PFD report

Terrance O’Connell · Prevention of Future Deaths report

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Issued 28 Aug 2013•Powys, Bridgend and Glamorgan Valleys

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
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
13

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. Failure of communication between the care home, district nurses and out of hours GP
    Part of recurring concern: Unreliable communication in district nursing care coordination
  2. Failure to provide timely clinical assessment of a patient's condition
    Part of recurring concern: Failure to conduct timely, appropriate clinical assessmentsPart of recurring concern: Failure to provide timely clinical care
  3. Lack of direct monitoring of oral input and urinary output at the care home
    Part of recurring concern: Failure to reliably monitor patient fluid balance
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.11

  1. Action

    Implement a clinical-assessment policy requiring transfer to A&E when health professionals cannot attend within one hour.

    Stated by the proprietor of Monkstone House Residential Home of 1 Locks Common, Porthcawl, CF36 3HUStated completedThe respondent said that this action was complete when they made their response on 28 August 2013.
  2. Action

    Hold senior-staff meetings to reinforce seeking medical advice and ensuring clients are seen by a professional when concerns arise.

    Stated by the proprietor of Monkstone House Residential Home of 1 Locks Common, Porthcawl, CF36 3HUStated completedThe respondent said that this action was complete when they made their response on 28 August 2013.
  3. Action

    Implement urinary input and output monitoring charts for all clients.

    Stated by the proprietor of Monkstone House Residential Home of 1 Locks Common, Porthcawl, CF36 3HUStated completedThe respondent said that this action was complete when they made their response on 28 August 2013.

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

  1. Position

    The communication breakdown was between district nurses and the out-of-hours GP service, not Monkstone House and those services.

    Stated by the proprietor of Monkstone House Residential Home of 1 Locks Common, Porthcawl, CF36 3HUDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 communication between the care home, district nurses and out of hours GP

Wider context from the report

“(1) There was a communication breakdown between the care home, district nurses and out of hours GP on the 3rd May 2013 resulting in Mr O’Connell not being seen by any clinical staff. ”

Is this part of a recurring concern?

Yes — Unreliable communication in district nursing care coordination.

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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

Failure to provide timely clinical assessment of a patient's condition

Wider context from the report

“(3) Mr O’Connell did not have any clinical assessment of his condition for 2 days until his admission to hospital ”

Is this part of a recurring concern?

Yes — Failure to conduct timely, appropriate clinical assessments; Failure to provide timely clinical care.

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

Lack of direct monitoring of oral input and urinary output at the care home

Wider context from the report

“(2) There was no direct monitoring of his oral input and urinary output at the care home which would have provided further evidence in support of a urinary tract infection. ”

Is this part of a recurring concern?

Yes — Failure to reliably monitor patient fluid balance.

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

Implement a clinical-assessment policy requiring transfer to A&E when health professionals cannot attend within one hour.

Verbatim wording from the response

“Notwithstanding this, the Monkstone House policy has now been changed with regard to clinical assessment. The effect of this is that if a health professional (either district nurse or GP) will not attend Monkstone House within one hour of being called, the patient will be sent to the local A&E Department.”

Source location

2013-0218-Response-by-Gabbandco
Page 2 · response
Published 28 August 2013

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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

Hold senior-staff meetings to reinforce seeking medical advice and ensuring clients are seen by a professional when concerns arise.

Verbatim wording from the response

“3 Meetings have been held with senior staff and if there are any concerns regarding clients, staff are to seek medical advice, ensuring that all clients are seen by a professional. If, for whatever reason clients cannot be seen at Monkstone House and if out of hours GP and nurses will not attend, Monkstone House will send the client to A&E department for assessment as soon as practical.”

Source location

2013-0218-Response-by-Gabbandco
Page 3 · response
Published 28 August 2013

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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 urinary input and output monitoring charts for all clients.

Verbatim wording from the response

“Notwithstanding this, the Monkstone House policy has been reviewed following Mr O’Connell’s death. The catheter care policy has been reviewed and all staff have now been given extra training. In addition, urinary input and output monitoring charts have been put in place for all clients. The Monkstone House Policy and procedures which are now in place have also been reviewed and approved by CSSIW, as documented in Monkstone House’s recent inspection report which took place in August 2013.”

Source location

2013-0218-Response-by-Gabbandco
Page 2 · response
Published 28 August 2013

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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

Record the substance of telephone conversations with families and professional agencies.

Verbatim wording from the response

“1 Telephone calls are now recorded to confirm the substance of all conversations between families and all other professional agencies.”

Source location

2013-0218-Response-by-Gabbandco
Page 3 · response
Published 28 August 2013

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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

Review and revise the catheter-care and fluid-input/output procedures.

Verbatim wording from the response

“Notwithstanding this, the Monkstone House policy has been reviewed following Mr O’Connell’s death. The catheter care policy has been reviewed and all staff have now been given extra training. In addition, urinary input and output monitoring charts have been put in place for all clients. The Monkstone House Policy and procedures which are now in place have also been reviewed and approved by CSSIW, as documented in Monkstone House’s recent inspection report which took place in August 2013.”

Source location

2013-0218-Response-by-Gabbandco
Page 2 · response
Published 28 August 2013

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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 clear out-of-hours escalation process for resolving disputed clinical issues.

Verbatim wording from the response

“Issue identified: Lack of process in place to escalate the issue re the dispute between the two clinicians.”

Source location

2013-0218-Response-by-University-Health-Board
Page 10 · response
Published 28 August 2013

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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 clear, auditable message sheets for out-of-hours district nursing referrals through the Princess of Wales Hospital switchboard.

Verbatim wording from the response

“The Health Board has implemented a clear and accurate message sheet, SBAR (Situation, Background, Assessment, Recommendation), for the switchboard staff at the Princess of Wales Hospital to record all of hours requests for District Nurses in greater detail. The SBAR forms will ensure clear, audible records of referrals to the District Nursing Service in the Bridgend Locality, supporting safe, high quality patient care and the ability to review information and audit.”

Source location

2013-0218-Response-by-University-Health-Board
Page 1 · response
Published 28 August 2013

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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

Introduce a Bridgend weekend rota of on-duty district nurse mobile telephone numbers for the out-of-hours GP service.

Verbatim wording from the response

“The District Nurses in Swansea and Neath Port Talbot Locality currently provide the GP OOH Service with a weekend rota of the District Nurse’s on duty mobile telephone numbers. It is planned that this system will be introduced in October 2013, in Bridgend, once the new 24 hour shift pattern is introduced.”

Source location

2013-0218-Response-by-University-Health-Board
Page 2 · response
Published 28 August 2013

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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 SBAR referral and handover documentation for district nursing and out-of-hours GP communication, with staff training on its use.

Verbatim wording from the response

“Issue identified: Need for clarity in communication with out of hours GP service.”

Source location

2013-0218-Response-by-University-Health-Board
Page 9 · response
Published 28 August 2013

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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

Disseminate reminders to out-of-hours GPs requiring direct discussion with the clinician accepting responsibility for a patient's care.

Verbatim wording from the response

“████████ has written to all the out of hours GP’s to remind them that they must speak directly to the clinician who they wish to involve in the patient’s care and ensure that responsibility has been passed to that person. It has been pointed out that this procedure must be followed at shift changing times and outstanding problems are communicated verbally and directly to the GP coming on shift.”

Source location

2013-0218-Response-by-University-Health-Board
Page 2 · response
Published 28 August 2013

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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

Require direct clinician-to-clinician handover of care and verbal communication of outstanding problems during shift changes.

Verbatim wording from the response

“████████ Clinical Manager for the GP OOH Service has discussed this case on two occasions with nurse management and agreed that in future all handover of care should be made person to person and not via messages left at switchboard.”

Source location

2013-0218-Response-by-University-Health-Board
Page 2 · response
Published 28 August 2013

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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

The communication breakdown was between district nurses and the out-of-hours GP service, not Monkstone House and those services.

Verbatim wording from the response

“You have indicated that in your view there was a communication breakdown between the care home, the district nurses and the out of hours GP service on 3rd May 2013 resulting in Mr O’Connell not been seen by any clinical staff. With respect, our clients do not accept that there was a communication problem between the three parties who you have indentified. The communication breakdown (assuming that such was the case) was between the district nurses and the GP out of hours service.”

Source location

2013-0218-Response-by-Gabbandco
Page 1 · response
Published 28 August 2013

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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

The district nursing assessment was appropriate because the catheter was draining freely; the patient required medical rather than nursing assessment.

Verbatim wording from the response

“The district nursing staff made an appropriate assessment on the information supplied by the care home i.e. that the catheter was draining freely, and therefore the cause of the pain would not have been a blocked catheter.”

Source location

2013-0218-Response-by-University-Health-Board
Page 7 · response
Published 28 August 2013

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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.2

  1. 1

    Provide additional catheter-care training to all staff.

    Stated by the proprietor of Monkstone House Residential Home of 1 Locks Common, Porthcawl, CF36 3HUStated completedThe respondent said that this action was complete when they made their response on 28 August 2013.
  2. 2

    Discontinue offering respite facilities to clients.

    Stated by the proprietor of Monkstone House Residential Home of 1 Locks Common, Porthcawl, CF36 3HUStated completedThe respondent said that this action was complete when they made their response on 28 August 2013.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Staff observed and recorded no significant deterioration before Sunday, when emergency treatment became necessary.

    Stated by the proprietor of Monkstone House Residential Home of 1 Locks Common, Porthcawl, CF36 3HUDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    The family decided that the resident should remain at Monkstone House rather than be sent to hospital, and staff followed that decision.

    Stated by the proprietor of Monkstone House Residential Home of 1 Locks Common, Porthcawl, CF36 3HURedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 additional catheter-care training to all staff.

Verbatim wording from the response

“Notwithstanding this, the Monkstone House policy has been reviewed following Mr O’Connell’s death. The catheter care policy has been reviewed and all staff have now been given extra training. In addition, urinary input and output monitoring charts have been put in place for all clients. The Monkstone House Policy and procedures which are now in place have also been reviewed and approved by CSSIW, as documented in Monkstone House’s recent inspection report which took place in August 2013.”

Source location

2013-0218-Response-by-Gabbandco
Page 2 · response
Published 28 August 2013

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

Discontinue offering respite facilities to clients.

Verbatim wording from the response

“4 Monkstone House is no longer offering respite facilities to clients.”

Source location

2013-0218-Response-by-Gabbandco
Page 3 · response
Published 28 August 2013

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

Staff observed and recorded no significant deterioration before Sunday, when emergency treatment became necessary.

Verbatim wording from the response

“From the Friday to Sunday Mr O’Connell was monitored by staff at Monkstone House and this was recorded in Monkstone House’s daily logs. Mr O’Connell was checked hourly throughout the night and his family were kept informed of his condition. No concerns were expressed and no visits were made by the family. Senior staff followed the family’s decision not to send Mr O’Connell to A&E. However, if senior staff felt at any point that Mr O’Connell’s condition was deteriorating any further, then medical advice would have been sought immediately, notwithstanding the fact that Mr O’Connell’s family had requested that he should not be admitted to hospital. Throughout the period from Friday to Sunday Mr O’Connell’s catheter was draining. Mr O’Connell appeared to be his normal self and in a jovial mood, evidence of which is contained in his daily records.”

Source location

2013-0218-Response-by-Gabbandco
Page 3 · response
Published 28 August 2013

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

The family decided that the resident should remain at Monkstone House rather than be sent to hospital, and staff followed that decision.

Verbatim wording from the response

“The last phone call to ████████ was at 12.40am. During the course of this telephone conversation a senior member of staff at Monkstone House informed ████████ that neither the district nurses nor the out of hours GP was going to attend to Mr O’Connell at Monkstone House. ████████ did not want to arrange for Mr O’Connell to go to A&E. ████████ informed the member of staff that he had spoken to the GP out of hours and he was happy for Mr O’Connell to remain at Monkstone House and he would ring in the morning to see what progress had been made. Staff at Monkstone continued to monitor Mr O’Connell throughout the night and there is documentation available to confirm this. No concerns were noted during this time.”

Source location

2013-0218-Response-by-Gabbandco
Page 2 · response
Published 28 August 2013

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