PFD report

Jennifer Ann Trigger · Prevention of Future Deaths report

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Issued 1 Mar 2024•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
8

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 of the bleep system to convey information electronically
    Part of recurring concern: Unreliable communication of patient-care information between clinical staffPart of recurring concern: Unreliable hospital bleep systems for urgent clinical communication
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.4

  1. Action

    Replace Ysbyty Gwynedd’s on-site paging with an integrated critical messaging service.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 6 March 2024.
  2. Action

    Test WiFi telephones and smartphone messaging applications with frontline clinicians to assess future communication options.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 6 March 2024.
  3. Action

    Upgrade critical messaging services at Ysbyty Glan Clwyd and Wrexham Maelor Hospital.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.

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 the bleep system to convey information electronically

Wider context from the report

“There was a miscommunication or misunderstanding when a ward nurse bleeped a junior doctor with a view to action being taken in relation to the administration of the beriplex infusion. This resulted in a delay in the doctor attending as she did not prioritise a task which was time critical and the subsequent delays resulted in an unrecoverable deterioration in the patient’s condition. Evidence was received in the course of the inquest that the current bleep system did not enable information to be conveyed electronically and that this in turn created a risk of misunderstanding as to work requirements and hence impacted upon prioritisation of tasks and therefore potential delays, the effects of which (as in this case) could be catastrophic in terms of patient safety. Evidence was also given that alternative systems existed that had the potential for mitigating or eliminating such risk by way of the electronic transfer of information and requests to doctors. ”

Is this part of a recurring concern?

Yes — Unreliable communication of patient-care information between clinical staff; Unreliable hospital bleep systems for urgent clinical communication.

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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

Replace Ysbyty Gwynedd’s on-site paging with an integrated critical messaging service.

Verbatim wording from the response

“The project involves the replacement of existing on-site paging at Ysbyty Gwynedd in Bangor with an integrated critical messaging service, as part of an overall solution with Ysbyty Glan Clwyd in Bodelwyddan and Wrexham Maelor Hospital.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 6 March 2024

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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

Test WiFi telephones and smartphone messaging applications with frontline clinicians to assess future communication options.

Verbatim wording from the response

“The new Multitone iMessage critical messaging system will improve resilience and will provide standardisation across the 3 general hospitals and switchboards, and will allow for inter-site paging and cross cover arrangements.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 March 2024

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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

Upgrade critical messaging services at Ysbyty Glan Clwyd and Wrexham Maelor Hospital.

Verbatim wording from the response

“The Health Board has been working on a paging system replacement and upgrade project for 12 months.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 6 March 2024

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

Decide the specific future communication solution using the results of technical testing with frontline clinicians.

Verbatim wording from the response

“The ongoing improvements in our systems will improve on site communication for staff to support patient referral, transfers, treatment and discharge and improve efficiencies. A number of technical options are being tested to achieve this, with the testing informing a decision on the specific future solution. These options include WiFi telephones (being tested with ward managers and matrons at Ysbyty Gwynedd) and smart phone devices with the Microsoft Teams and Cisco apps to enable calls and instant messaging through our network (being tested with 34 medical staff in Ysbyty Gwynedd). As with any new technology, it is vital we test the options with front line clinicians to inform the best solution and to ensure patient safety.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 March 2024

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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.4

  1. 1

    Issue an organisation-wide safety alert communicating learning from the case.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 6 March 2024.
  2. 2

    Mandate 3pm ward huddles across Wrexham Maelor Hospital wards to identify tasks before the end of in-hours working.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
  3. 3

    Share Wrexham Maelor Hospital’s bleep restrictions and ward-huddle improvements with medical directors at other general hospital sites.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
  4. 4

    Restrict out-of-hours bleep use at Wrexham Maelor Hospital to four specified patient-safety categories.

    Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Existing paging remains a proven, reliable system for rapidly reaching critical teams responding to 2222 emergency and urgent calls.

    Stated by Betsi Cadwaladr University LHBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Issue an organisation-wide safety alert communicating learning from the case.

Verbatim wording from the response

“We also recognise the issue of communicating important clinical and patient safety information and tasks goes beyond technology, and to that end we will be issuing a Safety Alert across the organisation to highlight the learning from this case. This alert will be issued by the end of April 2024.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 March 2024

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 3pm ward huddles across Wrexham Maelor Hospital wards to identify tasks before the end of in-hours working.

Verbatim wording from the response

“We have also taken other action to improve patient safety whilst a technical solution is implemented. At Wrexham Maelor Hospital, the use of the bleep system out of hours has been restricted to four key areas to reduce the load and distraction on junior doctors. These four areas are deteriorating patients, deceased patients, fallen patients and time critical medication. All other tasks now wait for the junior doctor to circulate the wards. The site have also mandated 3pm ward huddles across all wards so that junior doctors and nursing teams can assess what tasks need doing in the 2 hours before the end of the in hours working day, reducing the out of hours workload and urgency. These improvement have been shared with the medical directors for our other general hospital sites.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 March 2024

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 Wrexham Maelor Hospital’s bleep restrictions and ward-huddle improvements with medical directors at other general hospital sites.

Verbatim wording from the response

“We have also taken other action to improve patient safety whilst a technical solution is implemented. At Wrexham Maelor Hospital, the use of the bleep system out of hours has been restricted to four key areas to reduce the load and distraction on junior doctors. These four areas are deteriorating patients, deceased patients, fallen patients and time critical medication. All other tasks now wait for the junior doctor to circulate the wards. The site have also mandated 3pm ward huddles across all wards so that junior doctors and nursing teams can assess what tasks need doing in the 2 hours before the end of the in hours working day, reducing the out of hours workload and urgency. These improvement have been shared with the medical directors for our other general hospital sites.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 March 2024

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

Restrict out-of-hours bleep use at Wrexham Maelor Hospital to four specified patient-safety categories.

Verbatim wording from the response

“We have also taken other action to improve patient safety whilst a technical solution is implemented. At Wrexham Maelor Hospital, the use of the bleep system out of hours has been restricted to four key areas to reduce the load and distraction on junior doctors. These four areas are deteriorating patients, deceased patients, fallen patients and time critical medication. All other tasks now wait for the junior doctor to circulate the wards. The site have also mandated 3pm ward huddles across all wards so that junior doctors and nursing teams can assess what tasks need doing in the 2 hours before the end of the in hours working day, reducing the out of hours workload and urgency. These improvement have been shared with the medical directors for our other general hospital sites.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 March 2024

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 paging remains a proven, reliable system for rapidly reaching critical teams responding to 2222 emergency and urgent calls.

Verbatim wording from the response

“Paging systems have always been used (and still are) for critical paging for 2222 emergency and urgent calls. It is a proven and reliable system for getting hold of and delivering fast responses to those critical teams who need to respond to an emergency.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 March 2024

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