Vivian Herbert HUNT · Prevention of Future Deaths report

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Issued 6 Aug 2014•Powys, Bridgend and Glamorgan Valleys

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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

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

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Cwm Taf Morgannwg University Local Health Board

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

  2. Cwm Taf Morgannwg University Local Health Board

    Implement compliance with neurological investigations following head injury.

  3. Cwm Taf Morgannwg University Local Health Board

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

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

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

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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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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