PFD report

Danielle Rhian Robinson · Prevention of Future Deaths report

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Issued 31 May 2016•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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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

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Concerns raised2

  1. Failure to follow the Therapeutic Engagement and Observation Policy and escalate observation levels when required
    Part of recurring concern: Unreliable patient observation arrangements
  2. Lack of automatic escalation of observation levels after serious events placing patients at risk of immediate or imminent harm
    Part of recurring concern: Unreliable patient observation arrangements
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.3

  1. Action

    Hold a learning event and formally relaunch the updated policy at the event.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 31 May 2016.
  2. Action

    Integrate compliance auditing into the divisional audit cycle and report outcomes and improvement suggestions through divisional governance to QSE.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 31 May 2016.
  3. Action

    Update the Therapeutic Engagement and Observation Policy to require automatic escalation of observations after serious self-harm pending full MDT review.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 31 May 2016.

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 follow the Therapeutic Engagement and Observation Policy and escalate observation levels when required

Wider context from the report

“(1) That the Therapeutic Engagement and Observation Policy presently adopted by BCUHB is not being rigorously followed by staff with the result that opportunities to escalate the level of observations when required are being missed. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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 automatic escalation of observation levels after serious events placing patients at risk of immediate or imminent harm

Wider context from the report

“(2) That the current Therapeutic Engagement and Observation Policy there should be reviewed with consideration being given to implementing a system for situations where there is a serious event which places a patient at risk of immediate or imminent harm, that there should be an automatic escalation of observation levels to level 3 or 4 (within eyesight or arm’s length respectively) for a designated period and/or one to one engagement with the patient so as to provide an instant “safety net”. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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

Hold a learning event and formally relaunch the updated policy at the event.

Verbatim wording from the response

“The division has its first learning event planned for September 2016 and the policy will be formally re-launched at this event.”

Source location

2016-0205-Response-by-University-Health-Board
Page 1 · response
Published 31 May 2016

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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

Integrate compliance auditing into the divisional audit cycle and report outcomes and improvement suggestions through divisional governance to QSE.

Verbatim wording from the response

“Roles and responsibilities of all staff are clearly detailed within the policy. In relation to the ongoing monitoring of compliance, an audit process is included which will now form part of the divisional audit cycle with outcomes and suggestions for improvements formally reported through our divisional governance structure to QSE.”

Source location

2016-0205-Response-by-University-Health-Board
Page 1 · response
Published 31 May 2016

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

Update the Therapeutic Engagement and Observation Policy to require automatic escalation of observations after serious self-harm pending full MDT review.

Verbatim wording from the response

“In response to the Regulation 28, issued on May 28th 2016 as a result of the inquest into the death of Miss Danielle Rhian Robinson. I can confirm that the BCUHB Therapeutic Engagement and Observation Policy has been reviewed and updated to include the automatic escalation of observations following serious attempt of self-harm until a full multi-disciplinary team (MDT) review can take place, a copy is enclosed for your information.”

Source location

2016-0205-Response-by-University-Health-Board
Page 1 · response
Published 31 May 2016

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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