PFD report

Gareth Idris Johnson · Prevention of Future Deaths report

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Issued 12 Sep 2025•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
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
15

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. Failure of safeguards for moving patients requiring critical care during times of pressure
    Part of recurring concern: Unreliable healthcare patient transfer processes
  2. Lack of adequate hospital building maintenance
  3. Insufficient Critical Care capacity for patient volumes
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.13

  1. Action

    Work with Cardiff and Vale University Health Board to prioritise estate investment using the capital prioritisation exercise.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 19 September 2025.
  2. Action

    Provide £0.750 million funding for a detailed condition survey of the University Hospital of Wales buildings.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
  3. Action

    Write to Cardiff and Vale University Health Board to confirm clinical governance and safe clinical cover for future critical-care-unit maintenance.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 19 September 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The existing estate was not the primary cause of the death, although estate improvements and resulting patient relocation contributed to it.

    Stated by Welsh GovernmentDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 of safeguards for moving patients requiring critical care during times of pressure

Wider context from the report

“Due to the age of the hospital building, maintenance is a constant battle. There are also capacity issues in Critical Care due to patient volumes. Building infrastructure had been a constant feature on the corporate risk register and was now scored at its highest level. Whilst measures have been put in place to safeguard against moving patients who require critical care from the Critical Care Unit, there remained fears that these systems would fail during times of pressure. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes.

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 adequate hospital building maintenance

Wider context from the report

“Due to the age of the hospital building, maintenance is a constant battle. There are also capacity issues in Critical Care due to patient volumes. Building infrastructure had been a constant feature on the corporate risk register and was now scored at its highest level. Whilst measures have been put in place to safeguard against moving patients who require critical care from the Critical Care Unit, there remained fears that these systems would fail during times of pressure. ”

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

Insufficient Critical Care capacity for patient volumes

Wider context from the report

“Due to the age of the hospital building, maintenance is a constant battle. There are also capacity issues in Critical Care due to patient volumes. Building infrastructure had been a constant feature on the corporate risk register and was now scored at its highest level. Whilst measures have been put in place to safeguard against moving patients who require critical care from the Critical Care Unit, there remained fears that these systems would fail during times of pressure. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 Cardiff and Vale University Health Board to prioritise estate investment using the capital prioritisation exercise.

Verbatim wording from the response

“It is recognised there are many areas of the UHW estate that require significant investment. My officials are working closely with colleagues from Cardiff and Vale UHB about the priority areas for investment informed by a recent capital prioritisation exercise.”

Source location

Response from Department for Health and Social Care
Page 1 · response
Published 19 September 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

Provide £0.750 million funding for a detailed condition survey of the University Hospital of Wales buildings.

Verbatim wording from the response

“Specific funding (£0.750m) has been made available to Cardiff and Vale UHB to complete a detailed condition survey of the main buildings on the UHW site to ensure future investment is appropriately targeted. This work will inform short-term investments and whether the buildings are suitable for significant refurbishment in the future.”

Source location

Response from Department for Health and Social Care
Page 1 · response
Published 19 September 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

Write to Cardiff and Vale University Health Board to confirm clinical governance and safe clinical cover for future critical-care-unit maintenance.

Verbatim wording from the response

“2) To write to Cardiff and Vale UHB to confirm what clinical governance is in place to approve changes in the location of critical care and to ensure the appropriate clinical cover is in place to provide safe care during future planned maintenance of the critical care unit.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 19 September 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

Develop a business case to refurbish the intensive therapy unit at the University Hospital of Wales.

Verbatim wording from the response

“1) Officials met Cardiff and Vale UHB on 15 October with NHS Shared Services Partnership-Specialist Estate Services (NWSSP-SES) to discuss the infrastructure issues at the ITU, critical care and theatres departments at the University Hospital of Wales. A business case is being developed to refurbish the ITU. Due to a lack of available space to relocate patients and the nature of the work involved, this work will likely take a number of years to complete.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 19 September 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

Write to selected health boards, including Cardiff and Vale University Health Board, requesting responses to the critical care network estate census.

Verbatim wording from the response

“3) To write to selected health boards, including Cardiff and Vale UHB, to request them to respond to the NHS Performance and Improvement critical care network census. This includes questions about the estate, so Welsh Government can develop a national picture with expert context about the estate challenges for critical care across Wales. The census report will be considered by the Welsh Government to inform capital investment plans and health board planning.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 19 September 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

Consider the critical care census report to inform Welsh Government capital investment plans and health board planning.

Verbatim wording from the response

“3) To write to selected health boards, including Cardiff and Vale UHB, to request them to respond to the NHS Performance and Improvement critical care network census. This includes questions about the estate, so Welsh Government can develop a national picture with expert context about the estate challenges for critical care across Wales. The census report will be considered by the Welsh Government to inform capital investment plans and health board planning.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 19 September 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

Deliver scheduled infrastructure upgrades, including UPS installations and electrical-supply improvements, through the Estates programme.

Verbatim wording from the response

“• Infrastructure upgrades, including UPS installations and electrical supply improvements, scheduled as per the Estates programme.”

Source location

Response from Cardiff & Vale University Health Board
Page 3 · response
Published 19 September 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

Regularly review and simulate critical-care escalation and major-incident plans.

Verbatim wording from the response

“• Regular review and simulation of escalation and major incident plans.”

Source location

Response from Cardiff & Vale University Health Board
Page 3 · response
Published 19 September 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

Implemented a Critical Care Escalation Plan governing staffed bed capacity, patient prioritisation, delayed-transfer escalation, clinically led transfers and diversion arrangements.

Verbatim wording from the response

“The Health Board recognises the challenges posed by patient volumes and infrastructure. To address these, we have implemented the Critical Care Escalation Plan (October 2024), which details:”

Source location

Response from Cardiff & Vale University Health Board
Page 2 · response
Published 19 September 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

Developed a Major Incident Plan framework defining emergency command, reporting, escalation, evacuation, triage, patient transfer, communications and critical-care staff responsibilities.

Verbatim wording from the response

“The Major Incident Plan v1.04 (DRAFT) provides a comprehensive framework for emergency preparedness, in line with the Civil Contingencies Act 2004. Key elements include.”

Source location

Response from Cardiff & Vale University Health Board
Page 2 · response
Published 19 September 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

Conduct annual stress testing and live major-incident exercises at least every three years, maintaining training records.

Verbatim wording from the response

“• Annual stress testing and live exercises at least every three years, with training records maintained by the Critical Care Directorate.”

Source location

Response from Cardiff & Vale University Health Board
Page 3 · response
Published 19 September 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

Developed an Electrical Failure Emergency Action Card covering power-failure response, vulnerable-patient evacuation, emergency decanting and business-continuity arrangements.

Verbatim wording from the response

“In response, we have developed the Electrical Failure Emergency Action Card (E1, draft October 2025), which outlines: Immediate actions to confirm and respond to power failures, including switching to unaffected supplies and declaring an ICU emergency if required.”

Source location

Response from Cardiff & Vale University Health Board
Page 1 · response
Published 19 September 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

Provide ongoing staff training in major-incident response and escalation procedures.

Verbatim wording from the response

“• Ongoing staff training in major incident response and escalation procedures.”

Source location

Response from Cardiff & Vale University Health Board
Page 3 · response
Published 19 September 2025

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

The existing estate was not the primary cause of the death, although estate improvements and resulting patient relocation contributed to it.

Verbatim wording from the response

“There are plans being explored for further capital investment at the University Hospital of Wales. While the condition of the existing estate was not the primary cause of Mr Johnson’s death, the need to make estate improvements led to the relocation of patients, which was a contributory factor. I hope the actions I have set out above will result in robust measures being put in place to manage patient moves in the future.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 19 September 2025

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

Day-to-day operation and management of the hospital site and services remain the statutory responsibility of Cardiff and Vale University Health Board.

Verbatim wording from the response

“There are longer term plans being reviewed and considered by the health board for the redevelopment of the University Hospital of Wales site. This response focuses on the short and medium-term actions I will be seeking the health board to review at the site to address patient safety and ensure the continuity of healthcare services to the local population. The day-to-day operation and management of the site and the healthcare services provided remains the statutory responsibility of Cardiff and Vale University Health Board (UHB). There are also actions, which will be highlighted to other health boards in Wales.”

Source location

Response from Department for Health and Social Care
Page 1 · response
Published 19 September 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

    Discuss University Hospital of Wales infrastructure issues with Cardiff and Vale University Health Board and NHS Shared Services Partnership-Specialist Estate Services.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
  2. 2

    Operate governance processes for incident review and dissemination of learning.

    Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 19 September 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

Discuss University Hospital of Wales infrastructure issues with Cardiff and Vale University Health Board and NHS Shared Services Partnership-Specialist Estate Services.

Verbatim wording from the response

“1) Officials met Cardiff and Vale UHB on 15 October with NHS Shared Services Partnership-Specialist Estate Services (NWSSP-SES) to discuss the infrastructure issues at the ITU, critical care and theatres departments at the University Hospital of Wales. A business case is being developed to refurbish the ITU. Due to a lack of available space to relocate patients and the nature of the work involved, this work will likely take a number of years to complete.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 19 September 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

Operate governance processes for incident review and dissemination of learning.

Verbatim wording from the response

“• Governance processes for incident review and dissemination of learning.”

Source location

Response from Cardiff & Vale University Health Board
Page 3 · response
Published 19 September 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