PFD report

Percy Jacks · Prevention of Future Deaths report

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Issued 27 Jul 2017•South Wales 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
6

Raised in this report

Recipients
4

Named on the report

Responses found
4

Of 4 recipients

Stated actions
12

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 raised6

  1. Reliance of GP prescribing on receipt of hospital scan-result notification
    Part of recurring concern: Unreliable doctor-to-doctor coordination of prescribingPart of recurring concern: Unsafe medication prescribing
  2. Haphazard DVT management system
    Part of recurring concern: Unreliable DVT diagnosis and management
  3. Failure of the hospital-to-GP DVT result communication system
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
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.9

  1. Action

    Undertake a review of discharge arrangements, focusing on communication and documentation supporting discharge from secondary to primary healthcare.

    Stated by Healthcare Inspectorate WalesStated in progressThe respondent said that this action was in progress when they made their response on 2 December 2017.
  2. Action

    Discuss with CSSIW how to collaborate and jointly address fragile communication between health services and the care home.

    Stated by Healthcare Inspectorate WalesStated plannedThe respondent said that this action was planned when they made their response on 2 December 2017.
  3. Action

    Implement a streamlined DVT pathway directing suspected cases to radiology, initiating primary treatment before ultrasound, and ensuring positive and negative results receive appropriate follow-up.

    Stated by Hywel Dda University LHBStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Welsh Clinical Portal access was considered sufficient for the GP to review the patient's A&E attendance outcome despite the discharge summary issue.

    Stated by Hywel Dda University LHBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Reliance of GP prescribing on receipt of hospital scan-result notification

Wider context from the report

“(2) The system within the GP surgery for prescribing Rivaroxaban was poor and relied solely on receiving the notification of the results of the scan from the hospital. There was no facility to review the medication to ensure that the correct dosage for the correct period of time continued to be prescribed. ”

Is this part of a recurring concern?

Yes — Unreliable doctor-to-doctor coordination of prescribing; Unsafe medication prescribing.

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

Haphazard DVT management system

Wider context from the report

“(3) The evidence revealed a view from one of the hospital doctors to the effect that DVT management should be undertaken within the hospital setting rather than by the GP’s to ensure that a comprehensive and failsafe system operated rather than the somewhat haphazard one revealed by the evidence. ”

Is this part of a recurring concern?

Yes — Unreliable DVT diagnosis and management.

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 of the hospital-to-GP DVT result communication system

Wider context from the report

“(1) The investigation revealed that the system for the Bronglais Hospital contacting the GP was poor. The result of the DVT scan which took place on 6 February was sent to the incorrect GP surgery and despite an explanation as to why that happened no satisfactory explanation could be found. ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon.

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 reliably communicate medication and clinical plans from hospital to care home

Wider context from the report

“(4) The evidence further revealed a practice of sending details of the medication and clinical plan back with the driver of the patient who had taken the patient back from hospital to the care home. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services.

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 medication review for correct Rivaroxaban dosage and duration

Wider context from the report

“(2) The system within the GP surgery for prescribing Rivaroxaban was poor and relied solely on receiving the notification of the results of the scan from the hospital. There was no facility to review the medication to ensure that the correct dosage for the correct period of time continued to be prescribed. ”

Is this part of a recurring concern?

Yes — Failure to identify clinically significant medication risks; 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

Fragile communication system between GP, hospital and care home

Wider context from the report

“(5) Overall the evidence revealed a very fragile system of communication between GP hospital and care home in circumstances in which the deceased had moved between three care homes in a short period of time. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable multi-agency communication procedures.

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

Undertake a review of discharge arrangements, focusing on communication and documentation supporting discharge from secondary to primary healthcare.

Verbatim wording from the response

“HIW has noted the findings of the inquest and assure you that this information will be used to inform our work. HIW is currently undertaking a review of discharge arrangements focusing on communication and the quality of documentation used to support patient discharge from secondary to primary healthcare. I can confirm that this report has been shared with the review lead to consider.”

Source location

2017-0329-Response-by-Welsh-Government
Page 1 · response
Published 2 December 2017

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

Discuss with CSSIW how to collaborate and jointly address fragile communication between health services and the care home.

Verbatim wording from the response

“I note the concerns raised by the report regarding fragile communication between health services and the care home and will discuss further with CSSIW how we may seek to collaborate and address this issue jointly through our work.”

Source location

2017-0329-Response-by-Welsh-Government
Page 1 · response
Published 2 December 2017

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 a streamlined DVT pathway directing suspected cases to radiology, initiating primary treatment before ultrasound, and ensuring positive and negative results receive appropriate follow-up.

Verbatim wording from the response

“The process of managing potential DVT patients has been streamlined and a definite pathway introduced. All GP referrals which suspected DVTs are referred direct to the Hospital's Radiology Department as per the attached protocol. It is incumbent on the GPs to commence their primary prior to an ultrasound scan being undertaken. Following their scan, if the result is positive, the patient is referred back to the A & E Department where they are reviewed by the on-call Physicians. There is a pre-printed letter that is completed by the on-call physicians to the GP with recommendations and this is also copied to the Anticoagulation Clinic. If the result of the scan is negative, the patient is referred back to their GP for further evaluation.”

Source location

2017-0329-Response
Page 1 · response
Published 2 December 2017

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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

Record all suspected DVT referrals and follow up 48 hours later to confirm receipt of results.

Verbatim wording from the response

“We have discussed this in our practice meeting and have made the following changes.”

Source location

2017-0329-Response-by-Rhayader-Group-Practic
Page 1 · response
Published 2 December 2017

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

Refer patients through the Hereford Hospital or Bronglais Hospital DVT pathways.

Verbatim wording from the response

“We have discussed this in our practice meeting and have made the following changes.”

Source location

2017-0329-Response-by-Rhayader-Group-Practic
Page 1 · response
Published 2 December 2017

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

Fast-track medical records for new patients registering at nursing or care homes so doctors receive prior medical history promptly.

Verbatim wording from the response

“We have discussed this in our practice meeting and have made the following changes.”

Source location

2017-0329-Response-by-Rhayader-Group-Practic
Page 1 · response
Published 2 December 2017

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

Have inspectors use two specific information-sharing questions when reviewing practice safety from November 2017.

Verbatim wording from the response

“We have revised and improved the wording of our Key Lines of Enquiry and from November 2017 inspectors will be considering the following two specific questions when they are reviewing the safety of a practice, instead of one being a prompt supporting the other: ‘When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?’ and ‘How well do the systems that manage information about people who use services support staff, carers and partner agencies to deliver safe care and treatment? (This includes coordination between different electronic and paper-based systems and appropriate access for staff to records.)’”

Source location

2017-0329-Response-by-Care-Quality-Commission
Page 4 · response
Published 2 December 2017

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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

Revise and improve the wording of the Key Lines of Enquiry on information sharing during transfers between services.

Verbatim wording from the response

“We have revised and improved the wording of our Key Lines of Enquiry and from November 2017 inspectors will be considering the following two specific questions when they are reviewing the safety of a practice, instead of one being a prompt supporting the other: ‘When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?’ and ‘How well do the systems that manage information about people who use services support staff, carers and partner agencies to deliver safe care and treatment? (This includes coordination between different electronic and paper-based systems and appropriate access for staff to records.)’”

Source location

2017-0329-Response-by-Care-Quality-Commission
Page 4 · response
Published 2 December 2017

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 how inspections assess timely information transfer between services, using policy, medicines and clinical expertise.

Verbatim wording from the response

“As a result of the concerns being brought to our attention we have taken the opportunity to review how CQC checks that information about patients being transferred between services happens in a timely manner and whether there is any more we as a regulator can do to prevent an incident such as this from happening in future.”

Source location

2017-0329-Response-by-Care-Quality-Commission
Page 6 · response
Published 2 December 2017

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

Welsh Clinical Portal access was considered sufficient for the GP to review the patient's A&E attendance outcome despite the discharge summary issue.

Verbatim wording from the response

“All Primary and Secondary Care Doctors have access to the Welsh Clinical Portal. This allows them to access test, radiology and documentation for a patient wherever the patient receives cares in Wales, regardless of geographical or organisational boundaries. See attached printout from the NHS Wales Informatics Service website which provides further information. Mr Jacks' GP would have had access to this and would have been able to review the outcome of his attendance at the A & E Department at Bronglais General Hospital on 6 February 2017.”

Source location

2017-0329-Response
Page 2 · response
Published 2 December 2017

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

DVT management in primary care is accepted practice; hospital-only management was not considered necessary where appropriate safeguards are followed.

Verbatim wording from the response

“3. The evidence revealed a view from one of the hospital doctors to the effect that DVT management should be undertaken within the hospital setting rather than by the GPs to ensure that a comprehensive and failsafe system operated rather than the somewhat haphazard one revealed by the evidence.”

Source location

2017-0329-Response-by-Care-Quality-Commission
Page 5 · response
Published 2 December 2017

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

Including scan results with transferred patient records was considered sufficient, so no additional regulatory input was required.

Verbatim wording from the response

“Cantilupe Surgery has informed CQC that hard copies of Mr Jacks’ notes, along with the scan results which were sent in error to the surgery by Bronglais General Hospital were collected by Capita on 10 February 2017. While Cantilupe Surgery did not contact the Bronglais Hospital to inform them of the error, they considered that the action of including the scan results along with Mr Jacks’ patient records were sufficient to ensure the information would reach the new practice promptly. The practice have informed us that in the event of a repetition of this kind of error they would inform the hospital in the light of Mr Jacks’ case. We do not consider that there is cause for additional input from CQC here.”

Source location

2017-0329-Response-by-Care-Quality-Commission
Page 3 · response
Published 2 December 2017

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

Current inspection methodology was considered to cover the relevant care elements, so no additional policy change was required.

Verbatim wording from the response

“As a result of the concerns being brought to our attention we have taken the opportunity to review how CQC checks that information about patients being transferred between services happens in a timely manner and whether there is any more we as a regulator can do to prevent an incident such as this from happening in future.”

Source location

2017-0329-Response-by-Care-Quality-Commission
Page 6 · response
Published 2 December 2017

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.3

  1. 1

    Share the report with the discharge-arrangements review lead for consideration.

    Stated by Healthcare Inspectorate WalesStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
  2. 2

    Audit the DVT referral, treatment-information and care-home record processes in six months.

    Stated by RHAYADER GROUP PRACTICEStated plannedThe respondent said that this action was planned when they made their response on 2 December 2017.
  3. 3

    Inform patients with positive DVT results that they have been prescribed a three-month course of rivaroxaban.

    Stated by RHAYADER GROUP PRACTICEStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The prescribing failure did not occur at the reviewed care home or GP practice but at subsequent GP practices and care homes.

    Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 report with the discharge-arrangements review lead for consideration.

Verbatim wording from the response

“HIW has noted the findings of the inquest and assure you that this information will be used to inform our work. HIW is currently undertaking a review of discharge arrangements focusing on communication and the quality of documentation used to support patient discharge from secondary to primary healthcare. I can confirm that this report has been shared with the review lead to consider.”

Source location

2017-0329-Response-by-Welsh-Government
Page 1 · response
Published 2 December 2017

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

Audit the DVT referral, treatment-information and care-home record processes in six months.

Verbatim wording from the response

“The practice will audit the above process in 6 months time.”

Source location

2017-0329-Response-by-Rhayader-Group-Practic
Page 1 · response
Published 2 December 2017

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

Inform patients with positive DVT results that they have been prescribed a three-month course of rivaroxaban.

Verbatim wording from the response

“We have discussed this in our practice meeting and have made the following changes.”

Source location

2017-0329-Response-by-Rhayader-Group-Practic
Page 1 · response
Published 2 December 2017

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 prescribing failure did not occur at the reviewed care home or GP practice but at subsequent GP practices and care homes.

Verbatim wording from the response

“Following our review of the information made available to us by Pencombe Hall and Cantiloupe Surgery, we are satisfied that any failure to prescribe a continuing supply of rivaroxaban for Mr Jacks did not occur at either of these two services. At the point of leaving Cantiloupe surgery, Mr Jacks had been prescribed a sufficient amount of this medicine to last for 28 days, and so we conclude that the breakdown in the prescribing system occurred within the GP practices and care homes that Mr Jacks went to after he had been seen at Cantiloupe and had left Pencombe Hall. As outlined in the Regulation 28 Report, Mr Jacks’ last recorded dose of rivaroxaban took place on 12 March. This is some 12 days after his initial prescription from Cantiloupe would have run out had it been administered consistently, and 38 days after he had left Pencombe Hall.”

Source location

2017-0329-Response-by-Care-Quality-Commission
Page 5 · response
Published 2 December 2017

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