PFD report

Daniel Watson · Prevention of Future Deaths report

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Issued 18 Dec 2017•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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
10

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 staff understanding and empathy regarding care and service delivery issues
  2. Inadequate CMHT staff training in risk assessment
  3. Inadequate CMHT staff training in escalation of concerns towards formal psychiatric assessment
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.7

  1. Action

    Include Adult Social Care social workers in WARRN risk-assessment and suicide-assessment training programmes.

    Stated by Wrexham Adult Social CareStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.
  2. Action

    Provide feedback and management supervision to the social worker involved in the case.

    Stated by Wrexham Adult Social CareStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.
  3. Action

    Deliver the confirmed 2018 WARRN training dates through specialised accredited trainers.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.

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 staff understanding and empathy regarding care and service delivery issues

Wider context from the report

“1. The Concerns Root Cause Analysis Investigation undertaken by BCUHB revealed a multitude of care and service delivery problems and contributory factors in relation to the care and treatment of the Deceased which cumulatively represented missed opportunities to improve his mental health and the evidence given at the inquest by the social worker and community psychiatric nurse demonstrated a complete lack of understanding and empathy in relation to these issues. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Inadequate CMHT staff training in risk assessment

Wider context from the report

“2. That there needs to be a significant improvement in the training of staff within the CMHT in relation to their understanding of risk assessment and potential escalation of concerns towards a formal psychiatric assessment. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Inadequate CMHT staff training in escalation of concerns towards formal psychiatric assessment

Wider context from the report

“2. That there needs to be a significant improvement in the training of staff within the CMHT in relation to their understanding of risk assessment and potential escalation of concerns towards a formal psychiatric assessment. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Include Adult Social Care social workers in WARRN risk-assessment and suicide-assessment training programmes.

Verbatim wording from the response

“With respect to the issue of significant improvement in training of staff in Community Mental Health regarding risk assessment and escalation of concerns towards a formal psychiatric assessment, the Mental Health Learning Disability Division uses the Wales Applied Risk Research Network (WARRN) Asking Difficult Questions and Formulating Risk training programme. This is intended to provide a consistent and standard approach to risk assessment. New training has been confirmed for 2018 and the staff that provided care to Mr Watson have been booked onto the training. In addition the MHLD Division will supplement the WARRN training with specific training on assessment of suicide. Adult Social Care Social Workers within the integrated CMHT service will be included within these training programmes.”

Source location

2017-0370-Response-by-Wrexham-Borough-Council
Page 1 · response
Published 11 February 2018

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

Provide feedback and management supervision to the social worker involved in the case.

Verbatim wording from the response

“With respect to the evidence given at the inquest by the Social Worker involved showing a lack of understanding of issues and a lack of empathy, the member of staff concerned is to be given feedback and management supervision. The Mental Health and Learning Disability Supervision Guidance for Services and Support Workers Policy is being implemented by the BCU to improve discussion and reflection on cases in a structured and facilitated process and will apply also to social workers employed by Adult Social Care in the integrated team. A copy of this policy will be submitted by the BCU in its response.”

Source location

2017-0370-Response-by-Wrexham-Borough-Council
Page 1 · response
Published 11 February 2018

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

Deliver the confirmed 2018 WARRN training dates through specialised accredited trainers.

Verbatim wording from the response

“In relation to your second area of concern relating to a significant improvement in the training of staff within the CMHT in relation to their understanding of risk assessment and potential escalation of concerns to a formal Psychiatric Assessment. The Wales Applied Risk Research Network (WARRN) Asking Difficult Questions and Formulating Risk (WARRN ADQ) is a National Programme of training, endorsed by Welsh Government, in the assessment, formulation and management of risk to self or others. One of the main aims of WARRN is to drive forward a standardised and consistent approach to risk assessment and formulation nationally, across services. The MHL Division will continue to make available the WARRN Accredited Programme for Care Coordinators and new training dates have been confirmed for 2018 to be delivered through our group of specialised trainers.”

Source location

2017-0370-Response-by-University-Health-Board
Page 1 · response
Published 11 February 2018

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

Produce and provide an action plan addressing identified service-delivery and care problems.

Verbatim wording from the response

“In relation to your first matter of concern in that the Concerns Root Cause Analysis Investigation undertaken by BCUHB revealed a multitude of care and delivery problems which cumulatively represented missed opportunities to improve the Deceased’s mental health. As you are aware an action plan has been produced to improve on the service delivery and this has been provided to you. In relation to the evidence given at the Inquest by the Community Psychiatric Nurse (CPN), I can confirm that the CPN was provided with an initial debriefing session to reflect on the delivery of evidence provided at the Inquest. Further debriefing and on-going supervision will provide the opportunity for the CPN to optimise learning and provide a focus on their understanding and empathy for their continued professional development, which will be incorporated into their appraisal.”

Source location

2017-0370-Response-by-University-Health-Board
Page 1 · response
Published 11 February 2018

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

Provide initial debriefing and continue staff debriefing and supervision to support learning, empathy and professional development.

Verbatim wording from the response

“In relation to your first matter of concern in that the Concerns Root Cause Analysis Investigation undertaken by BCUHB revealed a multitude of care and delivery problems which cumulatively represented missed opportunities to improve the Deceased’s mental health. As you are aware an action plan has been produced to improve on the service delivery and this has been provided to you. In relation to the evidence given at the Inquest by the Community Psychiatric Nurse (CPN), I can confirm that the CPN was provided with an initial debriefing session to reflect on the delivery of evidence provided at the Inquest. Further debriefing and on-going supervision will provide the opportunity for the CPN to optimise learning and provide a focus on their understanding and empathy for their continued professional development, which will be incorporated into their appraisal.”

Source location

2017-0370-Response-by-University-Health-Board
Page 1 · response
Published 11 February 2018

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 making the accredited WARRN risk-assessment programme available to care coordinators.

Verbatim wording from the response

“In relation to your second area of concern relating to a significant improvement in the training of staff within the CMHT in relation to their understanding of risk assessment and potential escalation of concerns to a formal Psychiatric Assessment. The Wales Applied Risk Research Network (WARRN) Asking Difficult Questions and Formulating Risk (WARRN ADQ) is a National Programme of training, endorsed by Welsh Government, in the assessment, formulation and management of risk to self or others. One of the main aims of WARRN is to drive forward a standardised and consistent approach to risk assessment and formulation nationally, across services. The MHL Division will continue to make available the WARRN Accredited Programme for Care Coordinators and new training dates have been confirmed for 2018 to be delivered through our group of specialised trainers.”

Source location

2017-0370-Response-by-University-Health-Board
Page 1 · response
Published 11 February 2018

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

Deliver a focused learning session for the wider team on empathy toward families and transparency at inquests.

Verbatim wording from the response

“An initial focused session for the wider team’s learning will be held around awareness of empathy towards families and transparency to the Coroner at Inquest”

Source location

2017-0370-Response-by-University-Health-Board
Page 1 · response
Published 11 February 2018

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

    Undertake biannual Care and Treatment Plan audits using the Welsh Government-recommended audit tool, review findings and report them in the annual mental-health delivery report.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.
  2. 2

    Provide monthly Senior Management Team assurance on appraisal and training compliance through network-team performance reports.

    Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018.
  3. 3

    Update the supervision guidance policy for nurses and support workers to structure facilitated case discussion and reflection.

    Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.

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

Undertake biannual Care and Treatment Plan audits using the Welsh Government-recommended audit tool, review findings and report them in the annual mental-health delivery report.

Verbatim wording from the response

“Assurance regarding compliance with appraisals and training is provided to the Senior Management Team on a monthly basis through the network teams performance report. Additionally, the MHL Division has committed to undertaking a bi annual audit of Care and Treatment Plans using the Welsh Government recommended audit tool (see attached) which will be reviewed biannually within the divisions Quality and Safety Group and reported within our annual report on the local delivery of ‘Together for Mental Health’.”

Source location

2017-0370-Response-by-University-Health-Board
Page 2 · response
Published 11 February 2018

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

Provide monthly Senior Management Team assurance on appraisal and training compliance through network-team performance reports.

Verbatim wording from the response

“Assurance regarding compliance with appraisals and training is provided to the Senior Management Team on a monthly basis through the network teams performance report. Additionally, the MHL Division has committed to undertaking a bi annual audit of Care and Treatment Plans using the Welsh Government recommended audit tool (see attached) which will be reviewed biannually within the divisions Quality and Safety Group and reported within our annual report on the local delivery of ‘Together for Mental Health’.”

Source location

2017-0370-Response-by-University-Health-Board
Page 2 · response
Published 11 February 2018

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

Update the supervision guidance policy for nurses and support workers to structure facilitated case discussion and reflection.

Verbatim wording from the response

“I can also confirm that the MHL Division will have updated the MHL D Supervision Guidance for Nurses and Support Workers Policy by the end of February 2018 to ensure staff can discuss and reflect on cases in a structured and facilitated process. A copy of the draft MHL-D Supervision Guidance for Nurses and Support Workers Policy is attached.”

Source location

2017-0370-Response-by-University-Health-Board
Page 2 · response
Published 11 February 2018

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