PFD report

Nancy Hughes · Prevention of Future Deaths report

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Issued 12 Jun 2015•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
4

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

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 raised4

  1. Failure to provide access to mental health information during medical treatment
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unreliable circulation of safety-critical mental health information
  2. Failure to review medication in accordance with accepted medical practice
    Part of recurring concern: Failure to reliably conduct clinically required medication reviews
  3. Lack of a system to ensure medication review
    Part of recurring concern: Failure to reliably conduct clinically required medication reviews
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

    Develop and embed prescribing guidance for behavioural and psychological symptoms of dementia, including scheduled monitoring and medication review or discontinuation.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 12 June 2015.
  2. Action

    Allocate a named care coordinator or nurse within 24 hours and require medication review and continuity of contact during transfers.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 12 June 2015.
  3. Action

    Improve communication between transferring mental health wards and receiving acute hospitals, including transfer of mental health medical records.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2015.

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 provide access to mental health information during medical treatment

Wider context from the report

“2. That the evidence given by ████████ Consultant Orthopaedic Surgeon suggested that there was no cohesion between mental health treatment and medical treatment such that whilst receiving medical treatment he would not have access to mental health information relating to a patient and as a result there may be no consideration given to the care given to vulnerable patients requiring additional support. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable circulation of safety-critical mental health information.

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 review medication in accordance with accepted medical practice

Wider context from the report

“1. That there was no review of her medication in accordance with accepted medical practice and no system in place to ensure that this was undertaken. ”

Is this part of a recurring concern?

Yes — Failure to reliably conduct clinically required medication reviews.

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

Lack of a system to ensure medication review

Wider context from the report

“1. That there was no review of her medication in accordance with accepted medical practice and no system in place to ensure that this was undertaken. ”

Is this part of a recurring concern?

Yes — Failure to reliably conduct clinically required medication reviews.

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 consider care for vulnerable patients requiring additional support

Wider context from the report

“2. That the evidence given by ████████ Consultant Orthopaedic Surgeon suggested that there was no cohesion between mental health treatment and medical treatment such that whilst receiving medical treatment he would not have access to mental health information relating to a patient and as a result there may be no consideration given to the care given to vulnerable patients requiring additional support. ”

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

Develop and embed prescribing guidance for behavioural and psychological symptoms of dementia, including scheduled monitoring and medication review or discontinuation.

Verbatim wording from the response

“For patients known to community teams their care coordinator will be a member of staff from that team, this could be a Consultant, a nurse, a social work or other professional. For patients not previously known to community team prior to their admission, a named nurse (care coordinator) must be allocated to that patient within the first 24 hours of the admission – this is part of the patient’s 7 day admission pathway. The care coordinator, or named nurse has a responsibility for maintaining contact with the patient and the care team looking after the patient, if they are transferred for medical treatment into an acute hospital setting. This would include review of medication. BCUHB Mental Health Medicines Management Group has developed a Prescribing Guideline for the Management of Behavioural and Psychological Symptoms of Dementia.”

Source location

2015-0221-Response-by-University-Health-Board
Page 1 · response
Published 12 June 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

Allocate a named care coordinator or nurse within 24 hours and require medication review and continuity of contact during transfers.

Verbatim wording from the response

“This is a requirement under the Mental Health (Wales) Measure; there is a requirement for patients to have a named individual who coordinates their care, ie their Care Coordinator.”

Source location

2015-0221-Response-by-University-Health-Board
Page 1 · response
Published 12 June 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

Improve communication between transferring mental health wards and receiving acute hospitals, including transfer of mental health medical records.

Verbatim wording from the response

“The role of the Care coordinator or named nurse incorporates key responsibilities for ensuring effective communication between the transferring ward and receiving ward. When patients are transferred from mental health facilities to an acute secondary care setting, mental health medical records should follow the patient. The Mental Health Improvement Group is also working to improve this.”

Source location

2015-0221-Response-by-University-Health-Board
Page 2 · response
Published 12 June 2015

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