PFD report

Gerwyn James Thomas · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 6 Nov 2018•Carmarthenshire and Pembrokeshire

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
8

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to ensure nursing staff are trained to use the nutritional-needs diagnostic tool correctly
  2. Failure to discuss disputed acute dietetic referrals at a multidisciplinary team meeting
    Part of recurring concern: Unreliable governance and accountability of multidisciplinary team decisionsPart of recurring concern: Unreliable referrals to acute dietetic services
  3. Failure of nursing staff to act on referrals to the acute dietetic service
    Part of recurring concern: Unreliable referrals to acute dietetic services
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.7

  1. Action

    Provide refresher training for registered nurses on the current Nutrition Screening Tool, including additional ward-based sessions when requested.

    Stated by Hywel Dda University LHBStated in progressThe respondent said that this action was in progress when they made their response on 18 March 2019.
  2. Action

    Mandate the NHS Wales Food Record Chart e-learning programme to support nutrition screening and the hospital nutrition care pathway.

    Stated by Hywel Dda University LHBStated completedThe respondent said that this action was complete when they made their response on 18 March 2019.
  3. Action

    Use locum dietetic staff to support acute service capacity while substantive recruitment continues.

    Stated by Hywel Dda University LHBStated completedThe respondent said that this action was complete when they made their response on 18 March 2019.

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

  1. Position

    Low numbers of suitable applicants have prevented recruitment and adequate locum cover for acute dietetic vacancies, limiting staffing capacity.

    Stated by Hywel Dda 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

Failure to ensure nursing staff are trained to use the nutritional-needs diagnostic tool correctly

Wider context from the report

“2. The use of the diagnostic tool to assess a patient’s nutritional need, which nursing staff apply when a patient is admitted, requires training. When wrongly applied, this diagnostic tool will give an unreliable assessment. Training in the use of this diagnostic tool should be made mandatory for all nursing staff. ”

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 discuss disputed acute dietetic referrals at a multidisciplinary team meeting

Wider context from the report

“3. When a treating doctor identifies a need for a patient to be referred to the acute dietetic service, nursing staff should act upon this referral and in circumstances where nursing staff believe that such a referral is unnecessary this should be discussed at a multi-disciplinary team meeting. ”

Is this part of a recurring concern?

Yes — Unreliable governance and accountability of multidisciplinary team decisions; Unreliable referrals to acute dietetic services.

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 of nursing staff to act on referrals to the acute dietetic service

Wider context from the report

“3. When a treating doctor identifies a need for a patient to be referred to the acute dietetic service, nursing staff should act upon this referral and in circumstances where nursing staff believe that such a referral is unnecessary this should be discussed at a multi-disciplinary team meeting. ”

Is this part of a recurring concern?

Yes — Unreliable referrals to acute dietetic services.

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 staffing of the acute dietetic service for timely referral response

Wider context from the report

“1. The acute dietetic service lacks sufficient staff to respond to referrals in a timely way. ”

Is this part of a recurring concern?

Yes — Insufficient dietetic staffing capacity for timely patient care; Unreliable access to clinically necessary dietetic assessment and support.

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

Provide refresher training for registered nurses on the current Nutrition Screening Tool, including additional ward-based sessions when requested.

Verbatim wording from the response

“• In October 2018 the dietetic team initiated a programme of refresher training for Registered Nursing staff in Adult In-Patient locations regarding the current Nutrition Screening Tool which is used to screen a patient’s risk of malnutrition. Additional training sessions have also been provided by the Dietetic team for ward nursing teams when requested.”

Source location

2018-0342-Response-by-University-Health-Board
Page 2 · response
Published 18 March 2019

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

Mandate the NHS Wales Food Record Chart e-learning programme to support nutrition screening and the hospital nutrition care pathway.

Verbatim wording from the response

“• The NHS Wales Food Record Chart: All Wales E Learning programme is a mandated E-Learning module. This was established to support the introduction of the All Wales Hospital Nutrition Care Pathway (of which nutrition risk screening is the first step) and the All Wales Food Chart.”

Source location

2018-0342-Response-by-University-Health-Board
Page 2 · response
Published 18 March 2019

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 locum dietetic staff to support acute service capacity while substantive recruitment continues.

Verbatim wording from the response

“• Pro-actively working to recruit to pending and existing acute dietetic vacancies to ensure the substantive service capacity is maintained. It has not been possible to recruit to vacancies in the acute team in recent months due to very low numbers of suitable applicants, therefore locum dietetic resource is being used while efforts to recruit substantive staff continue.”

Source location

2018-0342-Response-by-University-Health-Board
Page 2 · response
Published 18 March 2019

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 nurses to read and acknowledge the memo setting out referral responsibilities, then disseminate it through nursing leadership across other Health Board sites.

Verbatim wording from the response

“The Head of Nursing at Glangwili General Hospital has sent a memo to all ward staff detailing the action required by the Coroner and how they are to achieve this. She will be asking for every nurse to read the memo and sign to say they have done so and understand their responsibilities. This will then be shared with the wider nursing teams through the Heads of Nursing at the other sites across the Health Board.”

Source location

2018-0342-Response-by-University-Health-Board
Page 3 · response
Published 18 March 2019

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

Recruit substantive staff to fill acute dietetic vacancies while continuing efforts to maintain service capacity.

Verbatim wording from the response

“• Pro-actively working to recruit to pending and existing acute dietetic vacancies to ensure the substantive service capacity is maintained. It has not been possible to recruit to vacancies in the acute team in recent months due to very low numbers of suitable applicants, therefore locum dietetic resource is being used while efforts to recruit substantive staff continue.”

Source location

2018-0342-Response-by-University-Health-Board
Page 2 · response
Published 18 March 2019

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

Propose increased acute dietetic establishment through additional registered dietitians and unregistered dietetic support workers.

Verbatim wording from the response

“• To address the staffing shortfall sustainably, dietetics have proposed an increase in acute dietetic staffing in the service submission to the Health Board intermediate plan, with an incremental increase in registered dieticians and unregistered dietetic support workers.”

Source location

2018-0342-Response-by-University-Health-Board
Page 2 · response
Published 18 March 2019

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

Prioritise high-risk patients for rapid dietetic referral and initiate an enhanced ward-based nutritional care pathway during staffing shortages.

Verbatim wording from the response

“• During November and December it has not been possible to secure adequate locum support to cover existing acute service vacancies; this has necessitated contingency arrangements to ensure patients at the greatest risk are rapidly flagged to dietetics for prioritisation and an enhanced ward based nutritional care pathway has been initiated to reduce the risk of not having timely dietetic access.”

Source location

2018-0342-Response-by-University-Health-Board
Page 2 · response
Published 18 March 2019

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

Low numbers of suitable applicants have prevented recruitment and adequate locum cover for acute dietetic vacancies, limiting staffing capacity.

Verbatim wording from the response

“• Pro-actively working to recruit to pending and existing acute dietetic vacancies to ensure the substantive service capacity is maintained. It has not been possible to recruit to vacancies in the acute team in recent months due to very low numbers of suitable applicants, therefore locum dietetic resource is being used while efforts to recruit substantive staff continue.”

Source location

2018-0342-Response-by-University-Health-Board
Page 2 · response
Published 18 March 2019

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.1

  1. 1

    Seek approval to adopt a different Nutrition Screening Tool for adult inpatient services through the All Wales documentation digitisation project.

    Stated by Hywel Dda University LHBStated plannedThe respondent said that this action was planned when they made their response on 18 March 2019.

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

Seek approval to adopt a different Nutrition Screening Tool for adult inpatient services through the All Wales documentation digitisation project.

Verbatim wording from the response

“• The Health Board will be asked to approve the adoption of a different Nutrition Screening Tool for Adult In-Patient services as part of the All Wales project to digitise nursing documentation in secondary care. The proposed tool has been submitted via the National Dietetic and”

Source location

2018-0342-Response-by-University-Health-Board
Page 2 · response
Published 18 March 2019

Open published response
Back to top

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