Patricia Catterall
PFD Report
2 of 2 responses identified
Ref: 2025-0189
All 2 listed responses identified
· Deadline: 6 Jun 2025
Coroner's Concerns (AI summary)
The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in missed critical patient information.
View full coroner's concerns
In the
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. – That the process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had been received and assessed prior to the patient being received into their care. Evidence was received that in the majority of cases (post Covid) there are no face to face assessments prior to patient transfer and that the assessment is therefore dependent on the documentation supplied to the Nursing Home by the Health Board which in some cases may result in not all relevant information being provided. In this instance evidence was given that the Nursing Home did not know that the deceased’s blood sugar levels were monitored three times per days whilst in the care of Health Board.
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. – That the process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had been received and assessed prior to the patient being received into their care. Evidence was received that in the majority of cases (post Covid) there are no face to face assessments prior to patient transfer and that the assessment is therefore dependent on the documentation supplied to the Nursing Home by the Health Board which in some cases may result in not all relevant information being provided. In this instance evidence was given that the Nursing Home did not know that the deceased’s blood sugar levels were monitored three times per days whilst in the care of Health Board.
Responses
Action Planned
A task and finish group has been set up to review the current discharge form for suitability to ensure that frequency of observations and medication is clearly defined within the document. Changes to the form, once finalised and approved, will be shared with the North Wales Care Home Forum, with support from the Quality Development Team. (AI summary)
A task and finish group has been set up to review the current discharge form for suitability to ensure that frequency of observations and medication is clearly defined within the document. Changes to the form, once finalised and approved, will be shared with the North Wales Care Home Forum, with support from the Quality Development Team. (AI summary)
View full response
Dear Mr Gittins,
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Patricia Ann Catterall
I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 11th April 2025, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Mrs Patricia Ann Catterall.
I would like to begin with offering my deepest condolences to the family and loved ones of Mrs Catterall.
In the notice, you highlighted your concern in relation to the level of information provided to care homes during the community hospital discharge and handover process.
In response to the notice, our senior nursing team in the East Integrated Health Community have led work to understand the issue across the Health Board. This work has identified that whilst there is a standardised form for discharge plans into care homes, the level of detail is varied.
A Task and Finish Group has been set up (consisting of Community Hospital Matrons and Discharge Nurses) to review the current form for suitability, and this work will specifically ensure that frequency of observations and medication is clearly defined within the document.
Changes to the form, once finalised and approved, will be shared with the North Wales Care Home Forum, with support from the Quality Development Team (this team supports improvements in quality across commissioned care home services).
The new form, and examples to support learning, will be shared with teams and will be included on Team Meeting Safety Briefs.
Ein cyf / Our ref:
Eichcyf / Your ref: :
Gofynnwch am / Ask for:
E-bost / Email: Dyddiad / Date: 04 June 2025 John Gittins HM Senior Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN Legal Services, Bron Afon, Bryn y Neuadd Hospital, Llanfairfechan LL33 0HH
---------------------------------------------- Gwasanaethau Cyfreithiol, Bron Afon, Ysbyty Bryn y Neuadd, Llanfairfechan LL33 0HH
Audit questions will be developed to monitor these changes which will be completed by Ward Managers and Matrons and included in the peer reviews across our services. The audit findings will be included in the monthly Matron Reports into local quality groups for assurance.
Our aim is to have this work completed by the end of June 2025.
I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed and mitigated.
We would be happy to meet with you and discuss our plans in more detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to the family and friends of Mrs Catterall for their loss.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Patricia Ann Catterall
I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 11th April 2025, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Mrs Patricia Ann Catterall.
I would like to begin with offering my deepest condolences to the family and loved ones of Mrs Catterall.
In the notice, you highlighted your concern in relation to the level of information provided to care homes during the community hospital discharge and handover process.
In response to the notice, our senior nursing team in the East Integrated Health Community have led work to understand the issue across the Health Board. This work has identified that whilst there is a standardised form for discharge plans into care homes, the level of detail is varied.
A Task and Finish Group has been set up (consisting of Community Hospital Matrons and Discharge Nurses) to review the current form for suitability, and this work will specifically ensure that frequency of observations and medication is clearly defined within the document.
Changes to the form, once finalised and approved, will be shared with the North Wales Care Home Forum, with support from the Quality Development Team (this team supports improvements in quality across commissioned care home services).
The new form, and examples to support learning, will be shared with teams and will be included on Team Meeting Safety Briefs.
Ein cyf / Our ref:
Eichcyf / Your ref: :
Gofynnwch am / Ask for:
E-bost / Email: Dyddiad / Date: 04 June 2025 John Gittins HM Senior Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN Legal Services, Bron Afon, Bryn y Neuadd Hospital, Llanfairfechan LL33 0HH
---------------------------------------------- Gwasanaethau Cyfreithiol, Bron Afon, Ysbyty Bryn y Neuadd, Llanfairfechan LL33 0HH
Audit questions will be developed to monitor these changes which will be completed by Ward Managers and Matrons and included in the peer reviews across our services. The audit findings will be included in the monthly Matron Reports into local quality groups for assurance.
Our aim is to have this work completed by the end of June 2025.
I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed and mitigated.
We would be happy to meet with you and discuss our plans in more detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to the family and friends of Mrs Catterall for their loss.
Action Taken
Pendine Park Care Organisation now conducts all pre-admission assessments in person (except emergency admissions) and has updated the pre-admission assessment document to include prompts to ensure all information is requested prior to admission, including a section for diabetes. (AI summary)
Pendine Park Care Organisation now conducts all pre-admission assessments in person (except emergency admissions) and has updated the pre-admission assessment document to include prompts to ensure all information is requested prior to admission, including a section for diabetes. (AI summary)
View full response
Dear Mr Giƫns
Following issue of the RegulaƟon 28 report please find below acƟons that have been taken by the Pendine Park Care OrganisaƟon.
1. All pre - admission assessments are now being conducted in person except for emergency admissions.
2. Our pre - admission assessment document has been updated and includes prompts to ensure all informaƟon is requested prior to admission , this includes a secƟon for diabetes , see atached pre- admission assessment document .
The informaƟon gathered in the pre -admission assessment is then used to formulate the care plan.
Following issue of the RegulaƟon 28 report please find below acƟons that have been taken by the Pendine Park Care OrganisaƟon.
1. All pre - admission assessments are now being conducted in person except for emergency admissions.
2. Our pre - admission assessment document has been updated and includes prompts to ensure all informaƟon is requested prior to admission , this includes a secƟon for diabetes , see atached pre- admission assessment document .
The informaƟon gathered in the pre -admission assessment is then used to formulate the care plan.
Sent To
- Betsi Cadwaladr University Health Board
Responses Identified
Responses identified
2 of 2
56-Day Deadline
6 Jun 2025
All listed responses identified
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 1st of July 2024 I commenced an investigation into the death of Patricia Ann Catterall (DOB 3.1.43 DOD 23.6.24). The investigation concluded at the end of the inquest on the 11th of April 2024. The cause of death was recorded as being due to 1(a) Hyperosmolar Hyperglycaemic Syndrome (“HHS”) and Sepsis with Pneumonia 2. Frailty of Old Age and Dementia and the conclusion of the inquest was that of a death from natural causes.
Circumstances of the Death
On the 11th of June 2024 the deceased’s care was transferred from the Health Board to the Nursing home following the deceased having spent 207 days in the care of the Health Board at Mold Community Hospital Whilst under the care of the Health Board, the deceased’s blood sugar levels were checked three times per day, however once she became resident at Pendine, they were only checked once a day. During the period between the 11th and the 19th of June 2024, the deceased’s condition deteriorated and on the 19th of June she was admitted to the Maelor Hospital Wrexham where she was diagnosed as having HHS and sepsis. Her condition and co-morbidities were such that it would have been inappropriate to aggressively treat these conditions and she passed away a few days later.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.