Mihangel ap Dafydd
PFD Report
All Responded
Ref: 2016-0169
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
All 2 responses received
· Deadline: 28 Jun 2016
Coroner's Concerns (AI summary)
Windows in Morlais Ward service user areas are not ligature-free, posing a safety risk, and planned remedial work has not yet been completed.
View full coroner's concerns
The MATTERS OF CONCERN is as follows:
The windows in service user areas at Morlais Ward are not ligature free and whilst it is intended to make them so following the death of Mr ap Dafydd this work has not yet been undertaken. 2
The windows in service user areas at Morlais Ward are not ligature free and whilst it is intended to make them so following the death of Mr ap Dafydd this work has not yet been undertaken. 2
Responses
Action Planned
The Welsh Government will issue an addendum to Health Building Note 35, highlighting the requirement for ligature-free design in both new and existing acute mental health unit facilities. They have also requested a formal review of HBN 35 by NHS Shared Services Partnership – Specialist Estate Services (NWSSP-SES). (AI summary)
The Welsh Government will issue an addendum to Health Building Note 35, highlighting the requirement for ligature-free design in both new and existing acute mental health unit facilities. They have also requested a formal review of HBN 35 by NHS Shared Services Partnership – Specialist Estate Services (NWSSP-SES). (AI summary)
View full response
Dear Mr Layton, Thank you for your email of 3 May to Acting Chief Medical Officer, enclosing your Regulation 28 report following the death of Mihangel ap Dafydd at Morlais Ward, West Wales General Hospital, Glangwilli. I am replying in my role as the lead official for NHS estates and facilities issues within Welsh Government. I note your report and requested actions have been sent to the Chief Executive of Hywel Dda University Health Board. However, given that you have identified issues which are of relevance to all NHS organisations, I can confirm that we will be issuing an addendum to Health Building Note 35 – “Accommodation for People with Mental Illness Part 1: The Acute Unit Ligature Free Design”. This addendum will specifically highlight the requirement for ligature free design in both new and existing acute mental health unit facilities in Wales. The addendum to the Health Building Note will also widen the requirements to other facilities dealing with acute mental health in-patients including Children & Adolescent Mental Health Services (CAMHS). This document is in the process of being finalised by Welsh Government officials and our NHS estates advisors and will issue by the end of this month. In addition to the above, I have also requested that NHS Shared Services Partnership – Specialist Estate Services (NWSSP-SES) undertake a formal review of HBN 35. This will consider if the HBN needs more substantial amendment or if it should be superseded by a revised HBN 03-01, amended, where required, to reflect further developments in Welsh Government policy and any specific needs of NHS Wales. Val Whiting Dirprwy Gyfarwyddwr, Cyfalaf, Ystadau a Cyfleusterau/ Deputy Director, Capital, Estates & Facilities
2 I will pick up the individual circumstances and actions taken by Hywel Dda University Health Board at Glangwili Hospital when I next meet the Health Board later this month. I hope you find this information useful. Please do not hesitate to contact me if you have further concerns or queries.
2 I will pick up the individual circumstances and actions taken by Hywel Dda University Health Board at Glangwili Hospital when I next meet the Health Board later this month. I hope you find this information useful. Please do not hesitate to contact me if you have further concerns or queries.
Action Planned
The Health Board will repeat ligature audits across mental health and learning disability in-patient units and submit prioritised recommendations for consideration by the 2016/17 Capital programme regarding replacement, repair or adaptation of windows. In the meantime, inpatient areas will continue to be subject to regular environmental risk assessment. (AI summary)
The Health Board will repeat ligature audits across mental health and learning disability in-patient units and submit prioritised recommendations for consideration by the 2016/17 Capital programme regarding replacement, repair or adaptation of windows. In the meantime, inpatient areas will continue to be subject to regular environmental risk assessment. (AI summary)
View full response
Dear Mr Layton Re: Inquest into the death of Mihangel ap Dafydd Thank you for your letter dated the 29th April, and the Regulation 28 report for the Health Board's attention. I can confirm that the Health Board undertakes an annual point of ligature audit programme across all of its mental health and learning disability in- patient units, which includes an audit of Morlais Ward on the West Wales General Hospital site The point of ligature audits undertaken following Mr. ap Dafydd's death identified potential point of ligature risks with windows on number of the in-patient units, including Morlais Ward which were reported through the Health Board'$ Capital programme: The point of ligature programme is considered alongside all of the annual priorities across the Health Board, and the replacement of windows was not deemed to be the greatest priority, as following identification of the risk, steps were taken to mitigate the risk, including the securing of windows in some areas. The point of ligature audit programme plans to repeat the audit of all inpatient units across mental health and learning disabilities in May/June 2016. Following which a prioritised recommendations will be submitted for consideration by the 2016/17 Capital programme, for each unit considering Swyddfeyda Corlforaethol, Adeilad Ystwyth, Corporate Offices Ystvyth Building Cadeirydd Chair Hafan Derwen, Parc Dewi Sart; Heol Ffyrnon Job, Hafan Derven St Davids Pamk, Jcb's Well Road Mrs Bernardine Rees OBE Caeryradin, Sir Gacrfyrdcin; SA31 3BB Cammarthcn, Carmarlhenshire, SA3I 3BB Prif Weithredwr Chiei Executive Mr Steve Moore 7
replacement, repair adaptation of the existing windows in line with the Department of Health Building Note 03-01. Whilst the programme of work is being developed and prioritised it is essential that the inpatient units that require adaptations to windows are able to provide a safe and therapeutic environment for patients. Ensuring patient dignity and safety are priority the Mental Health and Learning Disabilities Directorate_ During the programme of work that will be undertaken, inpatient areas will continue to be subject to regular environmental risk assessment; Where necessary, actions will be taken to mitigate risks that take into consideration patient dignity and comfort
replacement, repair adaptation of the existing windows in line with the Department of Health Building Note 03-01. Whilst the programme of work is being developed and prioritised it is essential that the inpatient units that require adaptations to windows are able to provide a safe and therapeutic environment for patients. Ensuring patient dignity and safety are priority the Mental Health and Learning Disabilities Directorate_ During the programme of work that will be undertaken, inpatient areas will continue to be subject to regular environmental risk assessment; Where necessary, actions will be taken to mitigate risks that take into consideration patient dignity and comfort
Sent To
- West Wales General Hospital
Response Status
Linked responses
2 of 1
56-Day Deadline
28 Jun 2016
All responses received
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 18th February 2014 I commenced an investigation into the death of Mihangel ap Dafydd. The investigation concluded at the end of the inquest on 29 April 2016. The conclusion reached by the jury was a narrative one namely that: On 16th February 2014 Mihangel ap Dafydd hanged himself on Morlais Ward Glangwili Hospital. He was properly assessed under the Mental Health Act upon his admission to hospital. His level of observation was appropriate in the circumstances. The procedure for removing items of property which could be used for the purposes of self-harm was undertaken incorrectly. The hospital unit had not been correctly adapted to prevent windows being used as a ligature point. These failings did contribute to his death.
Circumstances of the Death
(1) On 14th February 2014 Mr ap Dafydd was exhibiting signs of mental illness and was assessed as being at risk of self-harm. (2) He was detained under the Mental Health Act and placed under 15 minute observations on Morlais Ward Glangwili Hospital. (3) He was checked during the early hours of 16th February and was found hanging from a window having used a strap from his bag.
Copies Sent To
Welsh Government Cathays Park Cardiff CF10 3NQ
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.