Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 38
Velindre NHS Trust Maintain read-only Clinical WorkStation access for all Velindre dietitians as part of routine practice.
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Velindre NHS Trust Complete ratification and implementation of the multidisciplinary team checklist for complex nutritional care patients.
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Velindre NHS Trust Audit the multidisciplinary team checklist and share learning through quality and safety governance.
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Velindre NHS Trust Provide Clinical WorkStation access and training to new dietetic starters and record completion in staff training records.
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Velindre NHS Trust Continue monthly joint dietetic professional meetings with Aneurin Bevan University Health Board.
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Velindre NHS Trust Regularly audit implemented clinical pathways and report findings through internal governance.
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Velindre NHS Trust Implement the approved dietetic Standard Operating Procedure across relevant Velindre Cancer Service teams.
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Velindre NHS Trust Engage with Welsh dietetic leaders to strengthen cross-boundary referral and patient handover processes.
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Velindre NHS Trust Develop dietetic assessment standards and a Standard Operating Procedure for telephone reviews and face-to-face consultations.
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Velindre NHS Trust Audit the implemented dietetic Standard Operating Procedure and share learning through quality and safety governance.
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Velindre NHS Trust Strengthen dietetic governance through enhanced risk reporting, service-risk visibility and oversight of multidisciplinary clinical standards.
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Velindre NHS Trust Implement a joint communication protocol for shared-care patients across hospital and community dietetic services.
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Velindre NHS Trust Use the interim shared-care transfer document for transfers between Velindre Cancer Service and Aneurin Bevan University Health Board.
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Velindre NHS Trust Formalise digital access arrangements across all health boards commissioned to provide services to Velindre Cancer Service.
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Velindre NHS Trust Replicate pathway, communication and transfer safety processes across all health boards commissioned to provide services to Velindre Cancer Service.
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Velindre NHS Trust Review, develop and implement Upper Gastrointestinal and Head and Neck dietetic clinical pathways across both organisations.
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Velindre NHS Trust Collaborate with Digital Health Care Wales and health boards to address risks from multiple digital systems used across NHS Wales.
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Velindre NHS Trust Finalise the dietetic Standard Operating Procedure and submit it for internal governance approval.
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Velindre NHS Trust Monitor improvement work through the electronic quality tracker, executive reporting, committee oversight and monthly joint meetings with Aneurin Bevan University Health Board.
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Aneurin Bevan University LHB Embed peer review and clinical supervision within ABUHB dietetic governance, initially focusing on oncology cases.
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Aneurin Bevan University LHB Grant appropriate ABUHB dietitians access to WCP clinical records.
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Aneurin Bevan University LHB Adapt the ABUHB booking process to facilitate face-to-face review as an initial assessment.
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Aneurin Bevan University LHB Develop enhanced digital documentation tools for nutrition and hydration care.
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Aneurin Bevan University LHB Conduct annual joint audits of adherence to the transfer-of-care standard and assessment protocol, reporting findings through governance groups.
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Aneurin Bevan University LHB Implement and operate a strengthened nutrition and hydration governance framework with strategic and operational oversight groups.
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Aneurin Bevan University LHB Hold quarterly joint dietetic-lead meetings to review shared cases, incidents, communication issues and process improvement.
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Aneurin Bevan University LHB Present learning from the case at the ABUHB patient quality and safety learning and improvement forum.
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Aneurin Bevan University LHB Embed enhanced nutritional screening, fluid-balance monitoring, malnutrition escalation, documentation standards and ward accreditation requirements into routine practice.
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Aneurin Bevan University LHB Increase clinical supervision and reflective learning within dietetic teams.
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Aneurin Bevan University LHB Create and appoint a Consultant Dietitian post dedicated to nutrition and hydration.
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Aneurin Bevan University LHB Provide interim cross-organisational read-only clinical-record access for relevant dietitians.
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Aneurin Bevan University LHB Strengthen escalation frameworks for patients at nutritional risk.
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Aneurin Bevan University LHB Integrate requisite improvement actions into the ABUHB Nutrition and Hydration Group workplan and review progress biannually.
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Aneurin Bevan University LHB Introduce a decision-making tool requiring clinicians to document the rationale for remote or in-person assessment.
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Aneurin Bevan University LHB Log communication deficiencies through Datix, review them jointly and feed identified learning into professional development.
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Aneurin Bevan University LHB Develop and update a dietetic assessment guideline defining criteria for face-to-face and remote consultations.
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Aneurin Bevan University LHB Develop a joint transfer-of-care standard operating procedure defining referral, handover, documentation, response-time and professional-contact requirements.
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Aneurin Bevan University LHB Maintain joint monitoring meetings to review action-plan progress, share learning and resolve cross-boundary issues.
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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 govern and monitor decisions on face to face dietetic appointments
Wider context from the report “Steven Paul Turzynski died from the effects of cancer, which was also responsible for his nutritional status. However the almost absent communication between the two dietetic teams and the lack of adequate assessment during the last 12 months of Steven’s life contributed to his poor nutritional state.
I was informed at the inquest that the need for a face to face appointment is entirely a matter for the individual dietician. However, this decision making is not governed by guidelines nor is it monitored and can lead to an over-reliance of telephone assessments .
” 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 adequate dietetic assessment
Wider context from the report “Steven Paul Turzynski died from the effects of cancer, which was also responsible for his nutritional status. However the almost absent communication between the two dietetic teams and the lack of adequate assessment during the last 12 months of Steven’s life contributed to his poor nutritional state.
I was informed at the inquest that the need for a face to face appointment is entirely a matter for the individual dietician. However, this decision making is not governed by guidelines nor is it monitored and can lead to an over-reliance of telephone assessments.
” 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 Failure of communication between hospital and community dietetic teams
Wider context from the report “Steven Paul Turzynski died from the effects of cancer, which was also responsible for his nutritional status. However the almost absent communication between the two dietetic teams and the lack of adequate assessment during the last 12 months of Steven’s life contributed to his poor nutritional state.
I was informed at the inquest that the need for a face to face appointment is entirely a matter for the individual dietician. However, this decision making is not governed by guidelines nor is it monitored and can lead to an over-reliance of telephone assessments.
” 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 Maintain read-only Clinical WorkStation access for all Velindre dietitians as part of routine practice.
Verbatim wording from the response “1. Safety action description (SMART): To ensure all Dietitians have access to Clinical WorkStation (CWS) to enable full notes to be accessible between VCS and ABUHB.” Source location Response from Velindre University NHS Trust
Open published response
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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 ratification and implementation of the multidisciplinary team checklist for complex nutritional care patients.
Verbatim wording from the response “3.
Safety action description (SMART): To improve multi-disciplinary communication and working processes between VCS and ABUHB by introducing a shared communication protocol/checklist and establishing when urgent joint MDT meetings are required.” Source location Response from Velindre University NHS Trust
Open published response
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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 Audit the multidisciplinary team checklist and share learning through quality and safety governance.
Verbatim wording from the response “Proposed action: Draft MDT checklist will go through the internal ratification process and be implemented. To ensure the checklist is robust and fit for purpose, it is necessary to undertake an audit of the checklist. This will be recorded and tracked on our internal audit governance system (AMaT) and will be reported through internal governance at quality and safety board meetings.” Source location Response from Velindre University NHS Trust
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 Clinical WorkStation access and training to new dietetic starters and record completion in staff training records.
Verbatim wording from the response “Proposed action: All new starters within the Dietetic department will have access and training to CWS which will be recorded on our training needs analysis records kept for all staff.” Source location Response from Velindre University NHS Trust
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 monthly joint dietetic professional meetings with Aneurin Bevan University Health Board.
Verbatim wording from the response “• Quarterly joint dietetic meetings with ABUHB to support shared learning and early escalation of any potential risks or issues” Source location Response from Velindre University NHS Trust
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 Regularly audit implemented clinical pathways and report findings through internal governance.
Verbatim wording from the response “2.
Safety action description (SMART): To provide assurance that pathways developed under safety action #1 are completed and embedded into practice.” Source location Response from Velindre University NHS Trust
Open published response
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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 the approved dietetic Standard Operating Procedure across relevant Velindre Cancer Service teams.
Verbatim wording from the response “We also recognised following the inquest the risk of not seeing patients face to face and we have developed plans and guidelines to ensure the adequacy of dietetic assessments over the phone, and a minimum standard set for face-to-face consultations. The steps we have taken to date include benchmarking locally, regionally and nationally to help inform the development of a draft Standard Operating Procedure which, following approval, will be evaluated to ensure that it is embedded into practice.” Source location Response from Velindre University NHS Trust
Open published response
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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 Engage with Welsh dietetic leaders to strengthen cross-boundary referral and patient handover processes.
Verbatim wording from the response “• Active engagement with the Welsh Dietetic Leaders Advisory Group (WDLAG) to strengthen cross-boundary referral processes” Source location Response from Velindre University NHS Trust
Open published response
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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 dietetic assessment standards and a Standard Operating Procedure for telephone reviews and face-to-face consultations.
Verbatim wording from the response “We also recognised following the inquest the risk of not seeing patients face to face and we have developed plans and guidelines to ensure the adequacy of dietetic assessments over the phone, and a minimum standard set for face-to-face consultations. The steps we have taken to date include benchmarking locally, regionally and nationally to help inform the development of a draft Standard Operating Procedure which, following approval, will be evaluated to ensure that it is embedded into practice.” Source location Response from Velindre University NHS Trust
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 Audit the implemented dietetic Standard Operating Procedure and share learning through quality and safety governance.
Verbatim wording from the response “2. Safety action description (SMART): To provide assurance that the SOP developed under safety action #1 is robust and embedded into practice.” Source location Response from Velindre University NHS Trust
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 Strengthen dietetic governance through enhanced risk reporting, service-risk visibility and oversight of multidisciplinary clinical standards.
Verbatim wording from the response “To ensure sustained system-wide improvements, Velindre Cancer Service has strengthened its governance arrangements relating to dietetic care, including enhanced reporting mechanisms, improved visibility of service risks, and increased oversight of multi-professional clinical standards. We have implemented a series of measures to improve co-working and communication between hospital and community dietetic services, including:” Source location Response from Velindre University NHS Trust
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 Implement a joint communication protocol for shared-care patients across hospital and community dietetic services.
Verbatim wording from the response “To ensure sustained system-wide improvements, Velindre Cancer Service has strengthened its governance arrangements relating to dietetic care, including enhanced reporting mechanisms, improved visibility of service risks, and increased oversight of multi-professional clinical standards. We have implemented a series of measures to improve co-working and communication between hospital and community dietetic services, including:” Source location Response from Velindre University NHS Trust
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 the interim shared-care transfer document for transfers between Velindre Cancer Service and Aneurin Bevan University Health Board.
Verbatim wording from the response “• Development of an interim shared care transfer document until the All-Wales standard is formally approved” Source location Response from Velindre University NHS Trust
Open published response
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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 Formalise digital access arrangements across all health boards commissioned to provide services to Velindre Cancer Service.
Verbatim wording from the response “3. Safety action description (SMART): To ensure replication of safety action #1 & 2 above, across all VCS commissioned health boards in Wales.” Source location Response from Velindre University NHS Trust
Open published response
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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 Replicate pathway, communication and transfer safety processes across all health boards commissioned to provide services to Velindre Cancer Service.
Verbatim wording from the response “5. To ensure replication of safety action #1,3 &4 above, across all VCS commissioned health boards in Wales.” Source location Response from Velindre University NHS Trust
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, develop and implement Upper Gastrointestinal and Head and Neck dietetic clinical pathways across both organisations.
Verbatim wording from the response “• Review and confirmation of Upper Gastrointestinal and Head & Neck clinical pathways” Source location Response from Velindre University NHS Trust
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 Collaborate with Digital Health Care Wales and health boards to address risks from multiple digital systems used across NHS Wales.
Verbatim wording from the response “2. Safety action description (SMART): To schedule formal communication with the Chief AHP digital advisor in Digital Health Care Wales (DHCW) and Head of Dietetics at ABUHB, to review and discuss digital systems across Wales, identify any gaps or improvements, and agree on next steps for pathway optimisation.” Source location Response from Velindre University NHS Trust
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 Finalise the dietetic Standard Operating Procedure and submit it for internal governance approval.
Verbatim wording from the response “Proposed action: To finalise the Standard Operating Procedure (SOP) for dietetic provision of care and submit it through the Velindre Cancer Service (VCS) internal governance process for approval.” Source location Response from Velindre University NHS Trust
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 Monitor improvement work through the electronic quality tracker, executive reporting, committee oversight and monthly joint meetings with Aneurin Bevan University Health Board.
Verbatim wording from the response “Governance and Monitoring” Source location Response from Velindre University NHS Trust
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 Embed peer review and clinical supervision within ABUHB dietetic governance, initially focusing on oncology cases.
Verbatim wording from the response “• Quality Assurance: Peer review and clinical supervision sessions will be embedded into dietetic governance structures within ABUHB, focusing initially on oncology cases” Source location Response from Aneurin Bevan University Health Board
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 Grant appropriate ABUHB dietitians access to WCP clinical records.
Verbatim wording from the response “• Shared Access to Clinical Records:
Both organisations are reviewing long term digital interoperability options with potential single patient care records, dependant on Digital Health & Care Wales support. In the interim, read only access to ABUHB clinical system (CWS) has been granted to VUHNHST dieticians and WCP access will be granted to appropriate cohort of ABUHB Dietitians” Source location Response from Aneurin Bevan University Health Board
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 Adapt the ABUHB booking process to facilitate face-to-face review as an initial assessment.
Verbatim wording from the response “• Dietetic Assessment and Consultation Guideline: Development of an operating protocol to define clinical criteria for the mode of assessment. This will include consideration of disease complexity, nutritional risk, treatment phase, and patient preference. ABUHB booking process being adapted to facilitate face to face review as an initial assessment.” Source location Response from Aneurin Bevan University Health Board
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 Develop enhanced digital documentation tools for nutrition and hydration care.
Verbatim wording from the response “In parallel with the joint work undertaken with VUHNHST, ABUHB continues to strengthen its own internal systems to ensure that exacting standards of nutrition and hydration care are delivered consistently across all divisions. Locally, this includes the development of enhanced digital documentation tools, strengthened escalation frameworks for patients at nutritional risk, and increased use of clinical supervision and reflective learning within teams.” Source location Response from Aneurin Bevan University Health Board
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 Conduct annual joint audits of adherence to the transfer-of-care standard and assessment protocol, reporting findings through governance groups.
Verbatim wording from the response “• Annual Joint Audit: ABUHB and VUNHST will jointly audit adherence to the Dietetic Transfer of Care Standard Operating Procedure and Assessment Protocol, with findings reported to each organisation’s Nutrition & Hydration Group and/or Quality & Patient Safety assurance group” Source location Response from Aneurin Bevan University Health Board
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 Implement and operate a strengthened nutrition and hydration governance framework with strategic and operational oversight groups.
Verbatim wording from the response “To provide assurance that meaningful and lasting improvements are being achieved across the Health Board, we have implemented a strengthened governance framework dedicated to nutrition and hydration. This framework enhances organisational coordination, ensures accountability for quality improvement, and embeds systematic oversight within our Quality Management System.” Source location Response from Aneurin Bevan University Health Board
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 Hold quarterly joint dietetic-lead meetings to review shared cases, incidents, communication issues and process improvement.
Verbatim wording from the response “• Multidisciplinary Interface Meetings:
Quarterly meetings will be held between ABUHB and VUHNHST dietetic leads to discuss and review any shared oncology cases, clinical incidents, resolve communication issues, and identify opportunities for process improvement” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Present learning from the case at the ABUHB patient quality and safety learning and improvement forum.
Verbatim wording from the response “• Spreading the learning: Dietetics service will present learning from this case at the ABUHB patient quality & safety learning and improvement forum” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 enhanced nutritional screening, fluid-balance monitoring, malnutrition escalation, documentation standards and ward accreditation requirements into routine practice.
Verbatim wording from the response “This governance model has already accelerated the delivery of targeted improvements, such as enhanced nutritional screening, included in our ward accreditation programme, monitoring of fluid balance, strengthened escalation processes for patients at risk of malnutrition, and improved documentation standards. These developments are now being embedded into routine practice through the Quality Management System, supporting a proactive and transparent approach to preventing avoidable harm. The Health Board has also recently created and successfully appointed the first Consultant Dietitian post in Wales with a specific remit for Nutrition and Hydration. This senior clinical leader will embed Nutrition and Hydration at the core of our clinical care and strategically in our policies and clinical pathways.” Source location Response from Aneurin Bevan University Health Board
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 Increase clinical supervision and reflective learning within dietetic teams.
Verbatim wording from the response “In parallel with the joint work undertaken with VUHNHST, ABUHB continues to strengthen its own internal systems to ensure that exacting standards of nutrition and hydration care are delivered consistently across all divisions. Locally, this includes the development of enhanced digital documentation tools, strengthened escalation frameworks for patients at nutritional risk, and increased use of clinical supervision and reflective learning within teams.” Source location Response from Aneurin Bevan University Health Board
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 Create and appoint a Consultant Dietitian post dedicated to nutrition and hydration.
Verbatim wording from the response “This governance model has already accelerated the delivery of targeted improvements, such as enhanced nutritional screening, included in our ward accreditation programme, monitoring of fluid balance, strengthened escalation processes for patients at risk of malnutrition, and improved documentation standards. These developments are now being embedded into routine practice through the Quality Management System, supporting a proactive and transparent approach to preventing avoidable harm. The Health Board has also recently created and successfully appointed the first Consultant Dietitian post in Wales with a specific remit for Nutrition and Hydration. This senior clinical leader will embed Nutrition and Hydration at the core of our clinical care and strategically in our policies and clinical pathways.” Source location Response from Aneurin Bevan University Health Board
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 interim cross-organisational read-only clinical-record access for relevant dietitians.
Verbatim wording from the response “• Shared Access to Clinical Records:
Both organisations are reviewing long term digital interoperability options with potential single patient care records, dependant on Digital Health & Care Wales support. In the interim, read only access to ABUHB clinical system (CWS) has been granted to VUHNHST dieticians and WCP access will be granted to appropriate cohort of ABUHB Dietitians” Source location Response from Aneurin Bevan University Health Board
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 Strengthen escalation frameworks for patients at nutritional risk.
Verbatim wording from the response “In parallel with the joint work undertaken with VUHNHST, ABUHB continues to strengthen its own internal systems to ensure that exacting standards of nutrition and hydration care are delivered consistently across all divisions. Locally, this includes the development of enhanced digital documentation tools, strengthened escalation frameworks for patients at nutritional risk, and increased use of clinical supervision and reflective learning within teams.” Source location Response from Aneurin Bevan University Health Board
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 Integrate requisite improvement actions into the ABUHB Nutrition and Hydration Group workplan and review progress biannually.
Verbatim wording from the response “• Workplan Integration: Requisite improvement actions will be included within the ABUHB Nutrition & Hydration Group workplan, with progress reviewed bi-annually and updates shared with VUHNHST governance partners” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 decision-making tool requiring clinicians to document the rationale for remote or in-person assessment.
Verbatim wording from the response “• Decision-Making Tool: Decision-making tool to be introduced, requiring clinicians to record their rationale for remote versus in-person assessment in the patient’s notes, promoting transparency and auditability” Source location Response from Aneurin Bevan University Health Board
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 Log communication deficiencies through Datix, review them jointly and feed identified learning into professional development.
Verbatim wording from the response “• Exception and Learning Reporting: Any deficiencies or recurrent communication failures will be logged through Datix and reviewed at joint governance meetings. Themes and learning will be fed into professional development sessions.” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 update a dietetic assessment guideline defining criteria for face-to-face and remote consultations.
Verbatim wording from the response “Assurance Statement
The Health Board acknowledges the coroner’s concern regarding the absence of guidance for determining when dietetic assessments should be conducted face-to-face versus by telephone. The organisation, in collaboration with Velindre, is updating and enhancing existing clinical standards to guide assessment practice and ensure equity and quality of nutritional care” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 joint transfer-of-care standard operating procedure defining referral, handover, documentation, response-time and professional-contact requirements.
Verbatim wording from the response “Assurance Statement
Aneurin Bevan University Health Board (ABUHB) and Velindre University NHS Trust (VUNHST) recognise the coroner’s concern that inadequate communication between each organisations’ dietetic teams contributed to suboptimal nutritional management. Both organisations are committed to strengthening the safety and consistency of information exchange for all patients whose care is transferred across organisational boundaries.” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 Maintain joint monitoring meetings to review action-plan progress, share learning and resolve cross-boundary issues.
Verbatim wording from the response “At a system level, the Health Board and VUHNHST have committed to working in close partnership to maintain and monitor these improvements. Regular joint meetings between both organisations will review progress against the action plan, share emerging learning, and resolve any cross-boundary issues in real time.” Source location Response from Aneurin Bevan University Health Board
Open published response
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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 actions taken are considered robust enough to prevent future deaths related to dietetic support and provision.
Verbatim wording from the response “I hope that this response provides you with the assurance required that the action we have taken is robust enough to prevent future deaths related to dietetic support and provision.” Source location Response from Velindre University NHS Trust
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