Cwm Taf Morgannwg University Health Board

PFD Addressee
Reports: 39 Earliest: Jul 2014 Latest: 27 Feb 2026

67% 2-year response rate (below 83% average). 55% of classified responses show concrete action taken.

Response Status (last 2 years, 6 reports)
Responded 4 No Response 1
AI Classification
Action Taken 55%
Action Planned 29%
Noted 16%
Disputed 0%
Based on 31 classified responses
PFD Reports Received by Quarter
PFD Reports
39 results
Clive Davies
Historic (No Identified Response)
2017-0074 16 Mar 2017 South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Failures in conducting routine neurological and NEWS observations, including missed checks and an incorrectly calculated score, resulted in the deceased not receiving a necessary medical review.
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.
Ronald Bonfield
Historic (No Identified Response)
11 Sep 2015 Powys
Community health care and emergency services related deaths
Concerns summary (AI summary) Inconsistent practices for monitoring district nurse compliance with delegated INR testing across GP surgeries create a risk of unmonitored over-anticoagulation.
Mary James
Historic (No Identified Response)
4 Sep 2015 Powys
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy for a dementia patient, missing a critical hospital admission opportunity.
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.
Arthur Cook
Historic (No Identified Response)
2015-0300 27 Jul 2015 Powys, Bridgend and Glamorgan
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Low staffing of Tissue Viability Nurses, inadequate pressure ulcer documentation, and a lack of integrated skin care across services contributed to progression of MRSA-infected pressure ulcers.
Alun Walters
Historic (No Identified Response)
2015-0262 9 Jul 2015 Powys, Bridgend and Glamorgan Valleys
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The medical practice failed to use computer software for prescription decisions, breached its anti-coagulation register contract, and lacked systems for notifying GPs of missed INR tests or Warfarin withdrawal.
Gail Prentice
Historic (No Identified Response)
2015-0253 2 Jul 2015 Powys, Bridgend and Glamorgan Valleys
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There is no mandatory requirement for surgeons to acknowledge reading relevant Health Board and national clinical guidelines, potentially leading to inconsistencies in surgical practice and patient care.
Hilda Harris
Partially Responded
2015-0161 24 Apr 2015 Powys, Bridgend & Glamorgan Valleys
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The community INR testing booking system is unreliable due to failures in appointment transfer and an unreliable notification system for omissions by family or carers.
Action Taken (AI summary) The University Health Board has developed and implemented a Corrective Action Plan for Improvement, with actions taken forward by the Primary Community & Localities Directorate.
Barrie Lewis
All Responded
2015-0065 19 Feb 2015 Powys, Bridgend & Glamorgan Valleys
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The provided text is incomplete and does not contain any discernible coroner's concerns.
Action Taken (AI summary) A corrective Action Plan for Improvement was developed, and actions have been taken to improve communication and documentation, including a review of the Care Treatment Plan Policy, a new procedure on the role of the duty officer, and improved monitoring of recording systems.
Martin McCabe
Historic (No Identified Response)
2014-0505 20 Nov 2014 Powys, Bridgend & Glamorgan Valleys
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital failed to conduct an updated falls risk assessment upon Mr. McCabe's admission, relying on an outdated assessment and omitting crucial new information about recent falls and sedative use.
Nicholas Megginson
Historic (No Identified Response)
2014-0400 11 Sep 2014 Powys, Bridgend & Glamorgan Valleys
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Patients discharged post-surgery received inconsistent advice, both oral and written, regarding venous thromboembolism risks and critical signs requiring urgent medical attention.
Vivian Hunt
All Responded
2014-0363 6 Aug 2014 Powys, Bridgend and Glamorgan
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.
Action Taken (AI summary) The Health Board developed a Corrective Action Plan for Improvement to ensure effective action regarding compliance with neurological investigations post head injury, with actions taken by the Mental Health Directorate.
Thomas Smith
Historic (No Identified Response)
2014-0316 9 Jul 2014 Cardiff & the Vale of Glamorgan
Community health care and emergency services related deaths
Concerns summary (AI summary) Critical issues include incomplete handovers, slow response times for children, lack of ambulance transfer, outdated national guidance on pre-hospital antibiotics for meningitis, and fragmented hospital care with unaddressed nursing concerns.