PFD report

Vivian Herbert HUNT · Prevention of Future Deaths report

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Issued 6 Aug 2014•Powys, Bridgend and Glamorgan Valleys

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
1

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 raised1

  1. Failure to make neurological observations after falls and facial injury
    Part of recurring concern: Failure to carry out required neurological observationsPart of recurring concern: Unreliable post-fall assessment and clinical response
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.1

  1. Action

    Implement compliance with neurological investigations following head injury.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 6 August 2014.

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 make neurological observations after falls and facial injury

Wider context from the report

“(1) Despite the fall he suffered on 2nd April and despite suffering a clear injury to his face in the fall on 3rd April 2014, no neurological observations were made of him between 5am on 3rd April and between 12:30 and 13:15pm that day. ”

Is this part of a recurring concern?

Yes — Failure to carry out required neurological observations; Unreliable post-fall assessment and clinical response.

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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

Implement compliance with neurological investigations following head injury.

Verbatim wording from the response

“2. Actions implemented”

Source location

2014-0363-Response-by-University-Health-Board
Page 1 · response
Published 6 August 2014

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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.2

  1. 1

    Develop a corrective Action Plan for Improvement to ensure effective action.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 6 August 2014.
  2. 2

    Monitor incomplete improvement actions through Health Board governance groups until completion.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 6 August 2014.

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 corrective Action Plan for Improvement to ensure effective action.

Verbatim wording from the response

“1. Action taken to plan and monitor improvements”

Source location

2014-0363-Response-by-University-Health-Board
Page 1 · response
Published 6 August 2014

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 incomplete improvement actions through Health Board governance groups until completion.

Verbatim wording from the response

“I can confirm that the actions have been taken forward by the Mental Health Directorate with regards to compliance with neurological investigations post head injury; actions still in progress will be monitored through to completion by the Health Board’s governance groups. The progress made by 29th September 2014 is reflected in the updated plan as attached.”

Source location

2014-0363-Response-by-University-Health-Board
Page 1 · response
Published 6 August 2014

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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