PFD report

Maria Christine Shafighian · Prevention of Future Deaths report

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Issued 21 Apr 2023•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
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

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to bring urgent matters immediately to the attention of referring teams
  2. Failure to ensure timely handling of internal post
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

    Require urgent clinical developments needing ENT opinion to be emailed to the Head and Neck MDTs and supporting services.

    Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 23 June 2023.
  2. Action

    Route internal ENT referrals directly to Central Registration for electronic upload and consultant triage.

    Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 23 June 2023.
  3. Action

    Develop a generic internal electronic referral form for patients requiring ENT input or an opinion.

    Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 23 June 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

Failure to bring urgent matters immediately to the attention of referring teams

Wider context from the report

“During the inquest I heard that the process by which the SALT team notified the ENT department of the change in Maria’s presentation and the development of dysphagia was through an internal postal system. Following assessment by SALT on 4/5/2020, a letter was written to the ENT team which was printed and left in a pigeon hole. No evidence was forthcoming to describe a system whereby urgent matters would be brought immediately to the attention of the referring team and there was no process for ensuring that the post was dealt with in a timely manner. In Maria’s case there appears to have been a delay of a month between the letter being sent and being noticed by the ENT team. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 ensure timely handling of internal post

Wider context from the report

“During the inquest I heard that the process by which the SALT team notified the ENT department of the change in Maria’s presentation and the development of dysphagia was through an internal postal system. Following assessment by SALT on 4/5/2020, a letter was written to the ENT team which was printed and left in a pigeon hole. No evidence was forthcoming to describe a system whereby urgent matters would be brought immediately to the attention of the referring team and there was no process for ensuring that the post was dealt with in a timely manner. In Maria’s case there appears to have been a delay of a month between the letter being sent and being noticed by the ENT team. ”

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

Require urgent clinical developments needing ENT opinion to be emailed to the Head and Neck MDTs and supporting services.

Verbatim wording from the response

“In addition, ████████ Head and Neck Cancer Lead, has communicated to the Head and Neck MDTs and supporting services that for any urgent clinical developments requiring an ENT opinion, these should also be e-mailed.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 23 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

Route internal ENT referrals directly to Central Registration for electronic upload and consultant triage.

Verbatim wording from the response

“In order to improve the system, speed up the process, and provide a more robust audit trail of referral demands, it has been discussed and agreed that internal referrals to the ENT department need to be sent straight to the Central Registration department for them to take action and upload the information on the referral, and send this electronically to the ENT consultants for triage. This would mirror the GP process.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 23 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

Develop a generic internal electronic referral form for patients requiring ENT input or an opinion.

Verbatim wording from the response

“The Directorate is also in the process of developing a generic internal electronic referral form that would need to be completed for any patients needing ENT input or an opinion. This would remove the need for paper letters or referrals to be sent, speed up the process, and provide an audit trail of receipt and action on the system.”

Source location

Response from Aneurin Bevan University Health Board
Page 2 · response
Published 23 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