PFD report

Emily Corfield · Prevention of Future Deaths report

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Issued 14 Jul 2023•North Wales (East and 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
5

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
7

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 raised5

  1. Unavailability of telephone communication for people requiring support
    Part of recurring concern: Unreliable communication access for people requiring support
  2. Failure to retain and monitor correspondence relating to service users and people seeking support
  3. Delays in providing support sessions and counselling
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

    Update the service specification to include electronic contact, risk, signposting, referral and service-exit recording requirements.

    Stated by Adferiad Recovery LtdStated in progressThe respondent said that this action was in progress when they made their response on 21 July 2023.
  2. Action

    Seek updated automated communication routes for the service, such as text appointment reminders.

    Stated by Adferiad Recovery LtdStated in progressThe respondent said that this action was in progress when they made their response on 21 July 2023.
  3. Action

    Implement and roll out the updated service specification to all staff by the end of September 2023.

    Stated by Adferiad Recovery LtdStated plannedThe respondent said that this action was planned when they made their response on 21 July 2023.

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

  1. Position

    Funding decisions concerning the service are the responsibility of the Health Board and Welsh Government.

    Stated by Adferiad Recovery LtdRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 telephone communication for people requiring support

Wider context from the report

“Firstly, evidence was heard during the Inquest that Emily had self-referred on a number of occasions for support to Adferiad (formerly Cais). It could not be established whether or not Emily had received written correspondence from them relating to appointments and/or offer of support as correspondence was not retained by Adferiad. Emily was on occasion closed to the service for not having responded to correspondence. The system at the time was that communicating with service users was in writing only. It appears that more recently, policies and procedures have been established to ensure that correspondence relating to those who require support and / or contact the service is now retained though these were not provided at the Inquest. Without clear and thorough policies and procedures relating to all contact with service users or those who seek support, the organisation will not be able to adequately monitor the support processes. Secondly, it was indicated that due to resource restrictions that communication cannot be by telephone with those requiring support / service users (in writing only) and the waiting time for support sessions / counselling is long. This will have a detrimental impact and deaths may occur if the treatment and support is not afforded in a timely manner. ”

Is this part of a recurring concern?

Yes — Unreliable communication access for people requiring support.

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 retain and monitor correspondence relating to service users and people seeking support

Wider context from the report

“Firstly, evidence was heard during the Inquest that Emily had self-referred on a number of occasions for support to Adferiad (formerly Cais). It could not be established whether or not Emily had received written correspondence from them relating to appointments and/or offer of support as correspondence was not retained by Adferiad. Emily was on occasion closed to the service for not having responded to correspondence. The system at the time was that communicating with service users was in writing only. It appears that more recently, policies and procedures have been established to ensure that correspondence relating to those who require support and / or contact the service is now retained though these were not provided at the Inquest. Without clear and thorough policies and procedures relating to all contact with service users or those who seek support, the organisation will not be able to adequately monitor the support processes. Secondly, it was indicated that due to resource restrictions that communication cannot be by telephone with those requiring support / service users (in writing only) and the waiting time for support sessions / counselling is long. This will have a detrimental impact and deaths may occur if the treatment and support is not afforded in a timely manner. ”

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

Delays in providing support sessions and counselling

Wider context from the report

“Firstly, evidence was heard during the Inquest that Emily had self-referred on a number of occasions for support to Adferiad (formerly Cais). It could not be established whether or not Emily had received written correspondence from them relating to appointments and/or offer of support as correspondence was not retained by Adferiad. Emily was on occasion closed to the service for not having responded to correspondence. The system at the time was that communicating with service users was in writing only. It appears that more recently, policies and procedures have been established to ensure that correspondence relating to those who require support and / or contact the service is now retained though these were not provided at the Inquest. Without clear and thorough policies and procedures relating to all contact with service users or those who seek support, the organisation will not be able to adequately monitor the support processes. Secondly, it was indicated that due to resource restrictions that communication cannot be by telephone with those requiring support / service users (in writing only) and the waiting time for support sessions / counselling is long. This will have a detrimental impact and deaths may occur if the treatment and support is not afforded in a timely manner. ”

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 provide alcohol liaison team support to inpatients and outpatients

Wider context from the report

“Emily had two inpatient admissions in the year of her death. Whilst the clinician had noted that she was for referral to the alcohol liaison team there was no evidence that Emily had in fact received any input from them either as an inpatient or as an outpatient nor any referrals to external organisations. It is concerning that there appears to have been no evidence that Emily was receiving support from the Alcohol Liaison Team whilst an inpatient on either occasion despite her long history of alcohol misuse and need for support. In the event that clinicians advise referral to alcohol liaison team, either as an inpatient or as an outpatient there ought to be systems and processes to ensure that this occurs. ”

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

Lack of systems and processes to ensure completion of alcohol liaison team referrals

Wider context from the report

“Emily had two inpatient admissions in the year of her death. Whilst the clinician had noted that she was for referral to the alcohol liaison team there was no evidence that Emily had in fact received any input from them either as an inpatient or as an outpatient nor any referrals to external organisations. It is concerning that there appears to have been no evidence that Emily was receiving support from the Alcohol Liaison Team whilst an inpatient on either occasion despite her long history of alcohol misuse and need for support. In the event that clinicians advise referral to alcohol liaison team, either as an inpatient or as an outpatient there ought to be systems and processes to ensure that this occurs. ”

Is this part of a recurring concern?

Yes — Failure to reliably refer patients to required specialist services; Unreliable coordination of referrals between healthcare teams; Unreliable integration of substance misuse services into patient 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

Update the service specification to include electronic contact, risk, signposting, referral and service-exit recording requirements.

Verbatim wording from the response

“In addition, concerning the monitoring of support, the new system, amongst other things, allows a “red flag” to be displayed for those patients who are considered to be a risk to themselves or others, has the option to add viewable risk management plans, records signposting that has taken place and has an internal referral system to refer patients directly to another service. Further, if a patient leaves the service, staff need to input the exit date, reason and other relevant information. Adferiad is updating its service specification to incorporate these requirements. The updated service specification will be implemented and rolled out to all staff by the end of September 2023.”

Source location

Response from Adferiad
Page 3 · response
Published 21 July 2023

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

Seek updated automated communication routes for the service, such as text appointment reminders.

Verbatim wording from the response

“Adferiad is, however, currently in the process of seeking a range of updated automated communication routes for the service (such as a text reminder service) and as we proceed with this initiative, we will, of course, continue to have regard to your concern. However, we are unable to guarantee that patients will act on appointments; and/or respond to our telephone calls, messages, visits, or other forms of communication.”

Source location

Response from Adferiad
Page 4 · response
Published 21 July 2023

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 roll out the updated service specification to all staff by the end of September 2023.

Verbatim wording from the response

“In addition, concerning the monitoring of support, the new system, amongst other things, allows a “red flag” to be displayed for those patients who are considered to be a risk to themselves or others, has the option to add viewable risk management plans, records signposting that has taken place and has an internal referral system to refer patients directly to another service. Further, if a patient leaves the service, staff need to input the exit date, reason and other relevant information. Adferiad is updating its service specification to incorporate these requirements. The updated service specification will be implemented and rolled out to all staff by the end of September 2023.”

Source location

Response from Adferiad
Page 3 · response
Published 21 July 2023

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 electronic recording of patient correspondence and calls, with staff trained to use the system.

Verbatim wording from the response

“At the inquest, Adferiad's ████████ gave evidence that a new, better system and procedure is now in place, whereby all correspondence is kept electronically on a database, and all calls are logged. The system is the Adferiad Information Management System and is accompanied by the Aims User Guide. All staff have received training on this new system and are aware of Adferiad's requirements. Accordingly, Adferiad's current practice is that: every letter sent to a patient is scanned and stored electronically on our IT system; and every call made to/received from a patient is recorded electronically.”

Source location

Response from Adferiad
Page 3 · response
Published 21 July 2023

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 liaison psychiatry delivery framework with stakeholders and progress revisions through consultation and ratification.

Verbatim wording from the response

“Although in date and operational, the MHLD Liaison Psychiatry Services in Acute Hospitals Delivery Framework will be reviewed by a working group of stakeholders, to include liaison team managers and key clinicians, led by a senior manager to ensure the referral process is clear and unambiguous.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 21 July 2023

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

Issue communication clarifying the referral process to liaison services and share it with clinical teams across the Health Board.

Verbatim wording from the response

“During consideration of your concerns, it was identified that the liaison service did not receive a referral from the treating team located in our Integrated Health Community (East). In response to this, a communication has been produced that outlines the referral process to liaison services that will be shared with clinical teams across the Health Board to ensure there is clarity and consistency across all areas. This communication has now been issued.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 21 July 2023

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

Funding decisions concerning the service are the responsibility of the Health Board and Welsh Government.

Verbatim wording from the response

“We acknowledge your concerns regarding our service’s waiting times but, funding decisions concerning the service are matters for the Health Board and/or Welsh Government.”

Source location

Response from Adferiad
Page 4 · response
Published 21 July 2023

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

Routine telephone calls were not undertaken because administrators lacked therapeutic skills and using therapists would increase service pressure and waiting times.

Verbatim wording from the response

“At the material time, our administrators were responsible for sending out the abovementioned letters to patients. They did not, however, make routine calls to patients as this would require a different skill set given that in our experience, when patients are spoken to on the telephone, they often seek therapeutic engagement. Our administrators are not therapists and using our therapists to make routine telephone calls would add pressure to the service in the context of current resources and consequently, add to service waiting times.”

Source location

Response from Adferiad
Page 4 · response
Published 21 July 2023

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.1

  1. 1

    Monitor progress of the framework review and ratification, escalating potential delays to the Divisional Senior Leadership Team.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 21 July 2023.

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

  1. 1

    Patients’ attendance and responses to appointments or communications cannot be guaranteed.

    Stated by Adferiad Recovery LtdUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Monitor progress of the framework review and ratification, escalating potential delays to the Divisional Senior Leadership Team.

Verbatim wording from the response

“Once the review is complete, the revised framework will be subject to a period of consultation and will then proceed through the ratification process. Progress on the review and ratification process will be monitored by the Divisional Policy and Procedure Development Subgroup and any potential delays will be escalated to the Divisional Senior Leadership Team.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 21 July 2023

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

Patients’ attendance and responses to appointments or communications cannot be guaranteed.

Verbatim wording from the response

“Adferiad is, however, currently in the process of seeking a range of updated automated communication routes for the service (such as a text reminder service) and as we proceed with this initiative, we will, of course, continue to have regard to your concern. However, we are unable to guarantee that patients will act on appointments; and/or respond to our telephone calls, messages, visits, or other forms of communication.”

Source location

Response from Adferiad
Page 4 · response
Published 21 July 2023

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