PFD report

Neville Welton · Prevention of Future Deaths report

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Issued 17 May 2018•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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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 raised3

  1. Delays in formulating action plans after serious incident investigations and reviews
    Part of recurring concern: Failure to establish effective plans to address identified safety concerns
  2. Failure to implement action plans within agreed timescales
    Part of recurring concern: Failure to implement identified safety actions
  3. Delays in concluding serious incident investigations and reviews
    Part of recurring concern: Inadequate safety incident investigationsPart of recurring concern: Unreliable formal safety-incident management processes
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

    Implement a project-management approach for comprehensive investigations, including completion milestones agreed with the designated Chair.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 8 July 2018.
  2. Action

    Introduce a weekly Incident Review Meeting to review recent incidents, monitor delayed investigations, and drive investigations and action plans to completion.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 8 July 2018.
  3. Action

    Revise the serious-incident investigation model, pairing Corporate Concerns Team staff with catastrophic-incident investigators and expanding staff training capacity.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 8 July 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Legal advice was required before the investigation report could be signed off, delaying completion.

    Stated by Betsi Cadwaladr University LHBUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Delays in formulating action plans after serious incident investigations and reviews

Wider context from the report

“The various factors referred to in paragraph 4 will be further considered at the inquest hearing, however I am concerned firstly by the length of time taken by the Health Board to conclude its Confidential Investigation and to formulate an Action Plan as this was not completed until the 27th of April 2018, some four and a half months after Mr Welton’s death. I am further concerned that notwithstanding that an Action Plan had been established with agreed timescales for implementation of actions, these timescales have not been met and matters remain outstanding at the present time. Whilst this investigation and report relates to the death of Mr Welton, I am concerned generally by the length of time which is taken by the Health Board to conclude its Serious Incident Reviews and thereafter to formulate and implement Action Plans. ”

Is this part of a recurring concern?

Yes — Failure to establish effective plans to address identified safety concerns.

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 implement action plans within agreed timescales

Wider context from the report

“The various factors referred to in paragraph 4 will be further considered at the inquest hearing, however I am concerned firstly by the length of time taken by the Health Board to conclude its Confidential Investigation and to formulate an Action Plan as this was not completed until the 27th of April 2018, some four and a half months after Mr Welton’s death. I am further concerned that notwithstanding that an Action Plan had been established with agreed timescales for implementation of actions, these timescales have not been met and matters remain outstanding at the present time. Whilst this investigation and report relates to the death of Mr Welton, I am concerned generally by the length of time which is taken by the Health Board to conclude its Serious Incident Reviews and thereafter to formulate and implement Action Plans. ”

Is this part of a recurring concern?

Yes — Failure to implement identified safety actions.

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

Delays in concluding serious incident investigations and reviews

Wider context from the report

“The various factors referred to in paragraph 4 will be further considered at the inquest hearing, however I am concerned firstly by the length of time taken by the Health Board to conclude its Confidential Investigation and to formulate an Action Plan as this was not completed until the 27th of April 2018, some four and a half months after Mr Welton’s death. I am further concerned that notwithstanding that an Action Plan had been established with agreed timescales for implementation of actions, these timescales have not been met and matters remain outstanding at the present time. Whilst this investigation and report relates to the death of Mr Welton, I am concerned generally by the length of time which is taken by the Health Board to conclude its Serious Incident Reviews and thereafter to formulate and implement Action Plans. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations; Unreliable formal safety-incident management processes.

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

Implement a project-management approach for comprehensive investigations, including completion milestones agreed with the designated Chair.

Verbatim wording from the response

“3. A project management approach to be used when conducting a comprehensive investigation with milestones for completion signed up to by the designated Chair (see appendix 2). This approach is not yet in place and will be implemented as part of the revised model described above.”

Source location

2018-0150-Response-by-University-Health-Board
Page 3 · response
Published 8 July 2018

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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

Introduce a weekly Incident Review Meeting to review recent incidents, monitor delayed investigations, and drive investigations and action plans to completion.

Verbatim wording from the response

“2. The Health Board is to introduce a weekly Incident Review Meeting (Scoping document Appendix 1) to review on a regular basis all incidents reported on Datix in the previous 7 days. The meeting will be chaired by the Associate Director of Quality Assurance and attended by the senior staff with a specific responsibility for quality and patient safety from each division.”

Source location

2018-0150-Response-by-University-Health-Board
Page 3 · response
Published 8 July 2018

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

Revise the serious-incident investigation model, pairing Corporate Concerns Team staff with catastrophic-incident investigators and expanding staff training capacity.

Verbatim wording from the response

“Moving forward In terms of moving forward a number of actions are being implemented to improve the timeliness of our processes and the development of the action plans:”

Source location

2018-0150-Response-by-University-Health-Board
Page 2 · response
Published 8 July 2018

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

Legal advice was required before the investigation report could be signed off, delaying completion.

Verbatim wording from the response

“• Legal advice in relation to breach of duty, qualifying liability and causation was required and it was assessed that the report could not be signed off by the Chair until this was received.”

Source location

2018-0150-Response-by-University-Health-Board
Page 2 · response
Published 8 July 2018

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