PFD report

Vivienne Greener · Prevention of Future Deaths report

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Issued 18 Dec 2023•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
12

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
28

Described in 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 raised12

  1. Unavailability of out-of-hours emergency endoscopy
    Part of recurring concern: Failure to provide timely access to urgent and out-of-hours endoscopy
  2. Upper GI Bleeding Management and Principles of Care guidance no longer fit for purpose
    Part of recurring concern: Unsafe management of significant bleedingPart of recurring concern: Unsafe management of upper gastrointestinal bleeding
  3. Lack of clarity about when to call the Emergency Treatment Team
    Part of recurring concern: Unreliable activation of emergency medical response teams
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.22

  1. Action

    Implement an NHS Wales ambulance patient handover improvement plan for winter 2023/2024.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 28 December 2023.
  2. Action

    Communicate annual priorities requiring health boards to improve ambulance handovers and patient flow.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 28 December 2023.
  3. Action

    Direct the Chief Ambulance Services Commissioner to monitor improvement plans through Emergency Ambulance Services Committee governance.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 28 December 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.8

  1. Position

    Responsibility for delivering health services, including ambulance handover improvements, rests with the health board rather than Welsh Ministers.

    Stated by Welsh GovernmentRedirects 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

Unavailability of out-of-hours emergency endoscopy

Wider context from the report

“1. An out of hours emergency endoscopy is still not available at Glan Clwyd Hospital or in this area of North Wales as the provision has ‘collapsed’ at Wrexham Maelor Hospital, so no referrals can be made; ”

Is this part of a recurring concern?

Yes — Failure to provide timely access to urgent and out-of-hours endoscopy.

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

Upper GI Bleeding Management and Principles of Care guidance no longer fit for purpose

Wider context from the report

“6. The Health Board’s Upper GI Bleeding Management and Principles of Care 2022 is no longer fit for purpose; ”

Is this part of a recurring concern?

Yes — Unsafe management of significant bleeding; Unsafe management of upper gastrointestinal bleeding.

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 clarity about when to call the Emergency Treatment Team

Wider context from the report

“4. There is not a clear understanding of when the Emergency Treatment Team should be called; ”

Is this part of a recurring concern?

Yes — Unreliable activation of emergency medical response teams.

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

Insufficient Emergency Department space for patient demand

Wider context from the report

“2. There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department; ”

Is this part of a recurring concern?

Yes — Insufficient emergency-department 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

Insufficient doctors and nurses for Emergency Department patient demand

Wider context from the report

“2. There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department; ”

Is this part of a recurring concern?

Yes — Insufficient emergency-department capacity for timely patient care; Insufficient emergency-department staffing capacity for safe patient care; Insufficient medical staffing 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

Failure to adequately share investigation learning with practitioners

Wider context from the report

“7. Any learning from the Health Board’s Investigation Report is not adequately shared with its practitioners; ”

Is this part of a recurring concern?

Yes — Failure to reliably disseminate contextualised safety learning to relevant staff.

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 sufficiently identify and action issues from investigation findings

Wider context from the report

“8. A part of the Health Board’s Investigation Report changed in different versions and obscured the reason why the provision of blood products was delayed meaning issues are not sufficiently identified and actioned; ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 record triage of ambulance arrivals at the Emergency Department

Wider context from the report

“3. There is an ineffective triage and record of triage of patients arriving at Glan Clwyd Emergency Department by ambulance; ”

Is this part of a recurring concern?

Yes — Unreliable emergency-department triage.

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 maintain consistent investigation report content

Wider context from the report

“8. A part of the Health Board’s Investigation Report changed in different versions and obscured the reason why the provision of blood products was delayed meaning issues are not sufficiently identified and actioned; ”

Is this part of a recurring concern?

Yes — Unreliable safety investigation reports and disclosure.

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 admit ambulance patients promptly and return ambulances to active duty

Wider context from the report

“9. Ambulances and paramedics are being kept at the Emergency Department as an extension of the hospital and its staff, due to WAST being unable to get their patients admitted into the Emergency Department and back on active duty. ”

Is this part of a recurring concern?

Yes — Delays in ambulance-to-hospital patient handover; Failure to provide timely hospital admission.

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

Ineffective triage of ambulance arrivals at the Emergency Department

Wider context from the report

“3. There is an ineffective triage and record of triage of patients arriving at Glan Clwyd Emergency Department by ambulance; ”

Is this part of a recurring concern?

Yes — Unreliable emergency-department triage.

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 clarity about when to engage the Major Haemorrhage Pathway

Wider context from the report

“5. There is not a clear understanding of when the Major Haemorrhage Pathway should be engaged; ”

Is this part of a recurring concern?

Yes — Unreliable major haemorrhage response arrangements.

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 an NHS Wales ambulance patient handover improvement plan for winter 2023/2024.

Verbatim wording from the response

“In view of my concern, all health board chief executives were directed to prioritise three actions for delivery over the winter months as part of a new NHS Wales ambulance patient handover improvement plan implemented from the festive period 2023/2024. As part of their local plan, the Betsi Cadwaladr University Health Board priority actions include:”

Source location

Response from Welsh Government
Page 3 · response
Published 28 December 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

Communicate annual priorities requiring health boards to improve ambulance handovers and patient flow.

Verbatim wording from the response

“To provide clarity on priorities aligned to A Healthier Wales, I communicate my expectations of health boards and NHS trusts through an annual NHS planning framework. Organisations are expected to produce integrated medium-term plans annually, that respond to the priorities set in the NHS planning framework. The planning framework clearly sets out my expectation that health boards prioritise plans to improve timeliness of ambulance patient handovers to free up ambulance clinicians to respond to patients in the community. Given the relationship between both timely patient discharge and ambulance patient handover, I have also set a priority for improvement in patient flow.”

Source location

Response from Welsh Government
Page 2 · response
Published 28 December 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

Direct the Chief Ambulance Services Commissioner to monitor improvement plans through Emergency Ambulance Services Committee governance.

Verbatim wording from the response

“In addition, I directed the Chief Ambulance Services Commissioner to monitor delivery of plans intended to secure improvements through Emergency Ambulance Services Committee governance mechanisms. The Committee, made up of the seven chief executives of health boards, agreed to work towards eradicating all handover delays over four hours in length by the end of 2024/2025.”

Source location

Response from Welsh Government
Page 3 · response
Published 28 December 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

Hold health board chairs accountable for ambulance handover improvements and seek collective assurance through regular national meetings.

Verbatim wording from the response

“• I hold health board chairs to account for delivery and have incorporated ambulance patient handover improvement as a key objective for all chairs for 2023/2024. I consistently seek assurance from chairs as a collective on their organisations’ commitment to making improvements through regular national meetings.”

Source location

Response from Welsh Government
Page 3 · response
Published 28 December 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

Provide over £500,000 to improve Betsi Cadwaladr emergency-department facilities and waiting-room experiences.

Verbatim wording from the response

“Turning to strategic plans to support improvement in quality of care in emergency departments. I continue to support improvements in emergency departments through a range of measures and this year will publish a Quality Statement for care within the emergency departments, setting out my expectations for the service. To deliver this, we are bringing the voices of our clinical leaders together through the newly established Strategic Network for Critical Care, Trauma and Emergency Medicine and focusing on what matters most to people who use the service. I made over £500,000 of additional funding available to Betsi Cadwaladr University Health Board in December 2023 to support upgrades and improvements in their emergency departments which will enhance both patient and staff experiences in waiting rooms.”

Source location

Response from Welsh Government
Page 3 · response
Published 28 December 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

Provide £50 million in additional funding to support urgent and emergency care improvement.

Verbatim wording from the response

“To enable health boards and partners to deliver against these priorities, I established a national urgent and emergency care improvement programme in April 2022 and, in support, have made £50m in additional funding available over the past two years. I directed each health board to develop a local programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities. Progress has been made across a number of indicators in recent months to help reduce pressure on emergency care services and to release capacity for patients who need an immediate response:”

Source location

Response from Welsh Government
Page 2 · response
Published 28 December 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

Establish a national urgent and emergency care improvement programme and direct health boards to develop local improvement plans.

Verbatim wording from the response

“To enable health boards and partners to deliver against these priorities, I established a national urgent and emergency care improvement programme in April 2022 and, in support, have made £50m in additional funding available over the past two years. I directed each health board to develop a local programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities. Progress has been made across a number of indicators in recent months to help reduce pressure on emergency care services and to release capacity for patients who need an immediate response:”

Source location

Response from Welsh Government
Page 2 · response
Published 28 December 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

Use monthly integrated quality, planning and delivery meetings and six-monthly Joint Executive Team meetings to monitor and challenge ambulance handover performance.

Verbatim wording from the response

“• There are established national mechanisms for monitoring the quality, safety and effectiveness of services provided by health boards across Wales. Assurance is sought and challenge provided on a regular basis regarding ambulance patient handover performance, through ‘integrated quality, planning and delivery (IQPD)’ meetings between Welsh Government, the NHS Executive and NHS organisations.”

Source location

Response from Welsh Government
Page 3 · response
Published 28 December 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

Fund expanded same-day emergency care capacity across north Wales district general hospitals.

Verbatim wording from the response

“• We have funded extensions in capacity for same day emergency care services which are treating and discharging hundreds of patients per month across the three district general hospitals in north Wales, freeing up precious bed capacity;”

Source location

Response from Welsh Government
Page 2 · response
Published 28 December 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 and increase the Emergency Department nurse staffing roster template through the annual staffing review.

Verbatim wording from the response

“The YGC ED department along with the other two sites are in the process of being reviewed as part of the 2023/2024 annual nurse staffing review cycle and have they have proposed that the current staffing roster template is increased.”

Source location

Response from Betso Cadwaladr University Health Board
Page 4 · response
Published 28 December 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

Use the Manchester Triage Tool and electronic Symphony records for ambulance handovers and triage decisions.

Verbatim wording from the response

“Within the ED at YGC, the Manchester Triage Tool is in place (which staff have been trained in) which highlights prioritisation of patients. A waiting room member of the nursing team is in place 24 hours a day, 7 days a week and the triage registered nurse and nurse in charge will address stroke, chest pain and silver trauma – this is for walk in patients prior to formalised triage assessment. All ambulance handovers are triaged by a senior nurse. Triage outcomes and decisions are recorded electronically on Symphony system, which is a relatively new system that was introduced on 30th March 2022.”

Source location

Response from Betso Cadwaladr University Health Board
Page 5 · response
Published 28 December 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 a new incident process for sharing investigation learning with clinicians.

Verbatim wording from the response

“In relation to your concern that incident investigation reports are not shared with clinicians, I can confirm that following concerns from other coroners, a new incident process is being developed and will be implemented in April 2024.”

Source location

Response from Betso Cadwaladr University Health Board
Page 6 · response
Published 28 December 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

Display the Major Haemorrhage Pathway in all clinical areas, including the Emergency Department resuscitation area.

Verbatim wording from the response

“Any member of staff can trigger the Major Haemorrhage Pathway and it is printed on the wall in all clinical areas, including the resuscitation area in ED, and is clearly visible to all. Senior staff who are all very familiar with the pathway are always available and support all resuscitation cases, and can advise if agency staff are unsure or unfamiliar with the pathway.”

Source location

Response from Betso Cadwaladr University Health Board
Page 5 · response
Published 28 December 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

Continue expanding consultant staffing in the Emergency Department, now providing 8.6 whole-time-equivalent consultants plus one locum.

Verbatim wording from the response

“The Emergency Department at YGC is fully staffed with junior doctors, in line with the budgeted provision, and appropriate staffing levels are put in place through rota management each month, with mitigation in place for management of sickness and unplanned absence. In addition, staffing levels have been mitigated with the expansion of Consultant numbers since Mrs Greener’s death, and there are now 8.6 whole time equivalent Consultants plus 1 whole time equivalent locum. Our senior consultants, are also available 24/7 to attend to and support such cases as this, and all core clinical consultant shifts are covered.”

Source location

Response from Betso Cadwaladr University Health Board
Page 2 · response
Published 28 December 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

Display the Medical Emergency Team call process on NEWS charts for clinicians assessing observations.

Verbatim wording from the response

“With regards to understanding when to call the Medical Emergency Team (MET), evidence of the MET call process is included on the National Early Warning Score (NEWS) chart and is clearly visible to all clinicians assessing and reviewing patient recorded observations. For clarity, the Emergency Treatment Team is now known as the Medical Emergency Team.”

Source location

Response from Betso Cadwaladr University Health Board
Page 5 · response
Published 28 December 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 a suitable out-of-hours endoscopy rota.

Verbatim wording from the response

“Provision of out of hours endoscopy remains under review given the historical and on-going concerns and the teams will be working towards the development of a suitable rota.”

Source location

Response from Betso Cadwaladr University Health Board
Page 2 · response
Published 28 December 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

Update the Upper GI Bleeding Management and Principles of Care guideline to align with NICE and British Society of Gastroenterology guidance.

Verbatim wording from the response

“I can confirm this was updated in July 2023 and will be reviewed again in April 2024. This guideline follows the appropriate NICE guidelines and the acute upper GI bleed care bundle from the British Society of Gastroenterology.”

Source location

Response from Betso Cadwaladr University Health Board
Page 6 · response
Published 28 December 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 and formalise additional Emergency Department capacity, including a dedicated speciality waiting area.

Verbatim wording from the response

“Processes are taking place in respect of patient flow to release capacity, however, we are reviewing the opportunity to create additional capacity in terms of infrastructure changes and a review of our current START clinical area. This would create a dedicated speciality waiting area with cubicles for review. This scoping is work in progress, and will be formalised.”

Source location

Response from Betso Cadwaladr University Health Board
Page 5 · response
Published 28 December 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

Map the Emergency Department resource required to meet demand and national recommendations.

Verbatim wording from the response

“The Emergency Department are continuously reviewing staffing in relation to increasing the core numbers to meet national recommendations within the funding envelope available, and work is ongoing to map the resource required to meet demands.”

Source location

Response from Betso Cadwaladr University Health Board
Page 3 · response
Published 28 December 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

Implement the new incident process in April 2024.

Verbatim wording from the response

“In relation to your concern that incident investigation reports are not shared with clinicians, I can confirm that following concerns from other coroners, a new incident process is being developed and will be implemented in April 2024.”

Source location

Response from Betso Cadwaladr University Health Board
Page 6 · response
Published 28 December 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

Add a newly appointed gastroenterologist to the upper gastrointestinal rota from April 2024.

Verbatim wording from the response

“A new Gastroenterologist has been appointed in YGC and will start in April 2024 and they will be part of an upper GI rota.”

Source location

Response from Betso Cadwaladr University Health Board
Page 2 · response
Published 28 December 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

Introduce a report template identifying the final approved investigation version and distinguishing it from drafts.

Verbatim wording from the response

“Finally, regarding your concern that the investigation report changed in different versions and obscured the reason why the provision of blood products was delayed, I understand ████████, IHC Medical Director provided a statement regarding this. Our new incident process mentioned above will introduce a new report template making it clear which version is the final, approved version of the report avoiding any confusion between the final approved version and any draft versions.”

Source location

Response from Betso Cadwaladr University Health Board
Page 6 · response
Published 28 December 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

Responsibility for delivering health services, including ambulance handover improvements, rests with the health board rather than Welsh Ministers.

Verbatim wording from the response

“My response will largely focus upon the ninth matter of concern in the report, regarding the timeliness of ambulance patient handover, and the health board will reply on matters of concerns 1 – 8. My officials have worked with the health board to ensure that our responses are co-ordinated and consistent. It is important to ensure lines of accountability are clear given that responsibility for delivery of services falls with the health board. The role of the Welsh Ministers is to set the strategic direction for health boards and NHS trusts and to hold them to account for delivery of policy.”

Source location

Response from Welsh Government
Page 1 · response
Published 28 December 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

The NEWS chart clearly identifies when clinicians should call the Medical Emergency Team.

Verbatim wording from the response

“With regards to understanding when to call the Medical Emergency Team (MET), evidence of the MET call process is included on the National Early Warning Score (NEWS) chart and is clearly visible to all clinicians assessing and reviewing patient recorded observations. For clarity, the Emergency Treatment Team is now known as the Medical Emergency Team.”

Source location

Response from Betso Cadwaladr University Health Board
Page 5 · response
Published 28 December 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

Glan Clwyd Hospital lacks sufficient demand to support a 24/7 emergency endoscopy service under NICE guidance.

Verbatim wording from the response

“Out of hours emergency endoscopy not available at Glan Clwyd Hospital or in this area of North Wales”

Source location

Response from Betso Cadwaladr University Health Board
Page 1 · response
Published 28 December 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

Resuscitation, haemorrhage management, critical care monitoring and escalation pathways can stabilise most upper gastrointestinal bleeding until endoscopy.

Verbatim wording from the response

“Optimal resuscitation measures, excellent major haemorrhage management, close critical care monitoring (and use in extremis of the Sengstaken tube for variceal bleeds) can stabilise most Upper GI bleeding until endoscopy can be done at the earliest next opportunity. On very rare occasions when patients cannot be stabilised, and patients display evidence of ongoing life threatening bleeding such as overt large volume bleeding, haemodynamic compromise, shock, NEWS scores >8, or high Glasgow Blatchford scores the following key staff should be contacted - the on Call Consultant Physician, Surgeon, ITU team, and ED consultant to lead on the management and coordinate care.”

Source location

Response from Betso Cadwaladr University Health Board
Page 2 · response
Published 28 December 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

The upper gastrointestinal bleeding guideline was updated, follows NICE and British Society of Gastroenterology guidance, and is scheduled for review.

Verbatim wording from the response

“Upper GI Bleeding Management and Principles of Care 2022 is no longer fit for purpose”

Source location

Response from Betso Cadwaladr University Health Board
Page 6 · response
Published 28 December 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

Workforce challenges at Wrexham Maelor Hospital prevent continuation of cross-site cover for urgent upper gastrointestinal bleeds.

Verbatim wording from the response

“As you identified, Wrexham Maelor Hospital (WMH) would previously take over patients with urgent upper gastrointestinal bleeds, once they were stabilised at YGC. This cross-site cover has stopped due to workforce challenges at WMH. Currently the clinicians will adopt the recommendations set out in the Upper GI Bleeding – Management and Principles of Care at YGC ‘pathway. The pathway outlines the following:”

Source location

Response from Betso Cadwaladr University Health Board
Page 1 · response
Published 28 December 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

The Major Haemorrhage Pathway is available to all staff, visibly displayed, and supported by experienced senior staff.

Verbatim wording from the response

“Any member of staff can trigger the Major Haemorrhage Pathway and it is printed on the wall in all clinical areas, including the resuscitation area in ED, and is clearly visible to all. Senior staff who are all very familiar with the pathway are always available and support all resuscitation cases, and can advise if agency staff are unsure or unfamiliar with the pathway.”

Source location

Response from Betso Cadwaladr University Health Board
Page 5 · response
Published 28 December 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

Existing Manchester Triage, continuous nursing cover, senior ambulance triage and electronic recording address emergency department triage concerns.

Verbatim wording from the response

“Within the ED at YGC, the Manchester Triage Tool is in place (which staff have been trained in) which highlights prioritisation of patients. A waiting room member of the nursing team is in place 24 hours a day, 7 days a week and the triage registered nurse and nurse in charge will address stroke, chest pain and silver trauma – this is for walk in patients prior to formalised triage assessment. All ambulance handovers are triaged by a senior nurse. Triage outcomes and decisions are recorded electronically on Symphony system, which is a relatively new system that was introduced on 30th March 2022.”

Source location

Response from Betso Cadwaladr University Health Board
Page 5 · response
Published 28 December 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.6

  1. 1

    Establish the Strategic Network for Critical Care, Trauma and Emergency Medicine to bring clinical leaders together and focus service improvements on users.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 28 December 2023.
  2. 2

    Invest in ambulance clinical triage resources and video consultation technology to manage patients without emergency-department transport.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 28 December 2023.
  3. 3

    Publish a Quality Statement setting expectations for emergency-department care.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 28 December 2023.
  4. 4

    Provide £3 million to recruit 100 Welsh Ambulance Service staff and fund a St John Ambulance transport-avoidance pilot.

    Stated by Welsh GovernmentStated completedThe respondent said that this action was complete when they made their response on 28 December 2023.
  5. 5

    Review the Upper GI haemorrhage protocol in April 2024.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 28 December 2023.
  6. 6

    Maintain monthly executive review of out-of-hours endoscopy risks and progress toward future service provision.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 28 December 2023.

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 the Strategic Network for Critical Care, Trauma and Emergency Medicine to bring clinical leaders together and focus service improvements on users.

Verbatim wording from the response

“Turning to strategic plans to support improvement in quality of care in emergency departments. I continue to support improvements in emergency departments through a range of measures and this year will publish a Quality Statement for care within the emergency departments, setting out my expectations for the service. To deliver this, we are bringing the voices of our clinical leaders together through the newly established Strategic Network for Critical Care, Trauma and Emergency Medicine and focusing on what matters most to people who use the service. I made over £500,000 of additional funding available to Betsi Cadwaladr University Health Board in December 2023 to support upgrades and improvements in their emergency departments which will enhance both patient and staff experiences in waiting rooms.”

Source location

Response from Welsh Government
Page 3 · response
Published 28 December 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

Invest in ambulance clinical triage resources and video consultation technology to manage patients without emergency-department transport.

Verbatim wording from the response

“• We have targeted investment in 999 ambulance clinical triage resources and technology. This includes the use of video consultation technology. Around 4,500 (10-15%) patients across Wales per month are now managed without needing transport to an emergency department;”

Source location

Response from Welsh Government
Page 2 · response
Published 28 December 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

Publish a Quality Statement setting expectations for emergency-department care.

Verbatim wording from the response

“Turning to strategic plans to support improvement in quality of care in emergency departments. I continue to support improvements in emergency departments through a range of measures and this year will publish a Quality Statement for care within the emergency departments, setting out my expectations for the service. To deliver this, we are bringing the voices of our clinical leaders together through the newly established Strategic Network for Critical Care, Trauma and Emergency Medicine and focusing on what matters most to people who use the service. I made over £500,000 of additional funding available to Betsi Cadwaladr University Health Board in December 2023 to support upgrades and improvements in their emergency departments which will enhance both patient and staff experiences in waiting rooms.”

Source location

Response from Welsh Government
Page 3 · response
Published 28 December 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

Provide £3 million to recruit 100 Welsh Ambulance Service staff and fund a St John Ambulance transport-avoidance pilot.

Verbatim wording from the response

“• Welsh Government provided £3m to the Welsh Ambulance Service in 2022 to recruit 100 new staff, and also provided funding for a pilot delivered by St John Ambulance which is supporting around 50% of people referred to the service to safely avoid transport to hospital; and”

Source location

Response from Welsh Government
Page 2 · response
Published 28 December 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 the Upper GI haemorrhage protocol in April 2024.

Verbatim wording from the response

“Additionally, an instruction to ask switchboard to set up a conference call between the ED consultant, ITU consultant on call, consultant Physician and on call Consultant Surgeon to explore local options in North Wales and reach a joint decision. The detail of this process is outlined in the Upper GI haemorrhage protocol and that is due for review in April 2024.”

Source location

Response from Betso Cadwaladr University Health Board
Page 2 · response
Published 28 December 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

Maintain monthly executive review of out-of-hours endoscopy risks and progress toward future service provision.

Verbatim wording from the response

“The provision of out of hours endoscopy services is recognised as a corporate risk for the Health Board and is recorded on the risk register, which is reviewed monthly by the executive team for any escalating clinical concerns, or progress being made against submitted business cases for future provision of the service. Any incident of failure, or delay, to carry out an endoscopy procedure according to National Guidance (explicit in NICE recommendations) is reported via the Datix system, and is investigated by the Central Integrated Health Community Senior Leadership team. If necessary, the incident will be escalated to the Executive team for consideration of a more senior panel oversight to review all treatment actions and decisions in a Rapid Learning Panel, with recommendations for any learning identified through this process.”

Source location

Response from Betso Cadwaladr University Health Board
Page 2 · response
Published 28 December 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