PFD report

Barry Wilson · Prevention of Future Deaths report

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Issued 29 Apr 2015•North West Wales

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 detect a defective surgical anastomosis before hospital discharge
    Part of recurring concern: Failure to reliably prevent and detect defective surgical anastomosesPart of recurring concern: Unreliable hospital discharge processes
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.2

  1. Action

    Require all other Glan Clwyd surgical wards to develop and implement appropriate discharge checklists.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 29 April 2015.
  2. Action

    Implement a pre-discharge checklist for all patients leaving the Colo-Rectal Ward.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 29 April 2015.

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 detect a defective surgical anastomosis before hospital discharge

Wider context from the report

“(1) It would appear from the evidence that the deceased had undergone a right hemicolectomy and that the anastomosis had been made with staples. The anastomosis was defective and this should have been apparent either on or prior to the deceased's discharge from hospital. If the defect had been detected at that stage Mr. Wilson might not have died. ”

Is this part of a recurring concern?

Yes — Failure to reliably prevent and detect defective surgical anastomoses; Unreliable hospital discharge processes.

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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

Require all other Glan Clwyd surgical wards to develop and implement appropriate discharge checklists.

Verbatim wording from the response

“This being the case we will by (unless otherwise specified) the 6th July ensure the following are in place”

Source location

2015-0167-Response-by-University-Health-Board
Page 2 · response
Published 29 April 2015

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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 a pre-discharge checklist for all patients leaving the Colo-Rectal Ward.

Verbatim wording from the response

“This being the case we will by (unless otherwise specified) the 6th July ensure the following are in place”

Source location

2015-0167-Response-by-University-Health-Board
Page 2 · response
Published 29 April 2015

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

    Provide patients with a leaflet explaining warning symptoms, contact numbers, and required return arrangements for concerns after discharge.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 29 April 2015.
  2. 2

    Align emergency bowel-resection follow-up with planned surgery by requiring daily ward telephone reporting and Colo-Rectal Nurse Specialist contact within 48 hours.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 29 April 2015.

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 patients with a leaflet explaining warning symptoms, contact numbers, and required return arrangements for concerns after discharge.

Verbatim wording from the response

“This being the case we will by (unless otherwise specified) the 6th July ensure the following are in place”

Source location

2015-0167-Response-by-University-Health-Board
Page 2 · response
Published 29 April 2015

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

Align emergency bowel-resection follow-up with planned surgery by requiring daily ward telephone reporting and Colo-Rectal Nurse Specialist contact within 48 hours.

Verbatim wording from the response

“b. As part of this process follow up arrangements, to include direct contact within 48 hours, by a Colo-Rectal Nurse specialist bringing the service these emergency patients receive in-line with that already in place for those under-going colonic procedures on an elective / scheduled basis.”

Source location

2015-0167-Response-by-University-Health-Board
Page 2 · response
Published 29 April 2015

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