Aneurin Bevan University Health Board
PFD Addressee
Reports: 35
Earliest: Jan 2014
Latest: 27 Feb 2026
78% 2-year response rate (below 83% average). 47% of classified responses show concrete action taken.
PFD Reports
22 resultsDella Calvey
All Responded
2026-0063
5 Feb 2026
Gwent
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
Unsafe practice of routinely downgrading NEWS scores for all COPD patients without knowing individual baseline saturations leads to inadequate clinical assessments.
2 responses
from Aneurin Bevan University Health Board, Welsh Ambulance Service NHS Trust
Philip Hoggarth
All Responded
2025-0628
16 Dec 2025
Gwent
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A lack of consistent guidelines and processes for pre-operative iron administration to chronically anaemic patients, alongside no funding agreement, risks damaging delays in surgery.
Action Taken
(AI summary)
Aneurin Bevan University Health Board has a Standard Operating Pathway (SOP) for the management of surgical patients presenting to preassessment clinic with anaemia or iron deficiency. The cost of IV iron is charged to the relevant clinical area, regardless of patient residence or Health Board boundaries.
Steven Turzynski
All Responded
2025-0492
6 Oct 2025
Gwent
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate communication between dietetic teams and insufficient monitoring of telephone-based nutritional assessments for cancer patients led to poor nutritional status and potentially earlier death.
Action Taken
(AI summary)
The Trust has undertaken a review of practice and implemented actions including developing a Standard Operating Procedure (SOP) to ensure standards/guidance are set for dietitians to consider when making clinical decisions regarding telephone review and face to face sessions and an audit of the SOP once implemented. The Health Board has implemented a strengthened governance framework dedicated to nutrition and hydration, including a Strategic Nutrition and Hydration Group, supported by two operational sub-groups and is working with VUHNHST to ensure consistent standards when providing dietetic care.
Isaac Ingle-Gillis
All Responded
2025-0373
22 Jul 2025
Gwent
Alcohol, drug and medication related deaths
Suicide
Concerns summary (AI summary)
The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by preventing comprehensive mental health assessments, despite not altering the outcome in this instance.
Action Planned
(AI summary)
The Health Board supports broader access to patient medical records and has commenced work to broaden access to clinicians, including CRHTT, via the Welsh Clinical Portal. They are also working to allow patients fuller access to GP information via the NHS App.
Marina Waldron
All Responded
2025-0238
21 May 2025
Gwent
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
During hospital admission, there was a prolonged failure to address the patient's inadequate nutritional intake, including neglecting family concerns, not monitoring diet, and delaying proper nutritional intervention despite signs of malnutrition.
Action Planned
(AI summary)
Aneurin Bevan University Health Board has established a governance structure focused on nutrition and hydration and is implementing an action plan including improved recording of patient capacity, review of documentation, and nutrition-focused learning days.
Jean Thomas
All Responded
2025-0059
23 Oct 2024
Gwent
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
Critical fluid balance monitoring for a patient with severe cardiovascular and renal issues, complicated by sepsis, was entirely neglected by both nursing and medical staff.
Action Planned
(AI summary)
Aneurin Bevan University Health Board is committed to improving fluid balance monitoring, strengthening education programs, incorporating compliance into the Nutritional and Hydration Committee's work, standardizing the audit process, and adding fluid balance monitoring to the risk register.
Kay Simmonds
All Responded
2024-0463
15 Aug 2024
Gwent
Alcohol, drug and medication related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
Incorrect NEWS score calculation and subsequent failure to follow observation protocols led to missed recognition of a deteriorating patient, delaying senior medical review and putting lives at risk.
Action Planned
(AI summary)
The Aneurin Bevan University Health Board is seeking funding to implement the CareFlow electronic observation and NEWS recording system within the Emergency Department at the Grange University Hospital, with the digital team prioritising this project.
Sylvia Evans
All Responded
2024-0275
20 May 2024
Gwent
Emergency services related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
An extreme 9-hour ambulance delay for a patient with a life-threatening emergency, partly caused by hospital handover issues, resulted in her death before paramedics arrived.
Action Planned
(AI summary)
Aneurin Bevan University Health Board outlines ongoing efforts to reduce ambulance handover delays, including daily monitoring, escalation processes, and collaboration with WAST. They are also undertaking focused projects at specific hospitals to improve patient flow and discharge arrangements.
Neil Edwards
All Responded
2024-0153
20 Mar 2024
Gwent
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
The Trust failed to investigate all inpatient falls, including the one contributing to death, preventing learning and reassurance about future prevention measures.
Action Taken
(AI summary)
Aneurin Bevan University Health Board details its Falls Policy for inpatients, including risk assessments, post-fall reviews, and environmental safety measures. It also describes staffing level audits and processes to manage nurse staffing deficits.
Catriona Martin
All Responded
2023-0501
4 Dec 2023
Gwent
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
There are no guidelines for the delegation of nursing duties to family members, leading to unacceptable care levels and a lack of clear supervision or intervention by the nursing team.
Action Taken
(AI summary)
The Health Board clarifies its position on delegation of nursing responsibilities to family members. They also report implementation of a digital platform for visibility of staffing levels and dissemination of an 'Educational and Recommendations After Significant Events (ERASE) Poster' to share learning from the case.
Lynda Blackmore
All Responded
2024-0069
15 Nov 2023
South Wales Central
Emergency services related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
Significant ambulance handover delays at hospitals are severely impacting emergency response times, causing patients to wait many hours for treatment or conveyance. These delays pose a critical risk to patient safety.
Noted
(AI summary)
Welsh Ambulance Services NHS Trust does not propose further action directly, but is working with Aneurin Bevan University Health Board to implement additional measures in January 2024 to reduce conveyances to The Grange Hospital through direct admission to alternative sites, and the introduction of a new temporary facility. They also offer to meet to discuss the response in more detail. The Health Board acknowledges handover delays and that an ACA2 crewed ambulance could have attended. It states that reducing patient handovers is a focus and that the Chief Operating Officer and Clinical Executives are providing leadership to address the issue. NICE acknowledges the concerns but states that existing guidelines on fever, sepsis, and sore throat cover the diagnosis and early management of relevant symptoms, and they have not been asked to produce specific guidance on Group A streptococcus.
Kaye McCoy
All Responded
2023-0221
30 Jun 2023
Gwent
Mental Health related deaths
Suicide
Concerns summary (AI summary)
The health board failed to provide a strategy for family engagement and 24-hour crisis support, despite national recommendations, suggesting these crucial guidelines are not fully integrated into practice.
Action Planned
(AI summary)
The Health Board is considering the findings and recommendations of a 6-month pilot extending the hours of the Community Mental Health Team, exploring other alternatives for crisis support, and will continue to audit the use of the current pathway by the older adult population.
Maria Shafighian
All Responded
2023-0205
21 Apr 2023
Gwent
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
An inefficient internal postal system for communication between departments caused significant delays in escalating urgent changes in a patient's condition, specifically dysphagia, to the relevant team.
Action Planned
(AI summary)
To improve the internal referral process for the ENT department, referrals will be sent straight to the Central Registration department for upload and electronic triage, mirroring the GP process; a generic internal e-referral form will also be developed.
Lucy Jones
All Responded
2023-0012Deceased
11 Jan 2023
Gwent
Suicide
Concerns summary (AI summary)
Significant delays in providing Cognitive Behavioural Therapy and inadequate follow-up by the Community Psychiatric Nurse after discharge, including limited contact attempts, were identified.
Action Planned
(AI summary)
The health board has developed a Disengagement and Did Not Attend policy to guide clinicians when a person does not attend appointments, balancing duty of care with the patient's right to refuse treatment. The policy is currently in draft, with ratification expected by the end of March 2023. The Rosedale Surgery will add a sentence to patient records giving no more controlled medication than is needed for 48 hours when recording a diagnosis of an overdose. If a patient is admitted with more than 1 overdose within a 3 month period they will change their prescription to daily.
Gareth Williams
All Responded
2022-0270
31 Aug 2022
Gwent
Mental Health related deaths
Suicide
Wales prevention of future deaths reports
Concerns summary (AI summary)
The deceased fell between two non-communicating care teams (mental health and ENT), leading to insufficient support and an inability to resolve his complex health problems.
Action Planned
(AI summary)
Aneurin Bevan University Health Board is expanding a service called 'Adferiad' to include people with other medical and long-term conditions, which will be delivered by a multi-disciplinary team including medical, nursing, and Allied Health Professionals to improve interdisciplinary working between physical and mental health specialties.
Brian Wareham
All Responded
2022-0010
14 Jan 2022
Gwent
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged without adequate information or support regarding complex medical conditions.
Action Taken
(AI summary)
The Richmond Clinic investigated the matter, met with the Health Board, explored communication options between primary and secondary care, and ensured all clinical staff are aware of them. They have explored obstacles to communication in this case and addressed them. The Health Board has established a single point of access Flow Centre for urgent referrals for admission, launched direct access telephone advice lines, and created a directory of "bypass numbers". The Medical Examiner Service is now operating in Gwent and GPs receive a weekly message from the Deputy Medical Director, highlighting key information and any changes to Secondary Care Services.
Valmai West
All Responded
2021-0239
13 Jul 2021
Gwent
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for patient observations, posing a risk to future patients due to insufficient monitoring.
Noted
(AI summary)
The Health Board reviewed nurse staffing levels which they state were adequate at the time of the incident. They have also commissioned an in-depth review of nurse staffing levels for the Emergency Department (ED) at the Grange University Hospital, and a similar review of medical staffing is also being undertaken.
Elizabeth Robinson
All Responded
2021-0072
12 Mar 2021
Gwent
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess patient fall risk correctly, and were unaware of learning opportunities.
Action Taken
(AI summary)
Aneurin Bevan University Health Board has established a Ysbyty Ystrad Fawr (YYF) Health Care Support Worker (HCSW) pool in September 2020 to support enhanced care levels. The Corporate Serious Incident Team is implementing a training programme for Investigating Officers and trialling standardised template agendas for use at Serious Incident investigation meetings.
Alan Jones
All Responded
2021-0079
16 Feb 2021
Gwent
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The patient's level of confusion and agitation increased without a multidisciplinary approach to management, and despite being in the highest falls risk category, there was a failure in falls prevention strategy; inadequate supervision contributed to multiple falls, and the ward caring for high-risk patients was staffed at a minimum level without accounting for fluctuations in acuity.
Action Taken
(AI summary)
The Health Board has reported the death to the Health & Safety Executive, developed a dashboard within the Datix Incident Reporting system for falls resulting in significant harm, and incorporated a new section on reporting patient falls into the Standard Operating Procedure for RIDDOR.
Rory Attwood
All Responded
2021-0086
10 Dec 2020
Gwent
Alcohol, drug and medication related deaths
Community health care and emergency services related deaths
Mental Health related deaths
Concerns summary (AI summary)
The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious incident reviews, which limits learning and partnership working for community-supervised patients.
Action Taken
(AI summary)
Aneurin Bevan University Health Board has reviewed its practices regarding GP involvement in Serious Incident Reviews and devised a process and pro forma to ensure GPs are invited to participate. The Mental Health and Learning Disabilities Division is also reviewing processes to ensure third sector and other organisations' involvement is recorded sooner.
Diane Greenslade
All Responded
2018-0401
21 Dec 2018
Gwent
Community health care and emergency services related deaths
Concerns summary (AI summary)
Inadequate ambulance call categorisation without clinical assessment, failure to escalate after failed contact, and high demand compounded by hospital delays led to significant delays in medical intervention.
Action Planned
(AI summary)
The Health Board reports improvements in ambulance response times and highlights several initiatives to improve the timeliness of releasing crews at the hospital, including practitioners reviewing WAST calls and additional doctors in the Emergency Department. The Welsh Ambulance Services NHS Trust acknowledges concerns and has completed and continues to work on strategic and operational quality improvements in patient safety, including training of Clinical Contact Centre staff, recruitment of clinicians, and improvements to policies and collaborative working; the Trust will also undertake a concerns investigation to address whether the delay had any impact and would welcome an opportunity to meet with the family.
Ceriann Richards
All Responded
2017-0041
1 Mar 2017
South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Significant and prolonged handover delays between ambulance crews and hospital staff led to critical delays in ambulance dispatch and availability, worsening since new guidance.
Action Taken
(AI summary)
Aneurin Bevan University Health Board describes steps taken to address ambulance handover issues, including establishing an Urgent Care Board, implementing a Standard Operating Procedure for bed management, and introducing 'Breaking the Cycle' to improve patient flow, implementing transfer teams and discharge facilitators. The Welsh Government acknowledges concerns about handover delays and outlines existing initiatives by the Welsh Ambulance Services NHS Trust to limit conveyance rates, including an enhanced clinical desk, alternative pathways, and a frequent callers project.