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
Clear
PFD Reports
45 results
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.
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.
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.
Kate Pierce
All Responded
2017-0312 31 Oct 2017 North Wales (East & Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is a lack of clarity on when a sick child needs senior paediatrician review before discharge, especially with parental concerns. Additionally, the system for identifying and acting on learning opportunities from readmissions lacks clear, consistently applied criteria.
Action Taken (AI summary) The University Health Board confirms that it has a formal policy about discharging children from the children's assessment unit, and has altered the parent discharge information to explicitly state parents may escalate their desire to have a second opinion.
Raymond Edwards
All Responded
2017-0029 10 Feb 2017 North Wales (Eastern and Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information was not promptly reviewed, posing a significant risk of delayed diagnosis and treatment in future cases.
Action Taken (AI summary) The University Health Board developed BCUHB Procedure MD23 to mitigate risks due to failure to act on diagnostic results, based on NPSA 16 guidance, and approved at the end of 2016. An electronic reporting system (CHAI Ping app) is being developed to provide alerts to clinicians when histology reports are authorised for viewing.
Sarah Tyler
All Responded
2017-0002 13 Jan 2017 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Pervasive hospital admission delays due to insufficient beds were exacerbated by increased 'bed blocking' on weekends, stemming from reduced patient discharges. This systemic issue poses a significant risk to timely patient care.
Action Planned (AI summary) The Health Board is implementing an Unscheduled Care Plan in 2017/18 to improve waiting times for hospital admissions and reduce bed occupancy. The plan includes targets for each section and will be overseen by a Health Board-wide Transformation Group, with progress monitored monthly and by Welsh Government.
Christopher Jones
All Responded
2016-0319 7 Sep 2016 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate mental health care planning resulted in patients being without consultant review for extended periods post-discharge. Increased demand on services also created staff cover deficiencies.
Action Taken (AI summary) The Division produced a multi-agency document which became operational in August 2013 and has been reviewed regularly. MHM administrators send a report to managers of all CTPs due for review, 3 months in advance with a view to avoiding any CTPs becoming out of date and patients have reviews in a timely manner.
Pamela Conway
All Responded
2016-0309 26 Aug 2016 North Wales (East and Central)
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for other calls, creating ongoing risks to public safety.
Action Planned (AI summary) The Welsh Ambulance Service NHS Trust has made progress against key actions identified in an attached action plan, with the most significant impact from the Welsh Health Circular regarding hospital handover guidance. Lessons learned from the case are being monitored through a Task and Finish Group. The University Health Board is scrutinizing two working action plans relating to the case, which will be monitored by the Quality and Safety Group.
Danielle Robinson
All Responded
2016-0205 31 May 2016 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths Suicide
Concerns summary (AI summary) Staff are not rigorously following the Therapeutic Engagement and Observation Policy, leading to missed opportunities for escalating patient observation levels during critical risk periods.
Action Taken (AI summary) The University Health Board has reviewed and updated its Therapeutic Engagement and Observation Policy to include the automatic escalation of observations following a serious attempt of self-harm until a full multi-disciplinary team review can take place; the policy will be formally re-launched at a learning event planned for September 2016.
John Rogers
All Responded
2016-0097 9 Mar 2016 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for their required work.
Action Taken (AI summary) The University Health Board has undertaken and completed a detailed action plan relating to Ysbyty Glan Clwyd with specific training requirements. They are strengthening systems to ensure training and qualifications remain up to date, introducing a more rigorous approach to monitoring and a supportive approach for staff training.
Barry Wilson
All Responded
2015-0167 29 Apr 2015 North West Wales
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A defective surgical anastomosis, made with staples, was not detected prior to the patient's hospital discharge, directly contributing to their death.
Action Planned (AI summary) The University Health Board will implement a pre-discharge checklist, provide patients with information leaflets outlining symptoms of concern and contact numbers, ensure care aligns with planned surgery, and have patients report by telephone to the ward daily until contacted by a Colo-Rectal Nurse Specialist.
Sally Ellison
All Responded
2015-0163 27 Apr 2015 North Wales (East & Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and potentially delaying optimal treatment. A rapid testing and reporting service is urgently needed.
Action Planned (AI summary) NHS Wales, through the Pathology Clinical Programme Group, has reviewed the process for requesting urgent samples from primary care and is distributing a memorandum to GPs and Practice Managers with instructions on labeling and transportation to minimize delay, along with contact numbers for laboratories.
Anthony Williams
All Responded
2014-0523 2 Dec 2014 North Wales (East & Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Staff lacked clear guidance on psychiatric assessment pathways for 'exceptional cases', medical records were inaccessible out-of-hours, and there was insufficient engagement with family/carers on care plans.
Action Taken (AI summary) The health board now has a larger number of psychiatric nurses present on the Heddfan Adult Unit out of hours so socially anxious patients could be assessed at the Unit. The adoption of an electronic case record is currently being explored.
Clive Turner
All Responded
2014-0404 12 Sep 2014 North Wales (East & Central)
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital staff lacked knowledge of pre-hospital pain relief, there were no clear policies for overnight patient discharge, and senior clinical oversight was unavailable late at night.
Action Taken (AI summary) The Welsh Ambulance Service reviewed the delayed response, implemented a new clinical support desk for early triage of calls, staffed by paramedics and nurses, using the Manchester Triage System. This aims to provide clinical support for patients waiting longer than 8 minutes and improve the ambulance performance standard.
Ronald Perry
All Responded
2014-0302 2 Jul 2014 North Wales (East & Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inconsistent criteria for requesting CT scans based on time of day or weekend leads to varying levels of care and risks missed diagnoses for patients 'out of hours'.
Noted (AI summary) The University Health Board states that its radiology service operates a full service during weekday hours, with emergency on-call service at all other times, and a CT scan would have been performed had a ruptured abdominal aortic aneurysm been indicated. They are working to develop increased access outside of normal office hours.
Alun Sheppard
All Responded
2014-0268 13 Jun 2014 North Wales (East & Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, potentially hindering patient well-being.
Noted (AI summary) The Health Board agrees that familial support improves patient recovery and routinely encourages service users to engage with their families. The policy of the Health Board is to use a confidentiality form.
Frederick Pring
All Responded
2014-0024 21 Jan 2014 North Wales (East & Central)
Community health care and emergency services related deaths
Concerns summary (AI summary) Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for other critical calls.
Action Planned (AI summary) The Welsh Ambulance Service NHS Trust and Betsi Cadwaladr University Health Board are working towards completing an All Wales Handover Policy for patient handover between clinical teams. The Health Board also proposed acting as a 'Demonstrator Site' to implement recommendations regarding overcrowding in Emergency Departments.
Gwilym Pugh Jones
All Responded
2013-0239 25 Sep 2013 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Clinician-requested tests were not conducted, resulting in a missed opportunity for diagnosis and treatment.
Action Taken (AI summary) • The Corporate Governance Team was tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. • Of the 120 Corporate Policies and Procedures currently in place , 117 are now in date. • Three policies are subject to fundamental review; this process will be completed by 31st March 2014.