PFD report

Catherine Lisa Jones · Prevention of Future Deaths report

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Issued 12 Dec 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.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
8

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 raised1

  1. Lack of an approved, documented system of work for communication with patients’ consultants before pooled-list surgery
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.4

  1. Action

    Develop a clear, consistent organisation-wide policy through a task group involving Integrated Health Communities and Regional Specialist Services.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
  2. Action

    Complete a Health Board-wide review and assessment of pooled surgical-list practice to identify required policy improvements.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
  3. Action

    Obtain Planned Care Board approval for the new policy to establish operational and clinical ownership.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 19 December 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

Lack of an approved, documented system of work for communication with patients’ consultants before pooled-list surgery

Wider context from the report

“It was indicated that for many departments within the health board, surgery was conducted on the basis of “pooled lists” and although evidence was given that the common practice of one of the surgeons was to ensure that they had some form of communication with the patient’s consultant prior to surgery (by phone and/or email), there was no evidence that this practice was part of an approved system of work which was documented within the health board’s protocols. In the absence of this being a part of an adopted practice and procedure guidance, I am concerned that there may be a lack of cohesive care and treatment for patients undergoing surgery and that future death may occur as a result. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Develop a clear, consistent organisation-wide policy through a task group involving Integrated Health Communities and Regional Specialist Services.

Verbatim wording from the response

“Upon receiving the notice, I asked my deputy executive medical director, ████████ ████████ to review and assess practice across the Health Board. This work has been completed and has identified the need to develop a clear and consistent policy for the entire organisation.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 19 December 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 Health Board-wide review and assessment of pooled surgical-list practice to identify required policy improvements.

Verbatim wording from the response

“Upon receiving the notice, I asked my deputy executive medical director, ████████ ████████ to review and assess practice across the Health Board. This work has been completed and has identified the need to develop a clear and consistent policy for the entire organisation.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 19 December 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

Obtain Planned Care Board approval for the new policy to establish operational and clinical ownership.

Verbatim wording from the response

“The new policy will be approved at the Planned Care Board to ensure operational and clinical ownership. This group will also oversee the progress of the task group.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 19 December 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 new policy under divisional medical director leadership and report implementation progress to the task group.

Verbatim wording from the response

“Implementation of this new policy will then be led by the medical directors for our divisions and reported back into the group.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 19 December 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.4

  1. 1

    Share the notice with Integrated Health Communities and Regional Specialist Services so local learning can be applied while the policy is developed.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
  2. 2

    Encourage and support health boards and local authorities to implement, increase use of, and expand Digital Health and Care Record systems.

    Stated by Eluned MorganStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
  3. 3

    Work with Digital Health and Care Wales, health boards and local authorities to improve sharing and access to health and social care information across provider settings.

    Stated by Eluned MorganStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
  4. 4

    Work with NHS Wales to rationalise the systems clinicians access to obtain patient-care data, regardless of care setting.

    Stated by Eluned MorganStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The planned electronic service concerns community settings and is not expected to address the in-hospital record-sharing issue.

    Stated by Eluned MorganDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Health boards and local authorities are responsible for implementing and increasing use of digital shared-care record systems, with Welsh Government support.

    Stated by Eluned MorganRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 notice with Integrated Health Communities and Regional Specialist Services so local learning can be applied while the policy is developed.

Verbatim wording from the response

“Whilst we develop this new policy, to mitigate the risks, your notice has been shared with all our Integrated Health Communities and the relevant Regional Specialist Services so that local learning can be applied.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 19 December 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

Encourage and support health boards and local authorities to implement, increase use of, and expand Digital Health and Care Record systems.

Verbatim wording from the response

“We recognise the need for investing in developments to digital shared care systems and services to improve data sharing between settings and organisations across NHS and Social Care sectors. Working closely with our partners, the Welsh Government will endeavour to make every effort to encourage and support the implementation, and to increase the usage and spread, of Digital Health and Care Record systems by health boards and local authorities.”

Source location

Response from Welsh Government
Page 3 · response
Published 19 December 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

Work with Digital Health and Care Wales, health boards and local authorities to improve sharing and access to health and social care information across provider settings.

Verbatim wording from the response

“The Welsh Government’s Digital and data strategy for health and social care in Wales sets out our ambition to improve digital infrastructure and connectivity to deliver a secure and sustainable foundation for seamless sharing of health and social care data across services and sectors. This will be delivered by working with organisations, in particular Digital Health and Care Wales, health boards and local authorities to improve how information is shared and accessed across care provider settings.”

Source location

Response from Welsh Government
Page 2 · response
Published 19 December 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

Work with NHS Wales to rationalise the systems clinicians access to obtain patient-care data, regardless of care setting.

Verbatim wording from the response

“Therefore, histopathology test results are available for clinicians digitally. In line with ‘Mission 3’ of the Digital and Data Strategy for Health and Social Care we will work with NHS Wales to rationalise the number of systems that clinicians need to access to care for the data needed for patient care regardless of the setting they present at, making it simpler for them to identify relevant data.”

Source location

Response from Welsh Government
Page 2 · response
Published 19 December 2023

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

The planned electronic service concerns community settings and is not expected to address the in-hospital record-sharing issue.

Verbatim wording from the response

“In that letter, we confirmed that we aim to implement a new electronic service joining up clinical systems and data across all care sectors during the Summer of 2026. It is important to note that the programme scope and timescales described in that letter relate to community settings and would not be expected to directly impact on the circumstances described in the report into Ms Jones’ death.”

Source location

Response from Welsh Government
Page 1 · response
Published 19 December 2023

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

Health boards and local authorities are responsible for implementing and increasing use of digital shared-care record systems, with Welsh Government support.

Verbatim wording from the response

“The Welsh Government’s Digital and data strategy for health and social care in Wales sets out our ambition to improve digital infrastructure and connectivity to deliver a secure and sustainable foundation for seamless sharing of health and social care data across services and sectors. This will be delivered by working with organisations, in particular Digital Health and Care Wales, health boards and local authorities to improve how information is shared and accessed across care provider settings.”

Source location

Response from Welsh Government
Page 2 · response
Published 19 December 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