Cardiff and Vale University Health Board

PFD Addressee
Reports: 27 Earliest: Dec 2013 Latest: 6 Mar 2026

83% 2-year response rate (matches average). 55% of classified responses show concrete action taken.

Response Status (last 2 years, 6 reports)
Responded 5 No Response 1
AI Classification
Action Taken 55%
Action Planned 32%
Noted 13%
Disputed 0%
Based on 31 classified responses
PFD Reports Received by Quarter
PFD Reports
27 results
Alan Tomlinson
All Responded
2026-0131 6 Mar 2026 Gwent
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) A pacemaker clinic failed to refer a visibly unwell patient with high thresholds to cardiology, contributed to a delayed diagnosis. Concerns include lack of referral guidance, limited physiologist knowledge, and inconsistent clinical data communication.
Action Taken (AI summary) • A revised escalation and referral protocol has been implemented within the Cardiac Device Clinic. • A mandatory referral trigger is now in place if a device has lost a twofold safety margin, documented in the "Managing the Unwell Patient Standard Operating Procedure". • The Standard Operating Procedure has been shared with all Physiologists and will be presented at the departmental Quality and Safety meeting on the 13th of May.
Summer Mant
No Identified Response
2026-0118 27 Feb 2026 South Wales Central
Child Death Wales prevention of future deaths reports
Concerns summary (AI summary) A delay in obtaining adrenaline during resuscitation occurred due to non-standardised paediatric crash trolleys across hospitals, hindering junior doctors in a time-critical situation.
Gareth Johnson
All Responded
2025-0464 12 Sep 2025 South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) Deteriorating hospital infrastructure and critical care capacity issues pose a significant risk, as safeguards against moving critically ill patients may fail under pressure.
Action Planned (AI summary) The Health Board has developed an Electrical Failure Emergency Action Card outlining actions to respond to power failures, developed an updated Critical Care Escalation Plan, and integrated key elements into the Major Incident Plan. They are also undertaking regular review and simulation of escalation and major incident plans and ongoing staff training. Welsh Government officials met with Cardiff and Vale UHB to discuss infrastructure issues at the ITU, critical care and theatres departments and a business case is being developed to refurbish the ITU. The Welsh Government will also write to Cardiff and Vale UHB to confirm what clinical governance is in place to approve changes in the location of critical care and to ensure the appropriate clinical cover is in place and write to selected health boards to request them to respond to the NHS Performance and Improvement critical care network census.
Robert Smith
All Responded
2025-0240 21 May 2025 South Wales Central
Mental Health related deaths Suicide Wales prevention of future deaths reports
Concerns summary (AI summary) Mental health services lack clear guidance for clinicians on family information sharing and gathering, leading to inconsistent practices. Patient information leaflets also fail to adequately explain these processes.
Action Planned (AI summary) Cardiff and Vale University Health Board has worked to co-produce guidance on information sharing with families, revised a patient information leaflet, and commissioned a co-produced family engagement project to enhance family involvement.
Colin Colley
All Responded
2025-0145 17 Mar 2025 South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) Nursing staff and healthcare workers at St David’s hospital lack confidence and adequate training in falls risk assessments, enhanced supervision, and proper documentation, risking future deaths.
Action Taken (AI summary) The Health Board is expanding falls prevention training, undertaking improvement work regarding bedrails and auditing their use, updating the enhanced supervision framework and developing a new policy, and piloting education programmes for staff.
John Follon
All Responded
2024-0547 14 Oct 2024 South Wales Central.
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) The alarm system allows silencing without patient checks, especially during night shifts, and monitors are not continuously checked. This creates a significant risk of patients remaining unmonitored for extended periods.
Action Taken (AI summary) Cardiff and Vale University Health Board has made changes to the alarm system, such as making the alarm louder and ensuring a yellow ribbon appears at the top of the monitoring screen, and is implementing a workstream to replace bedside monitors and assess/evaluate configurations across all patient monitoring.
Alan Davies
All Responded
2024-0160 21 Mar 2024 South Wales Central
State Custody related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) There was limited communication between Caswell Clinic and HMP Cardiff regarding the patient's condition; discharge information was not provided in a clear format, and the patient was transferred without being accompanied by a member of Caswell Clinic staff.
Action Taken (AI summary) The Department of Health and Social Care outlines national measures to improve urgent and emergency care, including funding increases for ambulance trusts, hospital beds, and discharge support. It also notes improved Category 2 ambulance response times nationally and in the NWAS region, and decreased patient handover times. Swansea Bay University Health Board has developed a Standard Operating Procedure for transferring individuals with mental/physical health needs into their care. They have also improved the service level agreement with a local GP practice, recruited additional GPs and implemented changes to the night shift pattern to alleviate staff workload. HMPPS has received assurance from the Governing Governor at HMP Cardiff that all staff are aware of emergency medical codes via the radio system. The Governor is also committed to encouraging staff to raise concerns about an individual's management and will discuss with the Head of Healthcare how healthcare staff can be empowered to do so.
Ocean-Leigh Hayes
All Responded
2023-0455 15 Nov 2023 South Wales Central
Child Death
Concerns summary (AI summary) Health visitors are inconsistently conducting physical reviews of sleeping arrangements for babies, missing opportunities to risk assess co-sleeping environments and advise parents on dangers.
Action Planned (AI summary) Cardiff and Vale UHB will monitor and implement an assurance plan to completion through the Children and Women Clinical Board assurance framework, to address issues around health visitor communication regarding safe sleeping practices and visual assessment of sleeping areas.
Yvonne Rankin
All Responded
2022-0404 13 Dec 2022 South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) The family and patient lacked understanding of specific sepsis signs, delaying emergency intervention. Distributing information cards on sepsis to at-risk patients in the community could prevent future delayed recognition and response.
Action Taken (AI summary) Cardiff and Vale UHB has updated the eCORFLO booklet to include reference to sepsis and will provide an additional information sheet for early warning signs of sepsis. They will also provide adult and paediatric symptom cards to patients and parents and advise other Welsh health boards of these actions. Cardiff and Vale UHB updated patient information for new PEG patients to include sepsis signs (updated Jan 30, provided from Feb 6). The ANA team will ensure new patients receive this info by March 1. Cardiff and Vale UHB also ordered Adult and Paediatric Symptom Cards to give to patients with infection signs, with the ANA team distributing them by March 1.
Maria Whale
All Responded
2022-0362 9 Nov 2022 South Wales Central
Emergency services related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) The report identifies that the emergency services repeatedly advised a gravely ill, disabled woman to take a taxi to A&E, and a call responder concluded that if she could scream then she was not a priority.
Noted (AI summary) Cardiff and Vale University Health Board reviewed the patient's triage and management by the Out of Hours GP Service, sharing their initial findings. The board acknowledges that there was poor communication at the inquest hearing which may have led to some of the recommendations. The Welsh Ambulance Services NHS Trust acknowledges the concerns raised regarding triage and response times and the impact of system pressures. The Trust says it will continue to press for real systemic change at every opportunity.
Lewys Crawford
Historic (No Identified Response)
2020-0046 28 Feb 2020 South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) A&E consultants and agency nurses lacked adequate training in paediatric sepsis identification and management, including using risk stratification tools and appropriate terminology. Failures were noted in considering alternative antibiotic administration methods.
Christopher Summerhayes
All Responded
2019-0263 22 Aug 2019 South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) Complex polypharmacy involving Clozapine led to severe side effects and potential misinterpretation of overdose symptoms, while a possible contraindicating familial lipid disorder was not confirmed.
Action Planned (AI summary) The Health Board reported the death to the Medicines and Healthcare products Regulatory Agency (MHRA). A project proposal is in development by the Mental Health Clinical Board, Pharmacy and Information Technology to develop an interface between PARIS and PMS to improve the transfer of information.
Glenys Button
Partially Responded
2019-0192 10 Jun 2019 South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) Inefficient and outdated neurosurgical referral systems, relying on switchboards and bleeps, cause delays and miscommunications, with no backup for busy on-call doctors. Modern digital solutions are available but not utilized.
Action Planned (AI summary) An e-referral system is being piloted, with an evaluation to follow three months after the pilot starts; however, networking issues have delayed the pilot's extension. In the interim, additional measures and email communication have been implemented to avoid delays in urgent referrals.
John Preece
All Responded
2019-0019 15 Jan 2019 South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) Significant failures in falls management, head injury recognition, and neuro observation training among staff, compounded by a lack of appropriate monitoring and early warning systems for mentally unwell patients.
Noted (AI summary) The Health Board has implemented a falls training program developed by Practice Nurse Educators, introduced an escalation policy specifically for St Barruc ward, and uses NEWS across MHSOP wards in University Hospital Llandough with clear escalation policies. The NMC outlines its regulatory role in setting and maintaining standards for registered nurses and refers to new standards and assurance processes to ensure nurses entering the register are properly trained. They will pursue any regulatory concerns which it is appropriate for them to take, through their fitness to practise procedures.
Ruth Edwards
All Responded
2018-0395 18 Dec 2018 SouthWales Central
Community health care and emergency services related deaths Mental Health related deaths Suicide
Concerns summary (AI summary) Patient discharge after an overdose failed to include psychiatric liaison assessment, passing critical responsibility to the family. Inadequate history-taking led to underestimated risk, and insufficient GP medication reviews created an overdose risk.
Action Taken (AI summary) The practice has taken on a full-time Clinical Pharmacist to oversee repeat and acute prescribing, and patient monitoring. They achieved an NHS award for quality improvement in this area. The University Health Board conducted an internal review and will remind staff of the importance of full and diligent information taking. The matter of medication reviews has been raised with the Primary Community and Intermediate Care Clinical Board as a practice issue.
Joseph Page
Historic (No Identified Response)
2018-0347 12 Nov 2018 South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which led to an overdose.
Steven Welch
Partially Responded
2018-0267 7 Aug 2018 South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Errors in assessing head injury urgency and significant delays in transferring patients to neurosurgical centers, compounded by a lack of specialist radiologists and inadequate electronic radiology transfer systems, posed serious risks.
Noted (AI summary) NHS Wales Shared Services Partnership Legal and Risk Services outlines its role in advising and supporting health bodies in Wales regarding legal issues, clinical negligence claims, and risk management. They conduct reviews and provide training but do not have the authority to implement service changes. The Welsh Ambulance Services NHS Trust details existing training and monitoring systems for call takers, a review of recent call taker errors, and the intended use of Optima Predict software for demand prediction. They also highlight collaborative work with Cwm Taf University Health Board to reduce ambulance conveyance to emergency units.
Richard Barrett
All Responded
2018-0249 30 Jul 2018 South Wales Central
Community health care and emergency services related deaths
Concerns summary (AI summary) Seriously underestimated ambulance demand and unrealistic A&E turnaround targets led to severe ambulance shortages. Unreliable welfare call systems and failure to involve police for checks further delayed critical intervention.
Action Planned (AI summary) The Welsh Ambulance Services NHS Trust and Cardiff and Vale University Health Board confirmed the continued actions of reminding CCC Clinical Leads to address Protocol 23 cases promptly, approach the Police to extend the MOU to include overdose cases, expand the clinical desks, rolling out the APP model across Wales and implementing a Level 1 response to people who have fallen and are not injured. The Welsh Ambulance Services NHS Trust (WAST) is considering options to increase capacity on its clinical support desk and exploring options for third sector organisations to support delivery of welfare checks. The Cabinet Secretary has commissioned a review of the ‘Amber’ category.
David Evans
Historic (No Identified Response)
2017-0134 20 Apr 2017 South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate escalation of care for symptomatic patients with identified Abdominal Aortic Aneurysm.
David Griffiths
All Responded
2017-0013 31 Jan 2017 South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There were no local protocols or specific training for intercostal drain insertion, and recommended real-time ultrasound guidance was unavailable, raising significant safety concerns for patients.
Action Taken (AI summary) The University Health Board has discontinued the practice of inserting chest drains at a 'marked' point and has purchased equipment. A task and finish group will oversee implementation and assessment across the Health Board and will report to the Quality, Safety and Experience Committee.
Maurice Isaacs
Partially Responded
2016-0411 7 Nov 2016 South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate falls risk assessment, inconsistent 1:1 supervision, understaffing, and untrained staff performing neurological observations contributed to multiple falls and missed assessments.
Action Taken (AI summary) Following an internal investigation, the UHB has already completed an action plan including measures to improve falls risk assessment and recording, neurological observations, and escalation procedures. A Falls Delivery Group has also been established to review and monitor practice, and the Regulation 28 report will be shared with all Clinical Boards.
Imad Hassan
Partially Responded
2016-0315 5 Sep 2016 South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is no formal backup plan for PCI procedures when primary hospitals lack capacity, and no agreed pathways for accessing critical care beds outside Wales or for unconscious STEMI patients.
Action Planned (AI summary) Cwm Taf University Health Board has been working to develop an interim solution pending the completion of a comprehensive pathway in the summer of 2017. A local corrective Action Plan for improvement was developed and will be shared with clinical colleagues. The United Hospitals University Bristol Trust will accept patients if there is insufficient critical care capacity in South Wales, facilitated by the regional PPCI centre. Work is underway on an all Wales basis to agree a longer term strategy for these patients.
Geoffrey Parry
All Responded
2015-0400 7 Oct 2015 Cardiff and the Vale of Glamorgan
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was accidentally disconnected, highlighting a lack of clear labelling protocols.
Action Taken (AI summary) The University Health Board has reviewed systems for ECG storage, reinforced the use of the MUSE system, and implemented training on intravenous infusion labelling. The learnings from this incident will be shared, and the Regulation 28 report will be shared with all Clinical Boards.
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.
John Lloyd
Historic (No Identified Response)
2015-0282 16 Jul 2015 Cardiff and the Vale of Glamorgan
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and could lead to inappropriate treatment courses and poorer outcomes.