PFD report

Howell Glyndwr Fisher · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 21 Apr 2015•Powys, Bridgend and Glamorgan Valleys

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
3

Named on the report

Responses found
0

Of 3 recipients

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Lack of transfer handover information about high falls risk
    Part of recurring concern: Unreliable clinical handover processesPart of recurring concern: Unreliable healthcare patient transfer processes
  2. Failure to carry out falls risk assessments on readmission and after successive falls
    Part of recurring concern: Inadequate control of falls risks
  3. Insufficient staffing for required one-to-one nursing observation of patients at high risk of falls
    Part of recurring concern: Insufficient qualified healthcare staffing capacityPart of recurring concern: Insufficient staffing capacity for required one-to-one patient supportPart of recurring concern: Unsafe provision of one-to-one care
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 transfer handover information about high falls risk

Wider context from the report

“(2) There was no “handover material” at the point of transfer between the two hospitals detailing that he was at high risk of falls and further more on readmission to the Princess of Wales Hospital on the 20th November no falls risk assessment was carried out – indeed, after each successive fall in the Princess of Wales Hospital no formal assessment appears to have been undertaken. Throughout he remained at high risk of falls. ”

Is this part of a recurring concern?

Yes — Unreliable clinical handover processes; 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

Failure to carry out falls risk assessments on readmission and after successive falls

Wider context from the report

“(2) There was no “handover material” at the point of transfer between the two hospitals detailing that he was at high risk of falls and further more on readmission to the Princess of Wales Hospital on the 20th November no falls risk assessment was carried out – indeed, after each successive fall in the Princess of Wales Hospital no formal assessment appears to have been undertaken. Throughout he remained at high risk of falls. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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 staffing for required one-to-one nursing observation of patients at high risk of falls

Wider context from the report

“(1) Within the space of a month the deceased had at least 5 falls whilst being deemed as high risk of falls. He was identified as requiring one to one nursing but there were many occasions when insufficient staff numbers meant that this could not be delivered. ”

Is this part of a recurring concern?

Yes — Insufficient qualified healthcare staffing capacity; Insufficient staffing capacity for required one-to-one patient support; Unsafe provision of one-to-one care.

Open source report
Back to top

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