PFD report

Maureen Elizabeth Owens · Prevention of Future Deaths report

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Issued 2 Apr 2024•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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 to book urgent vascular surgery transfers with the Adult Critical Care Service Cymru
    Part of recurring concern: Failure to safely coordinate transfer of urgent surgical patients
  2. Lack of knowledge of the use and operation of the Adult Critical Care Service Cymru
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

    Re-share the agreed transfer process with all Integrated Health Communities and obtain confirmation that it has been cascaded.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 4 April 2024.
  2. Action

    Confirm site management teams at all acute sites as the single contact point for emergency transfers.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 4 April 2024.
  3. Action

    Review the Patient Transfer Procedure (NU19) led by the Head of Nursing and Head of Patient Safety.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 4 April 2024.

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

  1. Position

    ACCTS is commissioned only for patients requiring critical care; non-critical ward-to-ward transfers should be referred to the Welsh Ambulance Service Trust.

    Stated by Betsi Cadwaladr University LHBRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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 to book urgent vascular surgery transfers with the Adult Critical Care Service Cymru

Wider context from the report

“An investigation by the Health Board indicated that the transport request for urgent transfer for vascular surgery should have been booked by the ward with the Adult Critical Care Service Cymru (ACCTS) and not WAST and evidence was received in the course of the inquest which suggests that there is inadequate knowledge of the use of ACCTS and its operation across the whole of the Health Board, including clinical site managers as well as clinicians and nursing staff. ”

Is this part of a recurring concern?

Yes — Failure to safely coordinate transfer of urgent surgical patients.

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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

Lack of knowledge of the use and operation of the Adult Critical Care Service Cymru

Wider context from the report

“An investigation by the Health Board indicated that the transport request for urgent transfer for vascular surgery should have been booked by the ward with the Adult Critical Care Service Cymru (ACCTS) and not WAST and evidence was received in the course of the inquest which suggests that there is inadequate knowledge of the use of ACCTS and its operation across the whole of the Health Board, including clinical site managers as well as clinicians and nursing staff. ”

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

Re-share the agreed transfer process with all Integrated Health Communities and obtain confirmation that it has been cascaded.

Verbatim wording from the response

“1. | Re-share with all Integrated Health Communities (IHCs) the agreed transfer process and seek confirmation from them this has been cascaded | 13/05/2024 (Complete)”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 4 April 2024

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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

Confirm site management teams at all acute sites as the single contact point for emergency transfers.

Verbatim wording from the response

“2. | All acute sites to confirm site management teams as the single point of contact for emergency transfers from their respective sites | 10/06/2024”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 4 April 2024

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 Patient Transfer Procedure (NU19) led by the Head of Nursing and Head of Patient Safety.

Verbatim wording from the response

“4. | Review the Patient Transfer Procedure (NU19) – this work is already underway led by a Head of Nursing and the Head of Patient Safety | 01/08/2024”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 4 April 2024

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

ACCTS is commissioned only for patients requiring critical care; non-critical ward-to-ward transfers should be referred to the Welsh Ambulance Service Trust.

Verbatim wording from the response

“The ACCTS service is currently only commissioned to transfer patients with critical care requirements. Therefore, the referral was correctly made to the Welsh Ambulance Service Trust and the clinical urgency of the transfer should have determined the speed of response and transfer.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 4 April 2024

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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

Mrs Owens did not meet current ACCTS referral or transfer criteria because the proposed transfer was ward-to-ward without identified critical care needs.

Verbatim wording from the response

“They confirm that it is correct that the ACCTS were not contacted about the transfer of Mrs Owens, and from their review confirm Mrs Owens did not meet the current criteria for ACCTS referral or transfer since the proposed transfer was a ward to ward transfer and there were no critical care needs identified.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 4 April 2024

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

    Establish a Health Board-wide focus on intra-hospital transfers between hub and spoke sites through a workshop with national commissioners.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 4 April 2024.
  2. 2

    Develop a monitoring process for transfers and repatriations aligned with the All-Wales repatriation process.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 4 April 2024.
  3. 3

    Oversee delivery of the agreed actions and provide assurance to the Urgent and Emergency Care Programme Group.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 4 April 2024.

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

Establish a Health Board-wide focus on intra-hospital transfers between hub and spoke sites through a workshop with national commissioners.

Verbatim wording from the response

“3. | Health Board wide system focus on service provision required for intra-hospital transfers for specialties between Hub and spoke sites – a workshop date will be finalised (working closely with national commissioners) | 01/08/2024”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 4 April 2024

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 a monitoring process for transfers and repatriations aligned with the All-Wales repatriation process.

Verbatim wording from the response

“5. | Develop a monitoring process for transfers/repatriations in line with the All-Wales repatriation process as part of the Six Goals Programme for Urgent and Emergency Care | 01/09/2024”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 4 April 2024

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

Oversee delivery of the agreed actions and provide assurance to the Urgent and Emergency Care Programme Group.

Verbatim wording from the response

“Delivery against the above actions will be overseen by the Associate Director for Urgent and Emergency Care who will provide assurance to the Urgent and Emergency Care Programme Group that the above actions have been delivered.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 4 April 2024

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