Andrew John Shambrook · Prevention of Future Deaths report

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Issued 31 May 2023•North Wales (East and Central)

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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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

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. Lack of a documented and robust policy for future treatment and care pathways following referral to the Home Treatment Team
    Part of recurring concern: Unreliable community Home Treatment Team care pathways
  2. Lack of a documented and robust policy for decision-making and meeting criteria for patients referred to the Home Treatment Team
    Part of recurring concern: Unreliable community Home Treatment Team care pathways

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Betsi Cadwaladr University LHB

    Provide an interim policy addendum addressing the concerns identified at the inquest.

  2. Betsi Cadwaladr University LHB

    Progress review, consultation and ratification of the Home Treatment Team Operational Policy, incorporating the coroner’s concerns and monitored through divisional and corporate governance.

  3. Betsi Cadwaladr University LHB

    Share the interim policy addendum across the Mental Health and Learning Disability Division to promote consistency across services.

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 documented and robust policy for future treatment and care pathways following referral to the Home Treatment Team

Wider context from the report

“The health board (by their own admission through counsel) acknowledge that there is no documented or robust policy in relation to decision making/meeting criteria and thereafter future treatment and care pathways when a patient is referred to the Home Treatment Team ”

Is this part of a recurring concern?

Yes — Unreliable community Home Treatment Team care pathways.

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 documented and robust policy for decision-making and meeting criteria for patients referred to the Home Treatment Team

Wider context from the report

“The health board (by their own admission through counsel) acknowledge that there is no documented or robust policy in relation to decision making/meeting criteria and thereafter future treatment and care pathways when a patient is referred to the Home Treatment Team ”

Is this part of a recurring concern?

Yes — Unreliable community Home Treatment Team care pathways.

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

Provide an interim policy addendum addressing the concerns identified at the inquest.

Verbatim wording from the response

“As an interim measure, MHLD have provided an addendum to the policy to ensure the concerns noted at the inquest are addressed. The addendum to the Policy will be shared across MHLD to ensure that there is consistency across all areas and I have enclosed a copy of this for your reference.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 2 June 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

Progress review, consultation and ratification of the Home Treatment Team Operational Policy, incorporating the coroner’s concerns and monitored through divisional and corporate governance.

Verbatim wording from the response

“Firstly, I can confirm that there is an approved Home Treatment Team Operational Policy (MHLD 0035) that has been in use since April 2018. However, this operational policy has exceeded its review date and we are progressing this through the review and ratification process as a priority.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 2 June 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

Share the interim policy addendum across the Mental Health and Learning Disability Division to promote consistency across services.

Verbatim wording from the response

“As an interim measure, MHLD have provided an addendum to the policy to ensure the concerns noted at the inquest are addressed. The addendum to the Policy will be shared across MHLD to ensure that there is consistency across all areas and I have enclosed a copy of this for your reference.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 2 June 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