PFD report

Anthony Gwyn Williams · Prevention of Future Deaths report

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Issued 2 Dec 2014•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
3

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 raised3

  1. Lack of clear training or guidance on exceptional deviations from the recognised psychiatric assessment pathway
    Part of recurring concern: Failure of the Emergency Department mental health liaison assessment pathway to provide timely and safe assessment
  2. Insufficient engagement with family and carers about patients' Care and Treatment Plans
    Part of recurring concern: Failure to communicate safety-critical care information effectively between care providers and familiesPart of recurring concern: Failure to involve families and carers in safety-critical care decisions
  3. Failure to ensure continuous access to existing patients' medical records
    Part of recurring concern: Unreliable access to relevant clinical records for safe care
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.2

  1. Action

    Maintain increased out-of-hours psychiatric nursing presence on the Heddfan Adult Unit.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 2 December 2014.
  2. Action

    Explore electronic case records through the national procurement process and determine the preferred approach to developing them.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 2 December 2014.

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

  1. Position

    Family and carer involvement in care planning is legally limited where patients with capacity do not consent, unless overriding public interest justifies disclosure.

    Stated by Betsi Cadwaladr 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

Lack of clear training or guidance on exceptional deviations from the recognised psychiatric assessment pathway

Wider context from the report

“1. Although a memorandum has been issued to staff advising that there may be times when it is appropriate to deviate from the recognised pathway of psychiatric assessment within the Emergency Department, no clear training or guidance has been given to staff as to what may constitute such “exceptional cases”. ”

Is this part of a recurring concern?

Yes — Failure of the Emergency Department mental health liaison assessment pathway to provide timely and safe assessment.

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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

Insufficient engagement with family and carers about patients' Care and Treatment Plans

Wider context from the report

“3. There should be greater engagement with family and carers of patients (with patient consent) to ensure that they are aware of the contents of patient's Care and Treatment Plan especially with regard to the options which may exist in times of crisis. ”

Is this part of a recurring concern?

Yes — Failure to communicate safety-critical care information effectively between care providers and families; Failure to involve families and carers in safety-critical care decisions.

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 ensure continuous access to existing patients' medical records

Wider context from the report

“2. There needs to be access to the medical records of existing patients at all times including evenings and weekends especially regarding a patient's Care and Treatment Plan. ”

Is this part of a recurring concern?

Yes — Unreliable access to relevant clinical records for safe care.

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

Maintain increased out-of-hours psychiatric nursing presence on the Heddfan Adult Unit.

Verbatim wording from the response

“1. Although a memorandum from the Chief of Staff was circulated to all Medical, Inpatient and Psychiatric Liaison staff on 8 September 2014, it did not provide these staff groups with any guidance as to what constitutes ‘exceptional cases’ in terms of where out of hours psychiatric assessments should take place. I am pleased to report that since this incident, we now have a larger number of psychiatric nurses present on the Heddfan Adult Unit out of hours and in similar situations in the future, socially anxious patients such as Mr Williams could be assessed at the Unit and would not need to await psychiatric assessment at the Emergency Department. Notwithstanding this, our Business Manager for Safety & Regulation will fully discuss this matter at the next Operational Management meeting to ensure full understanding and compliance across the Mental Health & Learning Disabilities Division.”

Source location

2014-0523-Response-by-University-Health-Board
Page 1 · response
Published 2 December 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

Explore electronic case records through the national procurement process and determine the preferred approach to developing them.

Verbatim wording from the response

“2. In respect of medical and nursing staff having access to patients’ records, such as Care and Treatment Plans at all times, I can advise you that the adoption of an electronic case record is currently being explored as part of the Community Care Information System national procurement. The Health Board will determine its preferred approach to developing electronic records by March 2015.”

Source location

2014-0523-Response-by-University-Health-Board
Page 1 · response
Published 2 December 2014

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

Family and carer involvement in care planning is legally limited where patients with capacity do not consent, unless overriding public interest justifies disclosure.

Verbatim wording from the response

“general principal if a patient has capacity to make decisions about whether family members or carers are involved in a patient’s care planning and care, then services are obliged to respect that decision unless there is an overriding public interest, which merits disclosure of information. Where the involvement of family and carer’s is accepted by the patient, the sharing of the Care and Treatment Plan would be appropriate. I am assured that all patients are provided with a copy of their Care and Treatment Plans. If a patient lacks capacity to make decisions about the involvement of family or carers there should follow a best interest decision. I would suspect in the majority of cases the involvement of family and carers would be in a person’s best interest.”

Source location

2014-0523-Response-by-University-Health-Board
Page 2 · response
Published 2 December 2014

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

    Discuss out-of-hours psychiatric assessment arrangements at the next Operational Management meeting to ensure understanding and compliance across the division.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 2 December 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

Discuss out-of-hours psychiatric assessment arrangements at the next Operational Management meeting to ensure understanding and compliance across the division.

Verbatim wording from the response

“1. Although a memorandum from the Chief of Staff was circulated to all Medical, Inpatient and Psychiatric Liaison staff on 8 September 2014, it did not provide these staff groups with any guidance as to what constitutes ‘exceptional cases’ in terms of where out of hours psychiatric assessments should take place. I am pleased to report that since this incident, we now have a larger number of psychiatric nurses present on the Heddfan Adult Unit out of hours and in similar situations in the future, socially anxious patients such as Mr Williams could be assessed at the Unit and would not need to await psychiatric assessment at the Emergency Department. Notwithstanding this, our Business Manager for Safety & Regulation will fully discuss this matter at the next Operational Management meeting to ensure full understanding and compliance across the Mental Health & Learning Disabilities Division.”

Source location

2014-0523-Response-by-University-Health-Board
Page 1 · response
Published 2 December 2014

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

Data last updated 7 September 2026