence revealed that there were no local cardiothoracic department protocols that were available to guide the insertion of intercostal drains and no specific training given to new medical and nursing staff. ”

Is this part of a recurring concern?

Yes — Unreliable chest drain insertion and management.

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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

Unavailability of real-time ultrasound guidance for fluid chest drain insertion

Wider context from the report

“(2) The British Thoracic Society Guidelines strongly support the use of real time ultrasound guidance when inserting chest drains for fluid. Real time ultrasound guidance was not available in this case. ”

Is this part of a recurring concern?

Yes — Unreliable chest drain insertion and management.

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

Lack of local cardiothoracic department protocols for intercostal drain insertion

Wider context from the report

“(1) The evidence revealed that there were no local cardiothoracic department protocols that were available to guide the insertion of intercostal drains and no specific training given to new medical and nursing staff. ”

Is this part of a recurring concern?

Yes — Unreliable chest drain insertion and management.

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

Explore implementing a safety checklist for chest drain insertion.

Verbatim wording from the response

“A similar safety notice was published in NHS England in September 2015. Resources are therefore developed for use in NHS England that can be adapted and adopted for use in NHS Wales. The task and finish group intends to explore the implementation of a safety checklist for chest drain insertion. An example of such a tool, developed by the Intensive Care Society, is attached in Appendix 1.”

Source location

2017-0013-Response-by-University-Health-Board
Page 4 · response
Published 19 February 2017

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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 and oversee ongoing ultrasound training and competence assessment across the Health Board.

Verbatim wording from the response

“It is recognised that arrangements for ongoing training and competence assessment must be in place across the Health Board and this will be implemented and overseen by the task and finish group.”

Source location

2017-0013-Response-by-University-Health-Board
Page 3 · response
Published 19 February 2017

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

Purchase two additional ultrasound machines suitable for chest drain and pleural procedures.

Verbatim wording from the response

“I am pleased to be able to advise you that ████████ Consultant Physician and Respiratory Lead has also coordinated the purchase of two additional ultrasound machines suitable for use in these clinical circumstances. The purchase has been supported by the Health Board’s Medical Equipment Group and Procurement Department.”

Source location

2017-0013-Response-by-University-Health-Board
Page 3 · response
Published 19 February 2017

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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 direct ultrasound guidance for chest drain insertion and discontinue marked-spot insertion.

Verbatim wording from the response

“The UHB has considered the findings of the investigation and has taken the decision to discontinue the practice of inserting chest drains at a ‘marked”

Source location

2017-0013-Response-by-University-Health-Board
Page 1 · response
Published 19 February 2017

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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

Provide bespoke thoracic ultrasound training for the Cardiothoracic Directorate.

Verbatim wording from the response

“It is of paramount importance that staff are appropriately trained to insert intercostal drains using the ultrasound equipment that has been purchased.”

Source location

2017-0013-Response-by-University-Health-Board
Page 3 · response
Published 19 February 2017

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

Review the need for specific chest drain induction with the Welsh Deanery.

Verbatim wording from the response

“This group will also consider the requirement for specific induction in relation to chest drain insertion, on the basis, that registrars and specialist registrars across specific specialties are employed on the basis, that they are already competent in a number of core and essential skills, which would include chest drain insertion. The UHB is currently liaising with the Welsh Deanery on this issue.”

Source location

2017-0013-Response-by-University-Health-Board
Page 2 · response
Published 19 February 2017

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.4

  1. 1

    Provide respiratory on-call support for clinicians requiring in-hours assistance and contact the on-call medical team for specified out-of-hours procedures.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  2. 2

    Report the working group’s progress to the Quality, Safety and Experience Committee.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
  3. 3

    Share the response with Clinical Boards and request assurance that appropriate induction processes are in place.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
  4. 4

    Operate a multidisciplinary working group to improve intercostal chest drain safety and compliance with British Thoracic Society guidance.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.

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

  1. 1

    Existing corporate and local induction procedures are considered sufficient to support induction of new medical and nursing staff.

    Stated by Cwm Taf Morgannwg University Local Health BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 respiratory on-call support for clinicians requiring in-hours assistance and contact the on-call medical team for specified out-of-hours procedures.

Verbatim wording from the response

“In addition to this, additional support from the Respiratory on-call team has been made available in the in-hours scenario for doctors who require support and are not appropriately accredited. On the rare occasion that an out of hours pleural aspiration or drain insertion is required (e.g. for suspected pleural infection, significant symptomatic or haemodynamic compromise) it has been agreed that the on call medical team should be contacted.”

Source location

2017-0013-Response-by-University-Health-Board
Page 2 · response
Published 19 February 2017

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

Report the working group’s progress to the Quality, Safety and Experience Committee.

Verbatim wording from the response

“• The group will report to the Quality, Safety and Experience Committee which receives information regarding Regulation 28 – Prevention of Future Deaths Reports in order to ensure the necessary progress is being made.”

Source location

2017-0013-Response-by-University-Health-Board
Page 3 · response
Published 19 February 2017

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

Share the response with Clinical Boards and request assurance that appropriate induction processes are in place.

Verbatim wording from the response

“My response to the concerns that you have raised will be shared with all Clinical Boards with a request that they seek assurance from their Directorates that appropriate induction processes are in place across the Health Board.”

Source location

2017-0013-Response-by-University-Health-Board
Page 3 · response
Published 19 February 2017

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

Operate a multidisciplinary working group to improve intercostal chest drain safety and compliance with British Thoracic Society guidance.

Verbatim wording from the response

“A working group has been established with a specific remit to improve the safety of patients undergoing intercostal chest drain insertion and to ensure the Health Board’s compliance with the related British Thoracic Society guidance (Reference: Havelock T, Teoh R, Laws D, Gleeson F. Pleural procedures and Thoracic Ultrasound: British Thoracic Society Pleural Disease Guideline 2010. Thorax; 65(suppl 2):ii61-ii76).”

Source location

2017-0013-Response-by-University-Health-Board
Page 2 · response
Published 19 February 2017

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 corporate and local induction procedures are considered sufficient to support induction of new medical and nursing staff.

Verbatim wording from the response

“In relation to general induction programmes for all new medical and nursing staff, the Workforce and Organisational Development Department has procedures in place to assist managers to ensure the appropriate induction of new staff members to an individual department and wider organisation.”

Source location

2017-0013-Response-by-University-Health-Board
Page 2 · response
Published 19 February 2017

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