PFD report

Rachel Hollister · Prevention of Future Deaths report

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Issued 21 Jul 2015•Gwent

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.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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

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Concerns raised2

  1. Failure of medical staff and porters to follow or be aware of Health Board protocols
  2. Major obstetric haemorrhage protocol failing to meet published clinical guidelines
    Part of recurring concern: Unreliable major haemorrhage response arrangements
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 medical staff and porters to follow or be aware of Health Board protocols

Wider context from the report

“1. Medical staff and porters either did not follow or were unaware of the Health Board’s Protocols ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Major obstetric haemorrhage protocol failing to meet published clinical guidelines

Wider context from the report

“2. The major obstetric haemorrhage protocol does not meet the guidelines published by the Royal College of Obstetricians and Gynaecologists ”

Is this part of a recurring concern?

Yes — Unreliable major haemorrhage response arrangements.

Open source report
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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