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
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.
Simon Willans
Historic (No Identified Response)
2017-0280 5 Oct 2017 North West Wales
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The ambulatory care unit lacked effective scrutiny and the consultant failed to document patient care. Discharge by an uninvolved nurse practitioner, insufficient safety netting, and failure to commence heparin despite a DVT/PE differential posed significant risks.
Catherine Roberts
Historic (No Identified Response)
2017-0076 7 Jul 2017 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Problems with admission to the Emergency Department, resource availability, and patient flow continue despite previous reports to the Health Board, placing patients' lives at risk.
Daphne Williams
Partially Responded
2017-0167 25 May 2017 North Wales (East and Central)
Community health care and emergency services related deaths
Concerns summary (AI summary) Persistent issues with ambulance delays, emergency department admissions, resource availability, and patient flow continue to place patients' lives at risk despite previous reports.
Action Planned (AI summary) The University Health Board and Welsh Ambulance Services NHS Trust are collaborating on several actions to improve patient flow, including implementing SAFER patient flow bundles, developing integrated discharge hubs, and working with local authorities to reduce delayed transfers of care.
Lilly Baxandall
Partially Responded
2017-0160 17 May 2017 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, unresolved systemic issues, including ambulance handover delays, emergency department overcrowding, and bed blocking, continue to recur despite previous warnings, placing patients' lives at risk.
Action Planned (AI summary) Betsi Cadwaladr University Health Board, Welsh Ambulance Services NHS Trust, and the four Local Authorities are collaborating on actions to improve patient flow, including Innovation Unblocked event programmes and SAFER patient flow bundles.
Rebecca Evans
Partially Responded
2017-0077 14 Mar 2017 North Wales (East and Central)
Community health care and emergency services related deaths
Concerns summary (AI summary) Significant and recurring delays in patient handover at Emergency Departments led to late hospital admission and delayed medical treatment, tying up ambulance resources and risking future deaths.
Action Taken (AI summary) The University Health Board details a series of actions already taken, including improvements in performance indicators for ambulance handovers and emergency department waiting times, and implementation of patient navigators at YGC Emergency Department. They also mention an unscheduled care plan.
Carol Harvey
Partially Responded
2017-0059 10 Mar 2017 North Wales (East and Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is no procedure to confirm district nurse referral receipt and action, and significant delays exist in developing and implementing a safe patient discharge procedure from acute hospitals.
Action Planned (AI summary) The University Health Board has provided a working action plan relating to the case which will be monitored at the Secondary Care QSE meeting in July 2017.
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.
Vera Williams
Historic (No Identified Response)
2015-0428 6 Nov 2015 North East and North Central Wales
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Emergency Department doctors and staff lack a digital system to support their work.
Kathleen Neville
Historic (No Identified Response)
2015-0310 7 Aug 2015 Cardiff and the Vale of Glamorgan
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a significant risk of future deaths, particularly in other Health Boards without such a policy.
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.
Elouise Winship
Historic (No Identified Response)
2014-0431 7 Oct 2014 North Wales (East & Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is no documented standard practice for regular fetal heart auscultation after opiate administration or for further maternal examinations following a change in condition during labour.
Timothy Cowen
Historic (No Identified Response)
2014-0430 7 Oct 2014 North Wales (East & Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) New training on procedures is not mandatory for all staff, and the Acute Liaison Nurse role, crucial for patient support, lacks adequate cover during absences.
Christopher Davies
Historic (No Identified Response)
2014-0420 29 Sep 2014 North Wales (East & Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning signs of toxicity.
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.
Esther Jones
Historic (No Identified Response)
2014-0296 2 Jul 2014 North Wales (East & Central)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further patient harm.
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.