PFD report

Margaret Gertrude Kelly · Prevention of Future Deaths report

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Issued 9 Oct 2023•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
18

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. Unsustainable pressure on emergency department clinicians and other staff
    Part of recurring concern: Insufficient emergency-department staffing capacity for safe patient care
  2. Insufficient or ineffective strategic planning and support for reducing emergency department pressures
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.15

  1. Action

    Improve the information technology systems used for same-day emergency care.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2023.
  2. Action

    Re-establish fortnightly strategic meetings with the Welsh Ambulance Service to review demand, conveyances and demand-reduction actions.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 18 October 2023.
  3. Action

    Present ambulance performance data at emergency department governance meetings to review required actions and support zero-tolerance handover performance.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 18 October 2023.

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

Unsustainable pressure on emergency department clinicians and other staff

Wider context from the report

“Evidence was given at the inquest that when the deceased attended the emergency department it was at level 4 escalation (the highest level which they would escalate to), that this was far from unusual and that between March 2022 and the present day, the department would usually be operating between levels 3 & 4. I am concerned that the pressure on clinicians and other staff is unsustainable and that delays in treatment will result in deaths. I do not consider that the operating practices within the department are a direct cause for concern (and as a result I do not require hearing the views of any clinicians in respect thereof), however I am concerned that insufficient or ineffective strategic planning and support is being undertaken and I would therefore wish to hear from those responsible at an executive/managerial level as to the steps which are being taken to reduce pressures within the department at Glan Clwyd. ”

Is this part of a recurring concern?

Yes — Insufficient emergency-department staffing capacity for safe patient 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

Insufficient or ineffective strategic planning and support for reducing emergency department pressures

Wider context from the report

“Evidence was given at the inquest that when the deceased attended the emergency department it was at level 4 escalation (the highest level which they would escalate to), that this was far from unusual and that between March 2022 and the present day, the department would usually be operating between levels 3 & 4. I am concerned that the pressure on clinicians and other staff is unsustainable and that delays in treatment will result in deaths. I do not consider that the operating practices within the department are a direct cause for concern (and as a result I do not require hearing the views of any clinicians in respect thereof), however I am concerned that insufficient or ineffective strategic planning and support is being undertaken and I would therefore wish to hear from those responsible at an executive/managerial level as to the steps which are being taken to reduce pressures within the department at Glan Clwyd. ”

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

Improve the information technology systems used for same-day emergency care.

Verbatim wording from the response

“• Our Operational Management Team are working on two key areas around SDEC improvement: Improving the IT systems used by staff and using new telephony systems to support more referrals from GPs and WAST into the SDEC service.”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 2 · response
Published 18 October 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

Re-establish fortnightly strategic meetings with the Welsh Ambulance Service to review demand, conveyances and demand-reduction actions.

Verbatim wording from the response

“• The IHC have re-established fortnightly strategic meetings with WAST to review demand and conveyances and actions that can be taken to reduce demand.”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 3 · response
Published 18 October 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

Present ambulance performance data at emergency department governance meetings to review required actions and support zero-tolerance handover performance.

Verbatim wording from the response

“• On 12 October 2023, IHC Directors presented current ambulance performance data at the monthly ED Governance Meeting to review actions required and identify the support needed to achieve zero tolerance of 4 Hour Ambulance Handover from 1st November 2023.”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 3 · response
Published 18 October 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

Develop the YGC acute medical model, including its rota and working patterns, to provide timely senior decision-making and appropriate specialty care.

Verbatim wording from the response

“• Work is underway to improve the YGC acute medical model. Operational teams are developing the model, rota and working patterns to support this. The objectives of the new model are to deliver timely patient care, provide senior decision-making support to the ED, and ensuring patients are cared for by the best medical specialty and in the right place.”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 2 · response
Published 18 October 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

Develop a more efficient board-round system to expedite discharge and improve patient flow.

Verbatim wording from the response

“• Developing a more efficient board round system will expedite patients home in a timely manner, improving patient flow and relieving pressures upstream in the emergency department.”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 2 · response
Published 18 October 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

Implement the 8 Steps Project to improve emergency department patient flow and monitor performance through daily huddles and dashboards.

Verbatim wording from the response

“• The 8 Steps Project is aiming to improve each of the steps that patients take through their ED journey, creating efficiencies and therefore reducing the waiting time within the ED. Performance is being continuously monitored through a dashboard and to identify improvements to working practice. The 8 steps include:”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 2 · response
Published 18 October 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

Establish a dedicated project team to develop and deliver urgent and emergency care improvements.

Verbatim wording from the response

“Urgent & emergency care provision is one of the main priorities for the Central IHC and requires significant support and focus to deliver improvements. We have recognised that a programme management approach is required, and have established a dedicated project team to support the development and delivery of our improvement work related to urgent and emergency care. This additional capacity is vital in supporting operational teams to drive the programmes forward at pace and embed the change as we go.”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 1 · response
Published 18 October 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

Complete a Quality Check mock inspection to provide an objective update on emergency department improvement progress.

Verbatim wording from the response

“The ED at Ysbyty Glan Clwyd continues to face significant pressure. You will be aware that Healthcare Inspectorate Wales designated it a Service Requiring Significant Improvement. We have supported the ED to develop and deliver considerable improvement plans in response to three HIW inspections since February 2022, and during the summer of 2023 we supported a “mock inspection” (called a Quality Check) to provide an objective progress update. Our Executive Director of Nursing and Midwifery is overseeing the continuing actions arising from this process.”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 4 · response
Published 18 October 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

Scrutinise emergency department improvement plans and performance and provide executive support for their delivery.

Verbatim wording from the response

“As an Executive Team, we are fully committed to supporting the ED through the Central IHC to develop and deliver its improvement plans, which are outlined above. We will scrutinise those plans and performance, and provide support.”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 4 · response
Published 18 October 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

Oversee continuing actions arising from the emergency department inspection and improvement process.

Verbatim wording from the response

“The ED at Ysbyty Glan Clwyd continues to face significant pressure. You will be aware that Healthcare Inspectorate Wales designated it a Service Requiring Significant Improvement. We have supported the ED to develop and deliver considerable improvement plans in response to three HIW inspections since February 2022, and during the summer of 2023 we supported a “mock inspection” (called a Quality Check) to provide an objective progress update. Our Executive Director of Nursing and Midwifery is overseeing the continuing actions arising from this process.”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 4 · response
Published 18 October 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

Undertake a Monday-to-Friday daytime see-and-treat test to support staff learning and evaluate its effect on emergency department performance.

Verbatim wording from the response

“• A test of a Monday to Friday 9am-5pm ‘see and treat’ model will also be undertaken during November for staff learning and to evaluate impact on non-admitted performance and de-compressing ED.”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 3 · response
Published 18 October 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

Review the emergency department rota and skill mix to address identified doctor shortages.

Verbatim wording from the response

“• An ED rota review, including skill mix is scheduled for November as we have identified doctor shortages compared to attendances on Monday’s and Tuesday’s (two busiest days).”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 3 · response
Published 18 October 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

Return the GP Out of Hours Service to Ysbyty Glan Clwyd and co-locate it with emergency services.

Verbatim wording from the response

“• We are currently finalising plans to return the GP Out of Hours Service to the YGC. This is in line with Peer Review recommendations and will ensure co-located GP services to ED for nearly 70% of the week (6.30pm-8am Mon – Fri and all day Saturday and Sunday). We are currently working with operational leads to implement this provision before winter pressures this year. Patients presenting in YGC ED with primary care presentations during week day hours will be advised how they can access local primary care services (GP / Optometry / Community Pharmacy / Dental).”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 3 · response
Published 18 October 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

Support delivery of emergency department improvement plans responding to Healthcare Inspectorate Wales inspections.

Verbatim wording from the response

“The ED at Ysbyty Glan Clwyd continues to face significant pressure. You will be aware that Healthcare Inspectorate Wales designated it a Service Requiring Significant Improvement. We have supported the ED to develop and deliver considerable improvement plans in response to three HIW inspections since February 2022, and during the summer of 2023 we supported a “mock inspection” (called a Quality Check) to provide an objective progress update. Our Executive Director of Nursing and Midwifery is overseeing the continuing actions arising from this process.”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 4 · response
Published 18 October 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

Introduce telephony systems to support additional GP and ambulance-service referrals to same-day emergency care.

Verbatim wording from the response

“• Our Operational Management Team are working on two key areas around SDEC improvement: Improving the IT systems used by staff and using new telephony systems to support more referrals from GPs and WAST into the SDEC service.”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 2 · response
Published 18 October 2023

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.3

  1. 1

    Appoint new senior and independent Board leaders, including a permanent Chief Executive and interim Executive Director of Operations.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 18 October 2023.
  2. 2

    Strengthen Health Board planning, leadership and governance through the Special Measures programme.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2023.
  3. 3

    Conduct independent reviews of Health Board governance, planning and leadership to shape future changes.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2023.

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

Appoint new senior and independent Board leaders, including a permanent Chief Executive and interim Executive Director of Operations.

Verbatim wording from the response

“As you will know, the Health Board has been placed into Special Measures in February 2023 and since then, a new Interim Chair has been appointed, new Independent Members of the board are in place, and within the last few weeks, a new permanent Chief Executive has been appointed. A new interim Executive Director of Operations has also been appointed.”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 3 · response
Published 18 October 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

Strengthen Health Board planning, leadership and governance through the Special Measures programme.

Verbatim wording from the response

“The Special Measures programme is organised into three phases – Stabilisation, Standardisation and Sustainability. We are currently at the Stabilisation phase and are”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 3 · response
Published 18 October 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

Conduct independent reviews of Health Board governance, planning and leadership to shape future changes.

Verbatim wording from the response

“As part of our Special Measures programme, a number of Independent Reviews are underway into core aspects of the Health Board’s governance, planning and leadership. These reviews will help us shape how the Health Board will change in the future.”

Source location

Response from Betsi Cadwaladr Unviersity Health Board
Page 3 · response
Published 18 October 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