PFD report

Lisa Jayne Townsend · Prevention of Future Deaths report

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Issued 6 May 2026•South Wales 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
2

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
15

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 raised2

  1. Lack of an established protocol for escalation and referral of HPB-related matters to a tertiary centre
    Part of recurring concern: Failure to obtain timely specialist clinical advice when local expertise is insufficientPart of recurring concern: Unreliable referrals to tertiary specialist services
  2. Delays in seeking specialist advice and transferring patients to a tertiary centre
    Part of recurring concern: Failure to obtain timely specialist clinical advice when local expertise is insufficientPart of recurring concern: Unreliable referrals to tertiary specialist 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.8

  1. Action

    Require early consultant-to-consultant referral to the University Hospital of Wales HPB team for specialist advice and transfer decisions.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
  2. Action

    Transfer indicated patients promptly to the University Hospital of Wales HPB team and coordinate timely acceptance while avoiding unnecessary delays.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
  3. Action

    Share lessons from the case with other health boards to inform their inter-hospital pathway arrangements.

    Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 10 July 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Existing health board actions to improve clinical understanding, referral and inter-hospital transfer arrangements are considered appropriate and proportionate to resolve the concerns.

    Stated by Welsh GovernmentExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 an established protocol for escalation and referral of HPB-related matters to a tertiary centre

Wider context from the report

“During the inquest touching the death of Lisa Jayne Townsend, the Coroner heard evidence in respect of the absence of clear guidance and protocol for when a referral should be made by the local hospital (Princess of Wales, Bridgend) to the tertiary centre (University Hospital of Wales) in respect of Hepato-Pancreato-Biliary (HPB) related matters. There was a delay in advice being sought from and transfer to the tertiary centre taking place. There remains no established protocol to assist Clinicians with when they should escalate and seek further specialist advice from their tertiary centre to ensure timely consideration of the patient’s issue. ”

Is this part of a recurring concern?

Yes — Failure to obtain timely specialist clinical advice when local expertise is insufficient; Unreliable referrals to tertiary specialist services.

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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

Delays in seeking specialist advice and transferring patients to a tertiary centre

Wider context from the report

“During the inquest touching the death of Lisa Jayne Townsend, the Coroner heard evidence in respect of the absence of clear guidance and protocol for when a referral should be made by the local hospital (Princess of Wales, Bridgend) to the tertiary centre (University Hospital of Wales) in respect of Hepato-Pancreato-Biliary (HPB) related matters. There was a delay in advice being sought from and transfer to the tertiary centre taking place. There remains no established protocol to assist Clinicians with when they should escalate and seek further specialist advice from their tertiary centre to ensure timely consideration of the patient’s issue. ”

Is this part of a recurring concern?

Yes — Failure to obtain timely specialist clinical advice when local expertise is insufficient; Unreliable referrals to tertiary specialist services.

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

Require early consultant-to-consultant referral to the University Hospital of Wales HPB team for specialist advice and transfer decisions.

Verbatim wording from the response

“We have now changed our pathway and follow up for patients with this complication. Please see the new guidelines of clinicians as set out below.”

Source location

Response from Cwm Taf Morganwg University Health Board
Page 2 · response
Published 10 July 2026

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

Transfer indicated patients promptly to the University Hospital of Wales HPB team and coordinate timely acceptance while avoiding unnecessary delays.

Verbatim wording from the response

“We have now changed our pathway and follow up for patients with this complication. Please see the new guidelines of clinicians as set out below.”

Source location

Response from Cwm Taf Morganwg University Health Board
Page 2 · response
Published 10 July 2026

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

Share lessons from the case with other health boards to inform their inter-hospital pathway arrangements.

Verbatim wording from the response

“As a result, the NHS in Wales has undertaken appropriate and proportionate action in response to your report findings and I hope this resolves your concern. My officials will also ensure the lessons relating to this case are shared with other health boards to inform their pathway arrangements.”

Source location

Response from Cabinet Secretary for Health and Social Care in Wales, Welsh Government
Page 1 · response
Published 10 July 2026

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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

Embed learning through clinical governance, oversee implementation of revised escalation arrangements, confirm communication, and test compliance through audit or case review.

Verbatim wording from the response

“The Health Board will additionally ensure that the learning from this case is embedded through governance processes, with oversight of implementation through the appropriate clinical governance structure, including confirmation that the revised escalation arrangements have been communicated and that compliance can be tested through audit or case review. This expands the assurance language already present in your draft that the Health Board remains committed to enhancing educational initiatives and reinforcing assurance processes.”

Source location

Response from Cardiff and Vale University Health Board
Page 4 · response
Published 10 July 2026

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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

Reinforce the expectation of early consultant-level discussion for suspected bile duct injury and complex benign HPB cases.

Verbatim wording from the response

“In response to the concern identified, the Health Board has reviewed the issues raised in relation to regional escalation to specialist HPB services. Immediate work has been undertaken to reinforce the existing expectation that suspected bile duct injury and comparable complex benign HPB cases should trigger early consultant-level discussion with the tertiary HPB centre at the point of suspicion, including where concern arises intra-operatively or in the post-operative period. This aligns with the emphasis in your current draft on early identification, timely specialist consultation and appropriate transfer.”

Source location

Response from Cardiff and Vale University Health Board
Page 3 · response
Published 10 July 2026

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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 and disseminate a formal regional escalation and referral framework specifying triggers, discussion timescales, contacts and transfer expectations.

Verbatim wording from the response

“To address the Coroner’s concern more explicitly and transparently, the Health Board proposes further work to move from reliance on recognised but partly informal arrangements to a more clearly documented regional framework. This will include the development and dissemination of a formalised escalation and referral framework for suspected bile duct injury and other relevant complex benign HPB pathology, setting out referral triggers, expected timescales for consultant-to-consultant discussion, contact arrangements, and expectations regarding transfer where tertiary management is required. This builds directly on the current draft’s commitment to improve clarity and consistency through more formal frameworks. The Health Board also intends to continue engagement with regional partners, Welsh Government and relevant commissioning bodies regarding the current service model.”

Source location

Response from Cardiff and Vale University Health Board
Page 4 · response
Published 10 July 2026

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 focused communication and education to reinforce referral and escalation principles for suspected bile duct injury.

Verbatim wording from the response

“In addition, focused communication and educational activity is being used to reinforce the existing clinical principles underpinning referral and escalation for suspected bile duct injury. The purpose of this action is to reduce unwarranted variation in practice, strengthen clinician awareness of when specialist input should be sought, and support more reliable application of recognised standards across organisational boundaries.”

Source location

Response from Cardiff and Vale University Health Board
Page 3 · response
Published 10 July 2026

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

Remind relevant partners to use the existing HPB escalation framework, designated contacts and urgent advice procedures, and consider timely transfer.

Verbatim wording from the response

“The Health Board has also taken steps to remind relevant partners of the existing escalation framework for HPB complications, including the need for urgent advice to be sought promptly and for transfer to be considered without avoidable delay where specialist tertiary management is indicated. As reflected in the current draft, this includes reinforcing designated contact avenues, urgent advice procedures and the importance of timely escalation.”

Source location

Response from Cardiff and Vale University Health Board
Page 3 · response
Published 10 July 2026

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 health board actions to improve clinical understanding, referral and inter-hospital transfer arrangements are considered appropriate and proportionate to resolve the concerns.

Verbatim wording from the response

“I note that both health boards named in your report have now responded. These responses outline the steps each organisation has taken to improve understanding among the clinical teams about the delivering this pathway of care. Both health boards have also reported what action they have taken to improve referral and transfer arrangements between their organisations.”

Source location

Response from Cabinet Secretary for Health and Social Care in Wales, Welsh Government
Page 1 · response
Published 10 July 2026

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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

Established clinical standards provide guidance; the principal failure was inconsistent application, not absence of specialist knowledge or access.

Verbatim wording from the response

“The Health Board accepts that, in this case, there was delay in escalation from the treating Health Board ensuring referral for specialist HPB input, and it acknowledges the importance of ensuring greater clarity and consistency in regional referral arrangements for patients with suspected bile duct injury and other complex benign HPB pathology. At the same time, the Health Board considers it important to distinguish between a lack of clinical principles and a lack of formal commissioning arrangements. The management of suspected bile duct injury is guided by established national and international clinical standards which support early recognition, prompt discussion with a specialist HPB centre at the point of suspicion, and transfer where required for definitive expert management. These principles are embedded in surgical training and are recognised as standard practice.”

Source location

Response from Cardiff and Vale University Health Board
Page 2 · response
Published 10 July 2026

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.7

  1. 1

    Review all future bile duct injury cases against the new guidance to assess compliance.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
  2. 2

    Require consultant-level second opinions at the earliest opportunity for suspected or confirmed bile duct injuries.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
  3. 3

    Mandate monthly Morbidity and Mortality review of all bile duct injury cases as part of clinical governance and quality improvement.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
  4. 4

    Require documentation of all referrals and clinical discussions in the Welsh Clinical Portal and patient case notes.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
  5. 5

    Share structured tertiary-centre feedback and learning points with the wider surgical team to support organisational learning.

    Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
  6. 6

    Continue engagement with regional partners, Welsh Government and commissioning bodies regarding the current HPB service model.

    Stated by The Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 10 July 2026.
  7. 7

    Review issues concerning regional escalation to specialist HPB services.

    Stated by The Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.

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 all future bile duct injury cases against the new guidance to assess compliance.

Verbatim wording from the response

“We have now changed our pathway and follow up for patients with this complication. Please see the new guidelines of clinicians as set out below.”

Source location

Response from Cwm Taf Morganwg University Health Board
Page 2 · response
Published 10 July 2026

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 consultant-level second opinions at the earliest opportunity for suspected or confirmed bile duct injuries.

Verbatim wording from the response

“We have now changed our pathway and follow up for patients with this complication. Please see the new guidelines of clinicians as set out below.”

Source location

Response from Cwm Taf Morganwg University Health Board
Page 2 · response
Published 10 July 2026

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 monthly Morbidity and Mortality review of all bile duct injury cases as part of clinical governance and quality improvement.

Verbatim wording from the response

“We have now changed our pathway and follow up for patients with this complication. Please see the new guidelines of clinicians as set out below.”

Source location

Response from Cwm Taf Morganwg University Health Board
Page 2 · response
Published 10 July 2026

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 documentation of all referrals and clinical discussions in the Welsh Clinical Portal and patient case notes.

Verbatim wording from the response

“We have now changed our pathway and follow up for patients with this complication. Please see the new guidelines of clinicians as set out below.”

Source location

Response from Cwm Taf Morganwg University Health Board
Page 2 · response
Published 10 July 2026

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

Share structured tertiary-centre feedback and learning points with the wider surgical team to support organisational learning.

Verbatim wording from the response

“We have now changed our pathway and follow up for patients with this complication. Please see the new guidelines of clinicians as set out below.”

Source location

Response from Cwm Taf Morganwg University Health Board
Page 2 · response
Published 10 July 2026

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 engagement with regional partners, Welsh Government and commissioning bodies regarding the current HPB service model.

Verbatim wording from the response

“To address the Coroner’s concern more explicitly and transparently, the Health Board proposes further work to move from reliance on recognised but partly informal arrangements to a more clearly documented regional framework. This will include the development and dissemination of a formalised escalation and referral framework for suspected bile duct injury and other relevant complex benign HPB pathology, setting out referral triggers, expected timescales for consultant-to-consultant discussion, contact arrangements, and expectations regarding transfer where tertiary management is required. This builds directly on the current draft’s commitment to improve clarity and consistency through more formal frameworks. The Health Board also intends to continue engagement with regional partners, Welsh Government and relevant commissioning bodies regarding the current service model.”

Source location

Response from Cardiff and Vale University Health Board
Page 4 · response
Published 10 July 2026

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 issues concerning regional escalation to specialist HPB services.

Verbatim wording from the response

“In response to the concern identified, the Health Board has reviewed the issues raised in relation to regional escalation to specialist HPB services. Immediate work has been undertaken to reinforce the existing expectation that suspected bile duct injury and comparable complex benign HPB cases should trigger early consultant-level discussion with the tertiary HPB centre at the point of suspicion, including where concern arises intra-operatively or in the post-operative period. This aligns with the emphasis in your current draft on early identification, timely specialist consultation and appropriate transfer.”

Source location

Response from Cardiff and Vale University Health Board
Page 3 · response
Published 10 July 2026

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