Betsi Cadwaladr University Health Board

PFD Addressee
Reports: 77 Earliest: Sep 2013 Latest: 27 Feb 2026

83% 2-year response rate (matches average). 38% of classified responses show concrete action taken.

Response Status (last 2 years, 12 reports)
Responded 10 No Response 1
AI Classification
Action Taken 38%
Action Planned 56%
Noted 5%
Disputed 2%
Based on 66 classified responses
PFD Reports Received by Quarter
PFD Reports
77 results
Malcolm Unwin
All Responded
2023-0298 17 Aug 2023 North Wales East and Central
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The absence of bed rail assessments from the Welsh Nursing Care Record risks these critical safety evaluations being missed, potentially leading to patient falls and future deaths.
Action Planned (AI summary) The Health Board has reminded ward managers about paper-based assessment forms while awaiting a national update to the Welsh Nursing Care Record. They are also finalising an updated Bed Rails Procedure and are working to comply with a National Patient Safety Alert regarding bed rails.
Philip Hawkins
Historic (No Identified Response)
2023-0248 18 Jul 2023 North Wales East and Central
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant delays in hospital admission and bed allocation, coupled with inadequate staffing, resulted in poor personal care, missed observations, and incomplete documentation for a vulnerable patient.
Emily Corfield
All Responded
2023-0247 14 Jul 2023 North Wales East and Central
Alcohol, drug and medication related deaths
Concerns summary (AI summary) An addiction support service lacked robust communication and record-keeping policies, relying solely on written correspondence, which led to service users being disengaged and facing long waiting times.
Action Planned (AI summary) Adferiad is seeking a range of updated automated communication routes for the service (such as a text reminder service) and as we proceed with this initiative, we will, of course, continue to have regard to your concern. The Health Board has re-issued communication detailing the referral process to liaison services and will share it with clinical teams across the Health Board to ensure there is clarity and consistency across all areas. The MHLD Liaison Psychiatry Services in Acute Hospitals Delivery Framework will also be reviewed.
Jean Frickel
Historic (No Identified Response)
2023-0203 21 Jun 2023 North Wales East and Central
Emergency services related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) Persistent ambulance delays stem from patient flow issues caused by social care deficiencies, leading to hospital handover delays. Insufficient collaboration between ambulance services, health boards, and local authorities continues to risk future deaths.
Leonard Harmsworth
Historic (No Identified Response)
2023-0202 20 Jun 2023 North Wales East and Central
Emergency services related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) Significant ambulance response and hospital handover delays, extending over many hours, persist due to multifactorial issues including social care deficiencies and patient flow, posing a continued risk of future deaths.
Eifion Huws
All Responded
2023-0185 8 Jun 2023 North West Wales
Suicide
Concerns summary (AI summary) Inadequate access to comprehensive patient records (due to electronic vs. hard copy discrepancies) hindered emergency staff decision-making. The Health Board's investigation also failed to address this critical information-sharing flaw or improve overall investigation timeliness.
Action Taken (AI summary) The Health Board is implementing the Welsh Community Care Information System (WCCIS) for integrated health and social care records and has reviewed its incident process, implemented rapid learning panels, and prioritized completion of overdue investigations and action plans.
Andrew Shambrook
All Responded
2023-0177 31 May 2023 North Wales East and Central
Suicide Wales prevention of future deaths reports
Concerns summary (AI summary) The health board lacks a robust, documented policy for decision-making and care pathways when patients are referred to the Home Treatment Team.
Action Planned (AI summary) The Health Board will review and ratify its Home Treatment Team Operational Policy by 31 January 2024, incorporating the coroner's comments. An interim addendum has been created to address immediate concerns.
Nancy Price
All Responded
2023-0137 26 Apr 2023 North Wales East and Central
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) The health board's internal investigations are too slow, with unrealistic action plans and missed deadlines, significantly delaying learning and preventing the timely implementation of safety improvements.
Action Planned (AI summary) The Health Board is re-evaluating the incident process with a new procedure document to be developed by the end of August 2023, addressing overdue investigations with weekly meetings, and implementing training programmes after procedure approval. They have also commissioned a Patient Safety Improvement Programme.
Ben Harrison
Historic (No Identified Response)
2023-0099Deceased 22 Mar 2023 North Wales East and Central
Suicide Wales prevention of future deaths reports
Concerns summary (AI summary) The Health Board demonstrates an evident lack of strategic direction for investigations and learning, with significant delays in implementing action plans following a death, risking recurrence of similar incidents.
Twm Bryn
All Responded
2023-0064Deceased 17 Feb 2023 North West Wales
Suicide Wales prevention of future deaths reports
Concerns summary (AI summary) Persistent staffing shortages lead to extensive waiting lists and assessment delays in mental health services, while interim support for low-risk patients is inadequate and lacks proactive monitoring.
Action Planned (AI summary) The Health Board is redesigning Local Primary Mental Health Support Services (LPMHSS) as part of ministerial priorities for 2024/2025, including a review of referral processes and interim support for low-risk patients; they will report on progress in 3 months.
Glendys Roberts
All Responded
2022-0333 24 Oct 2022 North West Wales
Emergency services related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) Ambulance availability is critically low for inter-hospital transfers due to bed blocking and a lack of community care. Implementation of crucial reviews for intra-hospital transfers, vascular emergency pathways, and an ambulance handover plan has been unacceptably slow.
Action Planned (AI summary) Betsi Cadwaladr University Health Board is reviewing intra-hospital transfer processes with support from the National Collaborative Commissioning Unit and modeling service demand. They are also working with WAST on ambulance performance and handover delays, and have an Integrated Commissioning Action Plan. The Trust is working with Betsi Cadwaladr University Health Board and the National Collaborative Commissioning Unit to improve intra-hospital transfer resources, including developing a proposal for dedicated transfer resources, and is considering actions to address issues in the Regulation 28 report, including changes to Standard Operating Procedures.
Trevor Reynolds
Partially Responded
2022-0132 6 May 2022 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The health board experienced significant delays in fully implementing a new Standard Operating Procedure for irregular scan reports and auditing its effectiveness, allowing known patient risks to continue.
Action Taken (AI summary) The Health Board has made all oncology and haematology staff aware of the SOP for escalating urgent radiology results and added it to the induction checklist and secretarial meetings. Audits show improved compliance with the SOP after training, and monthly audits will continue. New leadership roles and an electronic audit system are also being implemented.
Nora Foulkes
Partially Responded
2022-0112 14 Apr 2022 North Wales (East and Central)
Care Home Health related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Advance Nurse Practitioners failed to routinely review elderly care home patients' medication regimes during multiple visits, missing critical errors due to time constraints, posing a significant risk to patient safety.
Action Taken (AI summary) Following a safeguarding referral and internal review, the Health Board has implemented improved record keeping and medication reviews. Additionally, the Health Board will review the Medicines Policy (MM01) by 30 September 2022, deliver medication administration training to residential and nursing homes, develop an audit of the existing training program, and explore collaborative medication reviews with the Central Community Pharmacy team.
Susan Merton
Partially Responded
2021-0375 9 Nov 2021 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) The Health Board consistently fails to implement its own action plan recommendations and address concerns within set timeframes, leading to ongoing risks to patient lives.
Action Taken (AI summary) BCUHB changed its serious incident process in April 2021, requiring all investigation reports to be submitted for scrutiny and approval at an Incident Learning Panel. The Health Board is tracking actions and auditing compliance through its Datix patient safety system.
Kyle Hurst
All Responded
2021-0359 26 Oct 2021 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths Suicide Wales prevention of future deaths reports
Concerns summary (AI summary) The Health Board failed to implement a beneficial medical protocol and delayed approving critical risk mitigation procedures for diagnostic results, despite setting their own deadlines, thereby putting lives at risk.
Action Planned (AI summary) BCUHB is considering adopting the SNAP protocol for paracetamol overdose treatment but requires local review and approval. The Health Board is reviewing historic action plans from serious incident investigations and tracking actions through their Datix patient safety system.
Rhian Roberts
Historic (No Identified Response)
2021-0242 14 Jul 2021 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) A toxicology screen requested on arrival at ICU may not have been undertaken; an updated SOP for communicating life-threatening blood results was still in draft form; and there are concerns about continual delays in investigating adverse incidents, sharing learning and implementing actions.
Hannah Browning
Partially Responded
2021-0106 13 Apr 2021 North Wales (East and Central)
Community health care and emergency services related deaths Mental Health related deaths Suicide
Concerns summary (AI summary) Mental Health Services failed to adequately protect a patient with an immediate self-harm plan, making no attempt to contact her or reinforce available crisis options.
Action Taken (AI summary) Wrexham County Borough Council has developed a social work checklist for mental health social work teams and duty cases, implemented in May 2021, to ensure clear guidance and process adherence regarding risk identification and escalation.
Arthur Hughes
Partially Responded
2020-0057 9 Mar 2020 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) A lack of protocol for assessing locum staff's practical skills and managerial reluctance to thoroughly check references created risks that locums might perform tasks beyond their capabilities.
Action Planned (AI summary) The Health Board is revising and implementing a SOP for locum appointments, including additional pre-employment checks and reviews of practice. Implementation was delayed due to COVID-19 but is intended from 01 June 2020.
Peter Connelly
Historic (No Identified Response)
2019-0376 7 Nov 2019 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) Persistent, unacceptable delays in patient handover at emergency departments and prolonged ambulance waits continue to put patients' lives at risk by delaying timely medical intervention, despite previous assurances.
Madeline Staples
Historic (No Identified Response)
2019-0041 11 Feb 2019 North Wales (East and Central)
Emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) Persistent, unacceptable delays in patient handovers at emergency departments continue to result in long ambulance waits and unavailable resources, despite previous warnings, placing patients' lives at ongoing risk.
Gladys Williams
Historic (No Identified Response)
2018-0292 10 Sep 2018 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Ongoing, multifactorial problems with ambulance delays, emergency department overcrowding, and patient flow continue to risk lives, despite previous warnings and reported mitigation efforts.
Margaret Evans
Historic (No Identified Response)
2018-0197 26 Jun 2018 North Wales (East and Central)
Community health care and emergency services related deaths
Concerns summary (AI summary) Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient safety.
Ester Wood
Historic (No Identified Response)
2018-0176 6 Jun 2018 North Wales (East and Central)
Community health care and emergency services related deaths
Concerns summary (AI summary) Ongoing, systemic problems with ambulance delays, emergency department access, and patient flow continue to place lives at risk, despite repeated prior warnings.
Neville Welton
Partially Responded
2018-0150 17 May 2018 North Wales (East & Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures outstanding for too long.
Action Planned (AI summary) The Health Board is establishing weekly meetings for senior staff to review incidents, track progress of investigations, and ensure timely action plan implementation, commencing July 12th, 2018. They will also use a project management approach with milestones for comprehensive investigations, to be implemented as part of the revised model.
Daniel Watson
Partially Responded
2017-0370 18 Dec 2017 North Wales (East and Central)
Community health care and emergency services related deaths Mental Health related deaths
Concerns summary (AI summary) A root cause analysis identified numerous care and service delivery problems, missed opportunities, and a lack of staff understanding. Significant improvements are needed in mental health teams' risk assessment and escalation training.
Action Planned (AI summary) The University Health Board will provide further debriefing and supervision for the Community Psychiatric Nurse (CPN), hold a focused session for the wider team on empathy and transparency, continue to make available the WARRN Accredited Programme for Care Coordinators, and update the MHLD Supervision Guidance for Nurses and Support Workers Policy by the end of February 2018. Wrexham Adult Social Care will provide feedback and management supervision to the social worker involved, implement the Mental Health and Learning Disability Supervision Guidance for Nurses and Support Workers Policy, and include relevant staff in the Wales Applied Risk Research Network (WARRN) training and specific training on assessment of suicide.