PFD report

Brian Wareham · Prevention of Future Deaths report

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Issued 14 Jan 2022•Gwent

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.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
9

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. Failure of communication and collaboration between primary and secondary care
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unreliable coordination and information sharing between primary and secondary care
  2. Failure to directly contact the responsible medical team to address significant concerns
    Part of recurring concern: Unreliable coordination and information sharing between primary and secondary care
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.8

  1. Action

    Provide GPs with intranet access to information on pathways, Secondary Care Services and advice lines.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
  2. Action

    Create a bypass-number directory enabling hospital teams to contact GP surgeries directly when immediately necessary.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
  3. Action

    Send GPs weekly updates from the Deputy Medical Director about key information and changes to Secondary Care Services.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.

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

  1. Position

    Existing clinical systems, letters, directories and switchboards provide GPs with sufficient access to hospital records, clinicians and support.

    Stated by Aneurin Bevan University LHBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 of communication and collaboration between primary and secondary care

Wider context from the report

“1. Communication and collaboration between primary and secondary care. Brian Wareham had been admitted to hospital in May 2020 with ongoing symptoms of weight loss, dysphagia and general weakness. He was discharged in June 2020 with a package of care and the treating clinicians felt that his condition had stabilised. There was no immediate cure for Brian’s problems and he was provided with advice about a softer, more manageable diet. In evidence his GP (Dr ████████of the Richmond clinic in Newport) stated that he thought Brian should have remained in hospital, that he was not fit to be at home. Dr ████████ stated that he did not understand the relationship between Brian’s gastroenterology problems and his newly diagnosed lung cancer, specifically whether he was for active treatment or whether the approach was to be palliative. Given the GPs considerable concerns which he voiced with frustration and disdain, I questioned why he made no effort to try to address these problems by directly contacting the medical team in Nevill Hall Hospital responsible for Mr Wareham and who had in fact written to the GP practice at the time of his discharge. When these questions were put to Dr ████████he stated that he thought this would be futile and it appeared that there was a significant breakdown in communication, trust and respect between primary and secondary care. The current situation appears to leave vulnerable patients without appropriate information and support due to a breakdown in the relationship between clinicians. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable coordination and information sharing between primary and secondary care.

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 directly contact the responsible medical team to address significant concerns

Wider context from the report

“1. Communication and collaboration between primary and secondary care. Brian Wareham had been admitted to hospital in May 2020 with ongoing symptoms of weight loss, dysphagia and general weakness. He was discharged in June 2020 with a package of care and the treating clinicians felt that his condition had stabilised. There was no immediate cure for Brian’s problems and he was provided with advice about a softer, more manageable diet. In evidence his GP (Dr ████████of the Richmond clinic in Newport) stated that he thought Brian should have remained in hospital, that he was not fit to be at home. Dr ████████ stated that he did not understand the relationship between Brian’s gastroenterology problems and his newly diagnosed lung cancer, specifically whether he was for active treatment or whether the approach was to be palliative. Given the GPs considerable concerns which he voiced with frustration and disdain, I questioned why he made no effort to try to address these problems by directly contacting the medical team in Nevill Hall Hospital responsible for Mr Wareham and who had in fact written to the GP practice at the time of his discharge. When these questions were put to Dr ████████he stated that he thought this would be futile and it appeared that there was a significant breakdown in communication, trust and respect between primary and secondary care. The current situation appears to leave vulnerable patients without appropriate information and support due to a breakdown in the relationship between clinicians. ”

Is this part of a recurring concern?

Yes — Unreliable coordination and information sharing between primary and secondary care.

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 GPs with intranet access to information on pathways, Secondary Care Services and advice lines.

Verbatim wording from the response

“We also send all GPs a weekly message from the Deputy Medical Director, highlighting key information and any changes to Secondary Care Services to ensure Primary Care remain up to date on how to access and communicate with Specialist Services. Information on pathways, Secondary Care Services and advice lines is also obtainable on the ABUHB intranet, which is accessible to GPs through the NHS computer network. As part of our urgent care and outpatient transformation work streams, we aim to keep these resources up to date as Services evolve.”

Source location

2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 3 · response
Published 20 January 2022

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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

Create a bypass-number directory enabling hospital teams to contact GP surgeries directly when immediately necessary.

Verbatim wording from the response

“Since 2020, major changes have taken place within ABUHB boundary due to Covid 19, but also due to the reorganisation of our Services and the opening of the Grange University Hospital. These changes have required us to develop methods and strategies to enhance communication at the interface between Primary and Secondary care. Some of the main changes we have made include:”

Source location

2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 3 · response
Published 20 January 2022

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

Send GPs weekly updates from the Deputy Medical Director about key information and changes to Secondary Care Services.

Verbatim wording from the response

“We also send all GPs a weekly message from the Deputy Medical Director, highlighting key information and any changes to Secondary Care Services to ensure Primary Care remain up to date on how to access and communicate with Specialist Services. Information on pathways, Secondary Care Services and advice lines is also obtainable on the ABUHB intranet, which is accessible to GPs through the NHS computer network. As part of our urgent care and outpatient transformation work streams, we aim to keep these resources up to date as Services evolve.”

Source location

2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 3 · response
Published 20 January 2022

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

Launch direct-access telephone advice lines for urgent and outpatient queries through Consultant Connect.

Verbatim wording from the response

“Since 2020, major changes have taken place within ABUHB boundary due to Covid 19, but also due to the reorganisation of our Services and the opening of the Grange University Hospital. These changes have required us to develop methods and strategies to enhance communication at the interface between Primary and Secondary care. Some of the main changes we have made include:”

Source location

2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 3 · response
Published 20 January 2022

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

Operate a Medical Examiner service with multidisciplinary panel review, including Primary Care input, to identify and review interface issues.

Verbatim wording from the response

“As you will be aware, the Medical Examiner (ME) Service is now operating in Gwent with cases referred by the ME being reviewed by a Multidisciplinary Panel, which includes Primary Care input. This provides us with a further mechanism to identify and review any issues regarding the interface between Primary and Secondary care.”

Source location

2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 3 · response
Published 20 January 2022

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

Provide access to a medical consultant for clinical advice through the Flow Centre telephone line.

Verbatim wording from the response

“Since 2020, major changes have taken place within ABUHB boundary due to Covid 19, but also due to the reorganisation of our Services and the opening of the Grange University Hospital. These changes have required us to develop methods and strategies to enhance communication at the interface between Primary and Secondary care. Some of the main changes we have made include:”

Source location

2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 3 · response
Published 20 January 2022

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

Explore primary–secondary care communication options, identify case-specific barriers, address them, and ensure clinical staff know the available routes.

Verbatim wording from the response

“As per section (6) – “Action should be taken”, I can confirm that this matter has been investigated within the practice. In addition, following a meeting between Dr ████████ and representatives of the Health Board on 2nd February 2022, we understand a further process is continuing within the Health Board, with which we are cooperating fully. As part of this process we have fully explored all current options and opportunities for communication between Primary and Secondary Care and have ensured that all clinical staff are aware of them. In particular we have explored specific obstacles to communication within this case and addressed them. We understand that there is an ongoing programme within the Health Board to further facilitate communication between primary and Secondary Care and we are engaging positively with that work.”

Source location

2022-0010-Response-from-The-Richmond-Clinic_Published
Page 1 · response
Published 20 January 2022

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

Continue cooperating with and positively engaging in the Health Board’s programme to facilitate primary–secondary care communication.

Verbatim wording from the response

“As per section (6) – “Action should be taken”, I can confirm that this matter has been investigated within the practice. In addition, following a meeting between Dr ████████ and representatives of the Health Board on 2nd February 2022, we understand a further process is continuing within the Health Board, with which we are cooperating fully. As part of this process we have fully explored all current options and opportunities for communication between Primary and Secondary Care and have ensured that all clinical staff are aware of them. In particular we have explored specific obstacles to communication within this case and addressed them. We understand that there is an ongoing programme within the Health Board to further facilitate communication between primary and Secondary Care and we are engaging positively with that work.”

Source location

2022-0010-Response-from-The-Richmond-Clinic_Published
Page 1 · response
Published 20 January 2022

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

Existing clinical systems, letters, directories and switchboards provide GPs with sufficient access to hospital records, clinicians and support.

Verbatim wording from the response

“In the Gwent area, GPs have access to the Clinical Workstation (CWS) system where all clinic letters and hospital records are stored. This enables a GP to review records and past/future appointments to ascertain which hospital clinicians are involved in an individual’s care. Clinic and Discharge letters would usually also be sent directly to a GP Practice, which will include the name of the responsible consultant and contact details for the secretary. Contact details for hospital based clinicians can be obtained through hospital telephony switchboards or via the NHS email address book, which is available to GPs. These sources of information and support would have been available to Dr ████████ when delivering care to Mr Wareham.”

Source location

2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 2 · response
Published 20 January 2022

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

For community patients, the registered GP and Primary Care team have overall responsibility for medical care coordination.

Verbatim wording from the response

“For individuals in the community, the registered GP has overall responsibility for their medical care. The Primary Care team will therefore be the first point of contact for most health issues, and will take the role of coordinators in a patient’s health care management. However, we acknowledge that in these situations it can be difficult for Primary Care teams to ascertain who is the most appropriate single point of contact when needing support to care for individuals who have multiple complex health issues. Due to specialisation in hospital medicine, there may not be a single point of contact which requires Primary Care teams to be a point of continuity and coordination. There are multiple ways in which Primary Care teams can obtain information regarding an individual’s hospital care.”

Source location

2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 2 · response
Published 20 January 2022

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.1

  1. 1

    Establish a single-point-of-access Flow Centre for urgent admission referrals.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.

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 a single-point-of-access Flow Centre for urgent admission referrals.

Verbatim wording from the response

“Since 2020, major changes have taken place within ABUHB boundary due to Covid 19, but also due to the reorganisation of our Services and the opening of the Grange University Hospital. These changes have required us to develop methods and strategies to enhance communication at the interface between Primary and Secondary care. Some of the main changes we have made include:”

Source location

2022-0010-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 3 · response
Published 20 January 2022

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