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.
PFD Reports
27 resultsRobert Stuart and Darren Hughes
Partially Responded
2014-0549
18 Dec 2014
Cardiff & the Vale of Glamorgan
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
NHSBT could improve the core donor data form with more information and ensure all relevant information is transmitted to transplant centres; UHW Cardiff should ensure consultants view the EOS system and employ a team approach for organ acceptance, and a written account of the deaths should be shared with the transplant community.
Action Taken
(AI summary)
NHSBT has already taken action, including a review of the incident, sharing learning points with specialist nurses, hosting a working group to reduce recurrence risk in March 2015, and commencing a monthly audit to review primary records for organ donors.
John Morgan
Partially Responded
2013-0372
17 Dec 2013
Cardiff & the Vale of Glamorgan
Mental Health related deaths
Concerns summary (AI summary)
Over-reliance on whiteboards rather than patient notes, the potential for human error to input incorrect information, and the use of a misleading DNR "red star" system pose risks to patient care.
Action Planned
(AI summary)
The Welsh Government requested that Health Boards and Trusts review the incident and make changes as appropriate. The Chief Medical Officer and Chief Nursing Officer will write to all Health Boards and Trusts in Wales to reinforce the need for robust systems where PSAG boards are in use. Welsh Government officials will also bring this to the attention of the 1000 Lives improvement service.