PFD report

Mr. Brian Francis · Prevention of Future Deaths report

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Issued 4 Mar 2015•Powys, Bridgend & Glamorgan Valleys

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
5

Named on the report

Responses found
1

Of 5 recipients

Stated actions
7

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 paper records to accurately document Consultant patient review
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Unavailability of Community medical records at hospital admission
    Part of recurring concern: Unreliable access to relevant clinical records for safe carePart of recurring concern: Unreliable admission assessment of patients
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.6

  1. Action

    Replace tick-box tracking with standardized ED and AMU registers requiring consultant signatures to provide auditable confirmation of patient review.

    Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 4 March 2015.
  2. Action

    Implement ward documentation requiring the senior reviewing clinician to record completion and timing of review for ward staff.

    Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 4 March 2015.
  3. Action

    Implement the national Symphony emergency department system across Health Board emergency and assessment units, beginning at specified hospitals in September 2015 and continuing in November 2015.

    Stated by Swansea Bay University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 4 March 2015.

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

  1. Position

    Electronic community health records cannot be provided locally until national pilot studies are completed and the service is extended to hospital emergency settings.

    Stated by Swansea Bay University Local Health BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 paper records to accurately document Consultant patient review

Wider context from the report

“(1) The process of a Consultant’s attendance on patient being noted by a ‘tick in the box’ on a paper record failed. The box had been ticked when in fact the patient had not been reviewed by the Consultant. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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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

Unavailability of Community medical records at hospital admission

Wider context from the report

“(2) Had the Community medical records been available at the time of hospital admission the patient would most probably have been assessed differently and in all probability, anti-coagulation therapy commenced immediately or shortly thereafter. ”

Is this part of a recurring concern?

Yes — Unreliable access to relevant clinical records for safe care; Unreliable admission assessment of patients.

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

Replace tick-box tracking with standardized ED and AMU registers requiring consultant signatures to provide auditable confirmation of patient review.

Verbatim wording from the response

“At the two entrances there are two registers one in the ED department and one in the AMU department and these are now formatted the same way and require the consultant to sign the register when he/she has seen the patient (Appendix 1). This enables the nursing and medical teams to see quickly who has been reviewed by whom and who has yet to be reviewed. This has replaced the tick box that previously existed; recognising that the ticks could have been entered by anyone and the system could not be reviewed and checked. The enclosed map (Appendix 2) shows the Clinical Decision Unit (now called the Acute Medical Unit) and Emergency Department are next to each other and the medical team works in both areas throughout the 24/7 service.”

Source location

2015-0085-Response-by-University-Health-Board
Page 2 · response
Published 4 March 2015

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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

Implement ward documentation requiring the senior reviewing clinician to record completion and timing of review for ward staff.

Verbatim wording from the response

“The current arrangements have been reviewed and it is clear that when a patient is admitted the clinical assessment documentation is completed by the admitting doctor. A copy of the document is attached (Appendix 3) and comes as a booklet rather than 8 separate sheets. Page 8 of that document has to be completed by the senior reviewing clinician. This record is sent to the ward with the patient and so ward staff can quickly identify whether senior review has taken place and the time that it took place.”

Source location

2015-0085-Response-by-University-Health-Board
Page 3 · response
Published 4 March 2015

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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

Implement the national Symphony emergency department system across Health Board emergency and assessment units, beginning at specified hospitals in September 2015 and continuing in November 2015.

Verbatim wording from the response

“From September 2015 a new National Emergency Department system (called Symphony) will be implemented within the Emergency Departments and Assessment Units throughout the Health Board. Initially the system will be introduced in Princess of Wales Hospital and Neath Port Talbot Hospitals in September 2015, the first sites in NHS Wales to go live with the new national system. This will be followed by implementation in Morriston and Singleton Hospitals in November 2015.”

Source location

2015-0085-Response-by-University-Health-Board
Page 3 · response
Published 4 March 2015

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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

Continue monitoring the review-tracking system and have the Clinical Director review consultant working practices while supporting development of an electronic system.

Verbatim wording from the response

“We will continue to monitor the system in place and the Clinical Director will review the working practices of the Consultant Physician body in this regard. The Clinical Director has reinforced to all Consultants that it is vital that they only sign the book after a review has taken place and is monitoring the system. All the teams are aware of this incident and have learned from that. They continue to monitor and review and support the ongoing pilot to develop an electronic system.”

Source location

2015-0085-Response-by-University-Health-Board
Page 2 · response
Published 4 March 2015

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

Reinforce with consultants and nursing staff their responsibilities for authenticating and checking documentation of senior patient review.

Verbatim wording from the response

“We will continue to monitor the system in place and the Clinical Director will review the working practices of the Consultant Physician body in this regard. The Clinical Director has reinforced to all Consultants that it is vital that they only sign the book after a review has taken place and is monitoring the system. All the teams are aware of this incident and have learned from that. They continue to monitor and review and support the ongoing pilot to develop an electronic system.”

Source location

2015-0085-Response-by-University-Health-Board
Page 2 · response
Published 4 March 2015

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

Pilot a live electronic work list to notify teams about patients requiring review and treatment decisions, with auditable, time-stamped entries.

Verbatim wording from the response

“We will continue to monitor the system in place and the Clinical Director will review the working practices of the Consultant Physician body in this regard. The Clinical Director has reinforced to all Consultants that it is vital that they only sign the book after a review has taken place and is monitoring the system. All the teams are aware of this incident and have learned from that. They continue to monitor and review and support the ongoing pilot to develop an electronic system.”

Source location

2015-0085-Response-by-University-Health-Board
Page 2 · response
Published 4 March 2015

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

Electronic community health records cannot be provided locally until national pilot studies are completed and the service is extended to hospital emergency settings.

Verbatim wording from the response

“A summary of the GP record is currently available in out-of-hours GP services. This national service is currently being extended for use in hospital emergency settings. Pilot projects are already underway in Cardiff and the Vale and Aneurin Bevan Health Boards and our Health Board has already indicated our eagerness to provide this service locally as soon as the pilot studies have been completed.”

Source location

2015-0085-Response-by-University-Health-Board
Page 3 · response
Published 4 March 2015

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 assessment documentation and nursing escalation arrangements sufficiently notify ward staff whether senior review has occurred.

Verbatim wording from the response

“The current arrangements have been reviewed and it is clear that when a patient is admitted the clinical assessment documentation is completed by the admitting doctor. A copy of the document is attached (Appendix 3) and comes as a booklet rather than 8 separate sheets. Page 8 of that document has to be completed by the senior reviewing clinician. This record is sent to the ward with the patient and so ward staff can quickly identify whether senior review has taken place and the time that it took place.”

Source location

2015-0085-Response-by-University-Health-Board
Page 3 · response
Published 4 March 2015

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

    Enhance emergency admission systems to ensure senior clinician or consultant review within 14 hours, or sooner when clinically indicated.

    Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 4 March 2015.

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

Enhance emergency admission systems to ensure senior clinician or consultant review within 14 hours, or sooner when clinically indicated.

Verbatim wording from the response

“The systems in the Princess of Wales Hospital have been reviewed, in the light of this serious incident and have been enhanced to ensure all emergency medical patients admitted to the hospital are reviewed by a senior clinician or consultant within 14 hours or sooner if clinically indicated.”

Source location

2015-0085-Response-by-University-Health-Board
Page 2 · response
Published 4 March 2015

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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