Dear Burge, am writing in response to Regulation 28 Report issued to Cwm Taf Morgannwg University Health Board (CTM UHB) o the 6th March 2025 following the inquest touching upon the death of Annette Lewis The Health Board acknowledges the matters of concerns raised in relation to the care that was provided at the Princess of Wales Hospital specifically in relation to failed discharge policy and action has been taken to address this.
1. General Surgery Policy CTM now has active and up to date guidelines to prevent recurrence of whathappened in Ms Lewis' case. This is a General Surgery policy that applies to the General Surgeons as well as to the Emergency Department (who have also had it discussed and shared Cadeirydd / Chair= Prif Weithredwr / Chief Executive; Croeso 'chiogyfathrebu &r bwrdd iechyd Yn Y Gymraeg neu'r Saesneg: Byddwn yn ymateb yn Yr un iaith a ni fydd hyn yn arwain at oedi. You are welcome to correspond with the Health Board in Welsh or English. We will respond accordingly and this will not delay the response; https (Ictuhbnhs alci Ms

wiueiy piease see peiow In Emergency Department section): The Guidelines for care and treatment for patients who return to an Emergency Department (ED) within CTM UHB with general surgical conditions following discharge from hospital within CTM UHB were approved at Quality & Safety Committee on the 25th March 2025. These guidelines are operational across the Health Board. It was discussed at the Surgical Governance Meeting (pan-health Board) on 13th March 2025 department Morbidity and Mortality meeting, and the new policy was shared with the entire team by email, Those involved have reflected and evidenced this as part oftheir appraisal. Finally, this policy has been included in our induction presentation to all starters. It is available on the Health Board SharePoint where all Guidelines and Policies are located for rapid access by colleagues:
2. Emergency Department Policy The Princess of Wales Emergency Department Guidelines have been circulated to all Doctors and Clinical Teams. In addition, information (including laminates clearly displayed on the department walls) is available in minors, paediatric and BRATZ (majors rapid assessment) for the whole multi-disciplinary team to see, be aware of and act upon; This is also the case in key areas in the other CTM Emergency Departments Royal Glamorgan and Prince Charles There is Princess of Wales Emergency Department Handbook and this policy has been added to it: This Handbook is available for all staff to refer to including agency and locum doctors: We hope that these actions, development and awareness of these guidelines can demonstrate a robust response to the extremely sad death of Mrs Annette Lewis and that the organisation has learned. We are confident that these steps would prevent further events of patient representing with symptoms