PFD report

Mr Twm Bryn · Prevention of Future Deaths report

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Issued 17 Feb 2023•North West Wales

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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
18

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.

Report evidence summary

Concerns raised4

  1. Insufficient Primary Mental Health Services staffing causing assessment and counselling support delays
    Part of recurring concern: Insufficient mental health service capacity for timely patient care
  2. Interim support for mild or low-risk patients requiring self-referral
    Part of recurring concern: Unreliable interim mental health support during care transitions
  3. Failure to offer or arrange interim contact or monitoring for patients awaiting counselling
    Part of recurring concern: Unreliable interim mental health support during care transitions
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

    Run additional assessment clinics using overtime staffing to address sickness and vacancy-related shortfalls.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 February 2023.
  2. Action

    Progress the unallocated-patient waiting-list protocol through consultation, approval, distribution and team launch.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2023.
  3. Action

    Offer additional shifts to mental health staff in West and Central services to complete assessments.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 February 2023.

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

  1. Position

    Unfilled vacancies and recruitment difficulties limit the ability to reduce waiting lists, caseloads and delays in access to care.

    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

Insufficient Primary Mental Health Services staffing causing assessment and counselling support delays

Wider context from the report

“(1) Continued staffing pressures within Primary Mental Health Services resulting in assessment delays and waiting lists for support e.g the waiting list for LPMHSS counselling remains at 4 – 6 months. There was no evidence that the waiting list would improve moving forward. ”

Is this part of a recurring concern?

Yes — Insufficient mental health service capacity for timely patient care.

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

Interim support for mild or low-risk patients requiring self-referral

Wider context from the report

“(2) Whilst awaiting counselling, the only interim support available to patients that are assessed as mild or low risk, are services that come with a requirement to self-refer, despite lack of motivation being a common symptom. The LPMHSS does not have a standardised process for referring low risk patients for interim support and no interim contact or monitoring is offered or arranged (unless patients have self-referred to an organisation providing such services). ”

Is this part of a recurring concern?

Yes — Unreliable interim mental health support during care transitions.

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 offer or arrange interim contact or monitoring for patients awaiting counselling

Wider context from the report

“(2) Whilst awaiting counselling, the only interim support available to patients that are assessed as mild or low risk, are services that come with a requirement to self-refer, despite lack of motivation being a common symptom. The LPMHSS does not have a standardised process for referring low risk patients for interim support and no interim contact or monitoring is offered or arranged (unless patients have self-referred to an organisation providing such services). ”

Is this part of a recurring concern?

Yes — Unreliable interim mental health support during care transitions.

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 standardised LPMHSS referral process for low-risk patients’ interim support

Wider context from the report

“(2) Whilst awaiting counselling, the only interim support available to patients that are assessed as mild or low risk, are services that come with a requirement to self-refer, despite lack of motivation being a common symptom. The LPMHSS does not have a standardised process for referring low risk patients for interim support and no interim contact or monitoring is offered or arranged (unless patients have self-referred to an organisation providing such services). ”

Is this part of a recurring concern?

Yes — Unreliable interim mental health support during care transitions; Unreliable mental health referral pathways.

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

Run additional assessment clinics using overtime staffing to address sickness and vacancy-related shortfalls.

Verbatim wording from the response

“Assessment clinics are planned utilising overtime staff to take into account any shortfall in staffing due to sickness absence and vacancies. There is a backlog of assessments despite this with the additional work only providing a short term maintenance position that is not sustainable in the longer term. We are exploring block booking of agency staff as a short term staffing solution to bring the service back into alignment with the Mental Health Measure performance standards.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 27 February 2023

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

Progress the unallocated-patient waiting-list protocol through consultation, approval, distribution and team launch.

Verbatim wording from the response

“Due to the variation in practice across the teams in terms of managing patients on a waiting list, an Unallocated Patient Waiting List Protocol has been developed. This draft protocol ensures that service users referred to the Health Board Community Mental Health Teams and Local Primary Mental Health Support Services are managed efficiently, equitably and consistently. The draft protocol will now progress through consultation, approval and distribution.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 3 · response
Published 27 February 2023

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

Offer additional shifts to mental health staff in West and Central services to complete assessments.

Verbatim wording from the response

“The Service Managers for Community Mental Health Services have been directed to offer additional shifts to staff working in other mental health services in West and Central to complete assessments.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 3 · response
Published 27 February 2023

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

Run a divisional recruitment drive using an external specialist recruitment firm.

Verbatim wording from the response

“Recognising the difficulty in recruiting to vacancies, as outlined earlier, a recruitment drive has been launched Divisionally using an external specialist firm, Just R Recruitment, to attract staff to the area. A review of job descriptions for LPMHSS is under way to consider what amendments would be required in order to recruit non-nursing care professionals such as Social Workers and Occupational Therapists, which would provide a wider scope of recruitment.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 3 · response
Published 27 February 2023

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 LPMHSS job descriptions to assess amendments enabling recruitment of non-nursing care professionals.

Verbatim wording from the response

“Recognising the difficulty in recruiting to vacancies, as outlined earlier, a recruitment drive has been launched Divisionally using an external specialist firm, Just R Recruitment, to attract staff to the area. A review of job descriptions for LPMHSS is under way to consider what amendments would be required in order to recruit non-nursing care professionals such as Social Workers and Occupational Therapists, which would provide a wider scope of recruitment.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 3 · response
Published 27 February 2023

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 expanding counselling options in the West to increase capacity and reduce waiting times.

Verbatim wording from the response

“Discussions are in progress regarding expanding additional counselling options made available in the West. This will create more capacity for counselling and reduce waiting times.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 3 · response
Published 27 February 2023

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 111+2 staff contact patients fortnightly to review needs and offer support while improvements are developed.

Verbatim wording from the response

“We recognise many of these improvements will take some time to develop and embed, and in many cases are reliant on the recruitment of staff. In the short term, 111+2 staff will contact patients on a fortnightly basis to review needs and offer any support as required.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 4 · response
Published 27 February 2023

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 assessment appointment scheduling and consider administrative or non-registered staff for scheduling tasks.

Verbatim wording from the response

“A scoping review is underway regarding scheduling of appointments for assessment, which has been found to take up a portion of time for clinical staff. Consideration is being given to administrative or non-registered staff performing this task, which would release more clinical time for assessments and interventions.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 3 · response
Published 27 February 2023

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

Explore block-booking agency staff as a short-term measure to reduce assessment backlogs and restore performance-standard alignment.

Verbatim wording from the response

“Assessment clinics are planned utilising overtime staff to take into account any shortfall in staffing due to sickness absence and vacancies. There is a backlog of assessments despite this with the additional work only providing a short term maintenance position that is not sustainable in the longer term. We are exploring block booking of agency staff as a short term staffing solution to bring the service back into alignment with the Mental Health Measure performance standards.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 27 February 2023

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

Unfilled vacancies and recruitment difficulties limit the ability to reduce waiting lists, caseloads and delays in access to care.

Verbatim wording from the response

“Any patients currently on waiting lists are supported by the duty teams whilst awaiting allocation. The waiting lists are due to currently unfilled vacancies that have been placed into recruitment but unfortunately not all have attracted candidates and have remained unfilled despite being advertised a number of times.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 27 February 2023

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.9

  1. 1

    Rationalise Community Mental Health Team administrative processes and agree division-wide Standard Operating Procedures.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2023.
  2. 2

    Strengthen public awareness through information sessions for patients, referrers, carers, families and community organisations.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2023.
  3. 3

    Review commissioned services and strengthen contractual arrangements supporting North Wales mental health provision.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 February 2023.
  4. 4

    Develop and refine short- and long-term LPMHSS service redesign options with partners and an Equality Impact Assessment.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2023.
  5. 5

    Require the Mental Health and Learning Disability Division to report improvement-action progress to the Health Board Leadership Team in three months.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 February 2023.
  6. 6

    Monitor progress of the improvement actions in response to the Notice.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2023.
  7. 7

    Undertake Care and Treatment Plan reviews to improve compliance with required standards.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 February 2023.
  8. 8

    Undertake an annual Mental Health Measure caseload audit across the Division.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2023.
  9. 9

    Scope demand, venue availability and costs for face-to-face therapeutic groups while continuing virtual group provision.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2023.

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

  1. 1

    Venue availability, costs, restrictions and risks to clients and communities constrain universal face-to-face group provision.

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

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

Rationalise Community Mental Health Team administrative processes and agree division-wide Standard Operating Procedures.

Verbatim wording from the response

“Work has begun to rationalise existing administrative processes across the Community Mental Health Teams to ensure we have removed where possible any variation in practice, and Standard Operating Procedures are being agreed for the Division as a whole.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 27 February 2023

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

Strengthen public awareness through information sessions for patients, referrers, carers, families and community organisations.

Verbatim wording from the response

“We will also continue to strengthen our working with patients, referrers, carers and families to develop public awareness to include information sessions held in local ICAN Hubs, GP Surgeries, Emergency Departments, Carer Groups and Third Party Organisations. Our helpline services will also continue to be a source of support.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 4 · response
Published 27 February 2023

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 commissioned services and strengthen contractual arrangements supporting North Wales mental health provision.

Verbatim wording from the response

“We will, alongside our internal service redesign, be reviewing our commissioned services to ensure we have robust contractual agreements that complement and enhance mental health services for the population of North Wales.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 27 February 2023

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 and refine short- and long-term LPMHSS service redesign options with partners and an Equality Impact Assessment.

Verbatim wording from the response

“I can advise that, as part of our response to the ministerial priorities for 2024/2025, we are looking at service change and redesign of our Local Primary Mental Health Support Services (LPMHSS). A workshop has taken place with key leads across the Division including team managers, our Deputy Medical Director and team members from our partnerships, planning and strategy teams to look at short term interim solutions along with the longer term service redesign options/models. When a shortlist of options is”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 27 February 2023

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

Require the Mental Health and Learning Disability Division to report improvement-action progress to the Health Board Leadership Team in three months.

Verbatim wording from the response

“I will also be requiring the MHLD Division to report to the Health Board Leadership Team, chaired by the CEO, on the progress of these improvement actions in 3 months’ time.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 4 · response
Published 27 February 2023

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

Monitor progress of the improvement actions in response to the Notice.

Verbatim wording from the response

“As this response describes a wide array of actions, we will closely monitor the actions we are taking in response to the Notice.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 4 · response
Published 27 February 2023

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

Undertake Care and Treatment Plan reviews to improve compliance with required standards.

Verbatim wording from the response

“Staff have been individually contacted with the names of their patients who currently have an expired Care and Treatment Plan (CTP), and have plans in place to make improvements to their compliance by undertaking CTP reviews with their patients. CTP compliance is routinely discussed in both monthly managerial supervision and on a case by case basis. Staff also receive a weekly update specific to their caseload and in addition also receive a list of those patient CTPs that will expire within the next 3 months to assist and inform them to bring their compliance back into alignment with the Mental Health Measure compliance standard required.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 3 · response
Published 27 February 2023

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

Undertake an annual Mental Health Measure caseload audit across the Division.

Verbatim wording from the response

“An Annual Mental Health Measure Caseload Audit is currently being undertaken across the Division.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 4 · response
Published 27 February 2023

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

Scope demand, venue availability and costs for face-to-face therapeutic groups while continuing virtual group provision.

Verbatim wording from the response

“Face to face groups are being scoped in terms of demand, third party venue availability and costs (in light of Covid-19 restrictions and the potential risk to individual clients and their communities through prolonged exposure in small environments). 1:1 interventions are undertaken on a patient choice basis. Virtual groups are consistently being provided and are well received by a proportion of service users - the intention is to provide virtual groups for the majority (in terms of accessibility and logistics) with face to face provided for those that have logistical issues or whose needs are better met in a face to face environment.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 27 February 2023

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

Venue availability, costs, restrictions and risks to clients and communities constrain universal face-to-face group provision.

Verbatim wording from the response

“Face to face groups are being scoped in terms of demand, third party venue availability and costs (in light of Covid-19 restrictions and the potential risk to individual clients and their communities through prolonged exposure in small environments). 1:1 interventions are undertaken on a patient choice basis. Virtual groups are consistently being provided and are well received by a proportion of service users - the intention is to provide virtual groups for the majority (in terms of accessibility and logistics) with face to face provided for those that have logistical issues or whose needs are better met in a face to face environment.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 27 February 2023

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