PFD report

Arthur Price Hughes · Prevention of Future Deaths report

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Issued 9 Mar 2020•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
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
12

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 raised2

  1. Reluctance to supplement locum references with telephone calls to referees
    Part of recurring concern: Failure to ensure safe appointment and oversight of locum doctors
  2. Lack of a recognised protocol for observing and assessing locum staff in practice
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.10

  1. Action

    Implement the locum staff local-induction requirement, including role expectations, limitations and supervised-practice arrangements.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 18 March 2020.
  2. Action

    Report compliance and remedial action for locum induction and assessment requirements through the monthly Medical Agency Locum Report.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 18 March 2020.
  3. Action

    Require Clinical Directors to provide interim verbal or email confirmation that supervised locum individuals are competent.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 18 March 2020.

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

  1. Position

    COVID-19 major incident response delayed approval and implementation of the revised reference-validation process until June 2020.

    Stated by Betsi Cadwaladr University LHBUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Reluctance to supplement locum references with telephone calls to referees

Wider context from the report

“2. Whilst it would appear that the process by which the taking up of references has improved significantly for the appointment of locums since 2014, evidence provided at the inquest appears to indicate that there is a marked reluctance at a managerial level for references to be supplemented by telephone calls to the referees. ”

Is this part of a recurring concern?

Yes — Failure to ensure safe appointment and oversight of locum doctors.

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 a recognised protocol for observing and assessing locum staff in practice

Wider context from the report

“1. The appointment of locum staff is a necessary requirement within the Health Board to provide continuity of service and the recruitment process in relation to locums ensures that they have the appropriate qualifications to undertake the roles for which they are appointed. However, there does not appear to a recognised protocol or policy by which their work is initially observed, assessed or evaluated in practice, with the result that locum staff could be required to undertake tasks or roles which are at the limit or beyond their capabilities thus creating a risk to patients which may include a risk to life. A more rigid or defined approach to observing and assessing (and where necessary mentoring) new recruits to ensure that their skills and working practices match their apparent qualifications could be beneficial in ensuring a quality of service. ”

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

Implement the locum staff local-induction requirement, including role expectations, limitations and supervised-practice arrangements.

Verbatim wording from the response

“A Standard Operating Procedure (SOP) had been revised and implemented previously as reported during the inquest. The SOP required clinical departments to undertake the following for all locum appointments (both fixed term contracts and agency locums).”

Source location

2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Page 2 · response
Published 18 March 2020

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 compliance and remedial action for locum induction and assessment requirements through the monthly Medical Agency Locum Report.

Verbatim wording from the response

“vi. Compliance and action taken to remedy non-compliance with both requirements included in the monthly Medical Agency Locum Report to the Executive Director of Workforce and Organisational Development and Board Committee – original due date 28 April 2020.”

Source location

2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Page 3 · response
Published 18 March 2020

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

Require Clinical Directors to provide interim verbal or email confirmation that supervised locum individuals are competent.

Verbatim wording from the response

“In the intervening period, Clinical Directors are required to provide verbal/email confirmation that individuals working under their supervision (accountability) are competent to do so.”

Source location

2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Page 3 · response
Published 18 March 2020

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

Audit compliance with locum induction and practice-assessment requirements across post-SOP appointments.

Verbatim wording from the response

“An audit of compliance had been undertaken in relation to the two requirements above against appointments (18 placements) made following revision of the SOP in 2019.”

Source location

2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Page 2 · response
Published 18 March 2020

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

Obtain completed practice-assessment forms for the remaining locum individuals.

Verbatim wording from the response

“ii. In addition to the immediate assurance, Clinical Directors were asked to provide completed assessment forms for each of the individuals – original due date 31 March 2020;”

Source location

2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Page 3 · response
Published 18 March 2020

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 the locum staff assessment-of-practice and performance requirement covering clinical skills, knowledge, attitudes, relationships and integrity.

Verbatim wording from the response

“A Standard Operating Procedure (SOP) had been revised and implemented previously as reported during the inquest. The SOP required clinical departments to undertake the following for all locum appointments (both fixed term contracts and agency locums).”

Source location

2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Page 2 · response
Published 18 March 2020

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

Establish central collection and follow-up of locum induction and practice-assessment forms through the amended SOP.

Verbatim wording from the response

“iii. The Standard Operating Procedure (SOP) has been amended to ensure central collection and follow up of both Local Induction and Assessment of Practice and Performance pro forma – due to be implemented 01 April 2020;”

Source location

2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Page 3 · response
Published 18 March 2020

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

Obtain capability and performance assurance for the 12 locum individuals remaining in the Health Board.

Verbatim wording from the response

“Action taken to date:”

Source location

2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Page 2 · response
Published 18 March 2020

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

Require locum practice-assessment forms by the tenth day of placement, signed by the Clinical Director and submitted to the Medical Bank Service.

Verbatim wording from the response

“v. Assessment of Practice and Performance pro forma required by the tenth day of placement, signed by the Clinical Director and submitted to the Medical Bank Service – original due date 10 April 2020;”

Source location

2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Page 3 · response
Published 18 March 2020

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 revised reference-validation process covering referee screening, pre-interview checks, recorded clarifications and additional competence or performance validation.

Verbatim wording from the response

“Action taken to date:”

Source location

2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Page 3 · response
Published 18 March 2020

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

COVID-19 major incident response delayed approval and implementation of the revised reference-validation process until June 2020.

Verbatim wording from the response

“The additional elements of this process were due to be reviewed, approved and implemented from 01 April. However, this has been delayed due to the activation of the Major Incident Response to COVID-19.”

Source location

2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Page 4 · response
Published 18 March 2020

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

COVID-19 major incident response delayed implementation of central locum induction and assessment documentation requirements until revised dates.

Verbatim wording from the response

“iii. The Standard Operating Procedure (SOP) has been amended to ensure central collection and follow up of both Local Induction and Assessment of Practice and Performance pro forma – due to be implemented 01 April 2020;”

Source location

2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Page 3 · response
Published 18 March 2020

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

    Track completion of the response actions through the Quality Assurance Department and report progress to the Board.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 18 March 2020.
  2. 2

    Require locum induction forms before processing Medical Bank Service payment.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 18 March 2020.

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

Track completion of the response actions through the Quality Assurance Department and report progress to the Board.

Verbatim wording from the response

“We have used the findings of the inquest to improve our services and I hope that our response provides confidence to you and Mr Hughes’s family that we have acted upon your findings at. The actions above will be tracked by our Quality Assurance Department to ensure that they are completed, and this will be reported to our Board.”

Source location

2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Page 4 · response
Published 18 March 2020

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

Require locum induction forms before processing Medical Bank Service payment.

Verbatim wording from the response

“iv. Locum Induction pro forma now to be submitted to the Medical Bank Service with payment not processed until received – original due date 01 April 2020;”

Source location

2020-0057-Response-from-Betsi-Cadwaladr-University-Health-Board-Redacted
Page 3 · response
Published 18 March 2020

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