Leanne Marie Carroll · Prevention of Future Deaths report

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Issued 19 Mar 2025•North Wales (East and Central)

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
6

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Report evidence summary

Concerns raised6

  1. Failure to document Single Point of Access triage discussions, decisions and actions in patient health records
    Part of recurring concern: Unreliable documentation of clinical triage decisions and advice
  2. Insufficient permanent perinatal health visitor coverage across all three Health Board areas
    Part of recurring concern: Insufficient health visitor capacity to support vulnerable families and young children
  3. Failure to document Single Point of Access meeting records and decisions
    Part of recurring concern: Unreliable documentation of clinical triage decisions and advice

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. Betsi Cadwaladr University LHB

    Deliver and disseminate perinatal mental health awareness training across relevant Health Board teams.

  2. Betsi Cadwaladr University LHB

    Progress the perinatal services Standard Operating Procedure through governance for ratification and implementation.

  3. Betsi Cadwaladr University LHB

    Implement the SPOAA Referral Checklist across the division for all SPOAA meetings.

  4. Betsi Cadwaladr University LHB

    Review Health Visiting Services and wider perinatal provision to identify access gaps and make recommendations.

  5. Betsi Cadwaladr University LHB

    Review the Mental Health Measure audit to standardise its SPOAA records template and frequency across the division.

  6. Betsi Cadwaladr University LHB

    Integrate perinatal mental health awareness training across the acute mental health care pathway, including inpatient services.

  7. Betsi Cadwaladr University LHB

    Develop perinatal mental health training for North Wales GPs covering illness recognition, assessment, support and referral.

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 document Single Point of Access triage discussions, decisions and actions in patient health records

Wider context from the report

“3. The Single Point of Access meetings which occur on a daily basis by way of triaging referrals do not provide written records of the discussions had and decisions made. This means that there is no written justification for decisions made or written actions and therefore these discussions and decisions do not form part of any health record for the patient which would be relevant to the overall management of the patient. ”

Is this part of a recurring concern?

Yes — Unreliable documentation of clinical triage decisions and advice.

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 permanent perinatal health visitor coverage across all three Health Board areas

Wider context from the report

“2. There are only 2 temporary perinatal health visitors across the 3 Health Board areas and not one in the Eastern area of the Health Board. By not having permanent perinatal health visitors across all three Health Board areas then those who need to access support will suffer ”

Is this part of a recurring concern?

Yes — Insufficient health visitor capacity to support vulnerable families and young children.

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 document Single Point of Access meeting records and decisions

Wider context from the report

“4. I am concerned that deaths will occur into the future as awareness of the Service is not at all adequate to health professionals, the Service is not adequately staffed and records of meetings and decisions made in the Single Point of Access are not documented. ”

Is this part of a recurring concern?

Yes — Unreliable documentation of clinical triage decisions and advice.

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 awareness of the Perinatal Mental Health Service among health professionals

Wider context from the report

“1. The Perinatal Mental Health Service was established across the Health Board around 5 years ago. It was accepted in evidence that there is insufficient awareness of the Service by health professionals including midwives, health visitors and GP’s. Whilst attempts have been made to raise awareness and encourage direct referrals to the Service (rather than via the Single Point of Access) this remains inadequate. If health professionals are unaware of the Service then mothers-to-be and mothers who require assistance will not be fully supported. ”

Is this part of a recurring concern?

Yes — Unreliable specialist perinatal mental-health service provision.

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

Inadequate staffing of the Perinatal Mental Health Service

Wider context from the report

“4. I am concerned that deaths will occur into the future as awareness of the Service is not at all adequate to health professionals, the Service is not adequately staffed and records of meetings and decisions made in the Single Point of Access are not documented. ”

Is this part of a recurring concern?

Yes — Insufficient mental health service capacity for timely patient care; Unreliable specialist perinatal mental-health service provision.

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 awareness of the Perinatal Mental Health Service among health professionals

Wider context from the report

“4. I am concerned that deaths will occur into the future as awareness of the Service is not at all adequate to health professionals, the Service is not adequately staffed and records of meetings and decisions made in the Single Point of Access are not documented. ”

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

Deliver and disseminate perinatal mental health awareness training across relevant Health Board teams.

Verbatim wording from the response

“Currently, mandatory perinatal mental health training is delivered to midwifery colleagues, student health visitors, obstetricians and gynaecologists, Community Mental Health Teams (CMHT’s) and Home Treatment Teams (HTT). As extended members of the team, specialist perinatal health visitors provide training relating to the “Ask, Assess and Act Assessment Framework” whilst promoting the role of the Perinatal Mental Health Service. In addition, Institute of Health Visiting perinatal training is offered six times per year to the Health Visiting Teams, and members of the Mental Health Perinatal Team have undertaken train the trainer modules to disseminate this training further across the Health Board.”

Source location

Response from BCUHB
Page 1 · response
Published 26 March 2025

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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

Progress the perinatal services Standard Operating Procedure through governance for ratification and implementation.

Verbatim wording from the response

“I would like to take this opportunity to provide you with an overview of how referrals to the Perinatal Mental Health Service are managed. These referrals are reviewed via the daily Perinatal Referrals Meeting. This meeting, like the Single Point of Access and Assessment meetings (SPOAAs) across the rest of the division, reviews each perinatal referral entering the system. The meeting is structured to meet the Royal College of Psychiatrist: Standards for Community Mental Health Services (6th Edition). The requirement is that all referrals are reviewed within 24 hours of receipt and the screening discussion and outcome communicated to the referrer within a further 24 hours. There is a draft Standard Operating Procedure for perinatal services and this is progressing through Health Board governance process prior to final ratification and implementation.”

Source location

Response from BCUHB
Page 2 · response
Published 26 March 2025

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 SPOAA Referral Checklist across the division for all SPOAA meetings.

Verbatim wording from the response

“As an outcome of the inquest and subsequent notice, we have identified that consistency across the whole division is required in terms of the documentation used to record the summary and outcome of SPOAA Meetings.”

Source location

Response from BCUHB
Page 3 · response
Published 26 March 2025

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 Health Visiting Services and wider perinatal provision to identify access gaps and make recommendations.

Verbatim wording from the response

“With regard to Perinatal Health Visitors and the equity of access across North Wales, I can confirm that a review of Health Visiting Services at the Health Board that relate to wider perinatal services will be undertaken to determine whether gaps in service are evident. This will include consideration of access to specialist Perinatal Mental Health Services and the Mental Health Perinatal Service Manager will be involved within this process. An action plan will be developed to address any identified areas of need in order to ensure that there is equitable and appropriate access to perinatal services. Consideration will be given to the role and function of the Perinatal Health Visitor posts currently in place in the central and west areas on a temporary basis. This review will be undertaken with recommendations for the Health Board to consider by the end of July 2025.”

Source location

Response from BCUHB
Page 2 · response
Published 26 March 2025

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 Mental Health Measure audit to standardise its SPOAA records template and frequency across the division.

Verbatim wording from the response

“The Community Transformation Meeting will review the existing Mental Health Measure audit that currently takes place, which includes SPOAA records, to ensure that the audit template and frequency is consistent across the division.”

Source location

Response from BCUHB
Page 3 · response
Published 26 March 2025

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

Integrate perinatal mental health awareness training across the acute mental health care pathway, including inpatient services.

Verbatim wording from the response

“Moving forwards, the long-term plan is to integrate perinatal mental health training across the whole of the mental health acute care pathway to include in-patient services in addition to HTT, Psychiatric Liaison, and CMHTs. This is being processed through the Mental Health and Learning Disabilities Training and Development Group and it is expected that the perinatal awareness training will be fully ratified at the end of July 2025.”

Source location

Response from BCUHB
Page 2 · response
Published 26 March 2025

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 perinatal mental health training for North Wales GPs covering illness recognition, assessment, support and referral.

Verbatim wording from the response

“Alongside this, the Health Board’s Perinatal Consultant Psychiatrist, ████████, is leading on the development of training for GPs across North Wales. This training intends to increase knowledge of perinatal mental illness and the role and referral process for access to perinatal mental health assessment and support. ████████ is in the process of liaising with GP colleagues with the aim of having initial training dates agreed by the beginning of September 2025.”

Source location

Response from BCUHB
Page 2 · response
Published 26 March 2025

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

Official responses located
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Data last updated 7 September 2026