PFD report

Malcolm Ralph Unwin · Prevention of Future Deaths report

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Issued 17 Aug 2023•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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 include bed rail assessment in the Welsh Nursing Care Record
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Unreliable bedrail safety controls
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.3

  1. Action

    Finalise and introduce the updated Bed Rails Procedure.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
  2. Action

    Remind ward managers, matrons and heads of nursing about paper-based bed-rail assessments and provide materials for staff safety briefings and ward display.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
  3. Action

    Raise the bed-rail assessment issue nationally to expedite standardisation and inclusion in the WNCR.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.

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

  1. Position

    Creation of a standardised bed-rails assessment tool is being led nationally by Cwm Taf Morgannwg University Health Board.

    Stated by Betsi Cadwaladr University LHBRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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 include bed rail assessment in the Welsh Nursing Care Record

Wider context from the report

“There was no evidence that the deceased had been assessed for bed rails, whilst in hospital although it is probable that they were in due at the time of his fall. Evidence was given that the bed rail assessment is not currently a part of the Welsh Nursing Care Record which staff access via iPad. In the absence of this being a part of the WNCR I am concerned that this assessment may be missed, and that future death may occur as a result. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable bedrail safety controls.

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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

Finalise and introduce the updated Bed Rails Procedure.

Verbatim wording from the response

“We are also in the process of finalising our updated Bed Rails Procedure which will be live within the next few weeks.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 September 2023

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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

Remind ward managers, matrons and heads of nursing about paper-based bed-rail assessments and provide materials for staff safety briefings and ward display.

Verbatim wording from the response

“In the interim period, I can confirm we have written to all ward managers, matrons and heads of nursing reminding them of the process for paper based assessment forms. We have provided information which can be used on ward safety briefs with staff and which can also be visibly placed in wards to remind staff.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 September 2023

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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

Raise the bed-rail assessment issue nationally to expedite standardisation and inclusion in the WNCR.

Verbatim wording from the response

“Following your Notice, we raised this issue nationally in order to expedite this process. The issue was discussed at the National Deputy Directors of Nursing Meeting on 07 September 2023, and in response Cwm Taf Morgannwg University Health Board has taken the lead in establishing a national working group to create a standardised bed rails assessment tool across Wales, and to propose this single version for inclusion in the WNCR.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 September 2023

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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

Creation of a standardised bed-rails assessment tool is being led nationally by Cwm Taf Morgannwg University Health Board.

Verbatim wording from the response

“Following your Notice, we raised this issue nationally in order to expedite this process. The issue was discussed at the National Deputy Directors of Nursing Meeting on 07 September 2023, and in response Cwm Taf Morgannwg University Health Board has taken the lead in establishing a national working group to create a standardised bed rails assessment tool across Wales, and to propose this single version for inclusion in the WNCR.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 September 2023

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.3

  1. 1

    Keep the bed-rail assessment issue open on the action tracker and escalate delays for executive intervention if necessary.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
  2. 2

    Complete required actions and develop a response to the National Patient Safety Alert on bed-rail safety considerations.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
  3. 3

    Add the bed-rail assessment issue to the risk register and maintain patient-safety visibility through patient safety and senior nursing team ownership.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.

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

Keep the bed-rail assessment issue open on the action tracker and escalate delays for executive intervention if necessary.

Verbatim wording from the response

“As this is national, collaborative work involving all Health Boards and Trusts in NHS Wales then I cannot advise a specific completion date. However I can confirm that this will remain open on our action tracker and should the matter be delayed, it will be escalated for executive director intervention.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 September 2023

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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

Complete required actions and develop a response to the National Patient Safety Alert on bed-rail safety considerations.

Verbatim wording from the response

“Finally, I would also advise that the Welsh Government (WG) and the Medicines and Healthcare products Regulatory Agency (MHRA) issued a National Patient Safety Alert on 30 August 2023 which includes safety considerations around bed rails. We are currently working through the actions required to comply with this alert and developing our response, which requires actions to be completed by 01 March 2024.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 September 2023

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

Add the bed-rail assessment issue to the risk register and maintain patient-safety visibility through patient safety and senior nursing team ownership.

Verbatim wording from the response

“We have also added this issue to our risk register until the transition to the WNCR is complete. This risk will be owned by our patient safety team and senior nursing team which will ensure the issue, and the risk to patient safety, remains visible until the national work is complete.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 September 2023

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