Swansea Bay University Health Board
PFD Addressee
Reports: 29
Earliest: Aug 2013
Latest: 27 Feb 2026
80% 2-year response rate (below 83% average). 54% of classified responses show concrete action taken.
PFD Reports
29 resultsSummer 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 Tatchell
All Responded
2025-0384
28 Jul 2025
SWANSEA NEATH & PORT TALBOT
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Persistent delays in cancer diagnostic, staging, and treatment pathways, especially for staging scans, are adversely affecting patient survivability rates and prognoses, making treatable cancers irresectable.
Action Planned
(AI summary)
The Health Board has secured locum cover for radiology for 12 months commencing in October 2025 and the data issue has been remedied with the information now captured on our data insights visualisation platform. A recent review of the head & neck single cancer pathway has confirmed positive compliance against key indicators. Although current monitoring requirements for clozapine remain unchanged, the Trust will circulate emerging scientific literature regarding less frequent blood count monitoring to all prescribers and pharmacists to increase scrutiny of abnormal blood count results in established treatment.
Jean Pike
All Responded
2025-0127
7 Mar 2025
SWANSEA & NEATH PORT TALBOT
Mental Health related deaths
Suicide
Wales prevention of future deaths reports
Concerns summary (AI summary)
Discharge decisions were made without essential multi-disciplinary meetings or consulting care coordinators, despite clear warnings of high suicide risk, indicating a systemic failure in communication and risk management.
Action Taken
(AI summary)
Swansea Bay University Health Board provided additional training to Serious Incident Investigators, focusing on process mapping to improve analysis of clinical input against specified processes, and implemented regular team meetings to reflect on the review process.
Amy Padley
All Responded
2025-0105
24 Feb 2025
SWANSEA & NEATH PORT TALBOT
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide
Concerns summary (AI summary)
Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, and are reluctant to offer simultaneous support for addiction and mental health.
Action Planned
(AI summary)
Swansea Bay University Health Board acknowledges concerns about treating individuals with both addiction and mental health diagnoses. They are developing a Standard Operating Procedure (SOP) and care pathway to address this, starting meetings in May 2025 to review practices and integrate mental health and substance use services.
Peter Parker
All Responded
2024-0565
22 Oct 2024
SWANSEA NEATH & PORT TALBOT
Emergency services related deaths
Other related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
Significant ambulance response delays, exceeding the expected survivability of severe injuries, were caused by ambulances being held up at Emergency Departments, preventing them from attending new calls.
Noted
(AI summary)
The Trust details existing processes for prioritising calls and rapid handover of patients, and offers a meeting to discuss their response and commitment to improvement. Swansea Bay University Health Board outlined existing plans to reduce delays within acute unscheduled care pathways, including reducing bed numbers and improving flow, implementation of a frailty assessment unit and SDEC, and providing alternative pathways for patients presenting to the Emergency Department. The Welsh Government notes that the Health Board and Ambulance Service will respond separately and summarises pressures on urgent and emergency care services in Wales, as well as the actions being taken to address them including '50 day challenge' and escalation of Swansea Bay University Health Board to level 4.
Nicholas Harrison
All Responded
2024-0224
24 Apr 2024
Swansea Neath and Port Talbot
Mental Health related deaths
Other related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
The Approved Mental Health Practitioner service repeatedly failed to conduct legally compliant Mental Health Act assessments, including insufficient collateral information gathering and inadequate medical attendance, despite family requests.
Action Planned
(AI summary)
The Welsh Government is focusing on improvements within several wards across health boards in Wales, including Ward F at Neath Port Talbot Hospital, setting national standards for risk assessment and discharge planning, and will monitor related metrics at regular intervals through UHB meetings. The council will continue to work with Swansea Bay University Health Board (SBUHB) to ensure mental health professionals who require access to the WCCIS system are granted access, and discussions are underway to ensure patient clinical notes are available across relevant systems accessed by both organisations. Swansea Bay University Health Board has implemented anti-ligature training, updated its observation policy, created a new assessment tool for environmental risks, established a process to review patients who do not attend appointments, and implemented a monthly monitoring system for Assertive Outreach Team referrals. The health board is reminding all clinical staff to ensure care plans are placed at the front of clinical notes or on the digital front page in WCCIS, and that plans are shared directly with relevant team members.
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.
Jacob Billington
All Responded
2024-0136
13 Mar 2024
Birmingham and Solihull
Other related deaths
Concerns summary (AI summary)
Release of high-risk prisoners is jeopardised by inadequate interagency communication, fragmented information systems, and a lack of clear guidance and understanding for discharge planning roles.
Noted
(AI summary)
HMP & YOI Parc has provided notice to offender managers to notify the relevant Community Offender Manager when a prisoner is being released at sentence end date and will be of no fixed abode, including providing information relating to a prisoner’s intentions in terms of where they are going on the day of release. G4S will continue to streamline its own data recording, to ensure as much information as possible is shared through the primary national prisons IT system, DPS. West Midlands Police have updated their systems with prompts to improve the identification of those at increased risk and will work with MAPPA partners to ensure the coordinator role and new policy are understood and cascaded to relevant staff. BSMHFT will develop a sustainable engagement strategy with MAPPA, review the Prison Discharge Coordinator's role, and explore amendments to the Systemone interface in HMP Birmingham to record community mental health team involvement, anticipating a decision within a month. The health board acknowledges the concerns raised in the report but states that it has no jurisdiction/power over the actions required for some of the concerns. However, it has alerted the MAPPA Coordinator to the concern regarding release of high-risk prisoners and will participate in Strategic Management Board discussions. West Midlands Probation Service is working with NHS-England Reconnect Service to ensure Probation Practitioners are aware of how to refer into this service in Prison for support “through the gate”, the transition period from prison into the community. West Midlands Probation Service will work with the Health Trust to support any Guidance revisions undertaken by the Health Trust to ensure that the Guidance is clear and enables effective information sharing and can be embedded within and understood by all in the Probation Service.
Jean Thomas
All Responded
2024-0121
4 Mar 2024
Swansea Neath and Port Talbot
Emergency services related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
Significant ambulance and hospital offload delays, far exceeding targets, led to the formation and exacerbation of a pressure sore due to prolonged patient immobility.
Action Planned
(AI summary)
Welsh Ambulance Service NHS Trust is not planning further action on ambulance delays, but highlights work to reduce patient harm from pressure damage including a new device. The Trust is finalising steps before beginning a pilot of the new mattress. Swansea Bay University Health Board is working on several initiatives to address access to emergency care and falls prevention, including reviewing referral processes, working with the Welsh Ambulance Service Trust to improve response times, implementing a digital application for non-injurious falls, utilizing the "Dance to Health" program, introducing a Podcast Series, and implementing an Intergenerational Falls Prevention Programme.
Shane West
All Responded
2023-0267
19 Jul 2023
Swansea Neath Port Talbot
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inconsistent medication records, challenges in assessing a learning-disabled patient's condition, and an unclear appreciation of respiratory risks associated with laxative administration for abdominal distension.
Action Planned
(AI summary)
Swansea Bay University Health Board will develop an explicit clinical management plan to address clinical issues throughout a patient's treatment, to be changed on a multi-professional basis. They will remind staff prescribing medications to select the correct drug and report adverse reactions and have reported the death nationally via the "Yellow Card" scheme.
Samuel Morgan
All Responded
2023-0163
18 May 2023
Swansea Neath Port Talbot
Suicide
Concerns summary (AI summary)
A lack of integrated electronic records between alcohol/drug addiction and mental health services prevents effective information sharing, particularly for complex dual diagnosis cases. This poses a significant risk that critical patient safety information will be lost between agencies.
Action Planned
(AI summary)
For Swansea based teams, technical changes to enable two-way information sharing between community mental health teams and drug and alcohol services via WCCIS will be completed within 10 working days, commencing 7th August 2023. For NPT based teams, access to WCCIS on a read-only basis will be extended, with implementation planned from 4th September 2023.
Catherine Best
All Responded
2021-0244
15 Jul 2021
Swansea, Neath & Port Talbot
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
An inadequate nasogastric tube feeding regime resulted in inconsistent calorie intake, compromising the patient's ability to fight infection.
Action Taken
(AI summary)
The Health Board has made changes to policies, procedures, guidance and training regarding nutrition and hydration since 2012. They have also adopted Clinical Standards for Inpatient Nutritional Support since 2017, with audits every 2 years.
Pamela Moran
Historic (No Identified Response)
2019-0367
12 Nov 2019
Swansea Neath & Port Talbot
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
Missed opportunities for a CT scan and lack of a system for overnight consultants to authorise scans contributed to delayed diagnosis and potentially preventable death.
Jane Livingston
All Responded
2019-0359
4 Oct 2019
Swansea Neath & Port Talbot
Mental Health related deaths
Suicide
Wales prevention of future deaths reports
Concerns summary (AI summary)
Gateway assessors lacked full access to patient notes, risking incomplete assessments and treatment plans based on insufficient information.
Action Taken
(AI summary)
• A detailed review of the information in the report has been undertaken by the Quality and Safety team for the Mental Health Swansea locality at Swansea Bay University Health Board.
• A full investigation has been conducted into the events of the 14th December.
• The Health Board confirms that the PARIS system has been audited during our investigation, and can confirm that the CMHT staff accessed the system at 12.29hrs on the 14th December 2018 to document the duty assessment conducted on Ms Livingston.
Jane Livington
Historic (No Identified Response)
2019-0359-wp26871
4 Oct 2019
Swansea Neath & Port Talbot
Mental Health related deaths
Suicide
Wales prevention of future deaths reports
Concerns summary (AI summary)
Gateway assessors had incomplete access to patient notes, potentially resulting in inadequate assessments and treatment plans due to missing critical 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.
Keith Heatley
All Responded
2019-0478
26 Feb 2019
South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with inconsistent recording of MDT meetings and no clinical review before high-risk patient leave.
Action Taken
(AI summary)
The health board implemented a checklist to ensure multidisciplinary team members, including the Community Mental Health Team and family, can express their views on patient leave. They also appointed a ward clerk, developed a carers' forum, implemented a risk assessment model (WARNN), created a Patient Experience Group (PEG), involved carers in 15-step reviews, and arranged a learning event.
Christopher Roberts
Historic (No Identified Response)
2017-0283
5 Oct 2017
Swansea, Neath and Port Talbot
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Care plan reviews lacked documentation, making it impossible to confirm outcomes or whether previous suicide attempts were considered. Additionally, Nomad trays might be unsuitable for certain patients, impeding medication benefits.
Hedley Greenland
Partially Responded
2017-0235
26 Sep 2017
South Wales Central
Care Home Health related deaths
Concerns summary (AI summary)
Nursing staff failed to use a fluid balance chart or monitor urine output, hindering detection of critical issues. A nurse was untrained in male catheterisation, and there was a general lack of understanding and training in managing long-term indwelling catheters.
Action Taken
(AI summary)
The Health Board has implemented a booking and attendance system for community training recorded in an electronic central booking diary and responsibility for catheterisation training is shared between community and secondary care. A catheter passport was introduced in hospital and community settings which will be extended to care homes.
Dennis Redmore
All Responded
2017-0315
9 Aug 2017
South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Clear failures in neurological monitoring, with substantial observation gaps and delayed action on elevated vital signs, were identified. There was also a lack of appropriate management to ensure nurses adhered to observation guidelines.
Action Planned
(AI summary)
The health board has incorporated actions into a formal plan with clear timescales and responsibilities for monitoring Mr Redmore's neurological state, acting upon NEWS observations, and undertaking observations in line with guidance. An advisory group will help deliver improvements.
Anton Kusz
Partially Responded
2017-0140
27 Apr 2017
South Wales Central
Community health care and emergency services related deaths
Concerns summary (AI summary)
An eight-hour ambulance delay for a patient with a fractured hip was caused by insufficient clinician capacity for 999 calls and widespread ambulance unavailability due to extensive hospital handover delays.
Action Taken
(AI summary)
The University Health Board details multiple improvements to reduce waiting times in the ED, including an Unscheduled Care Plan, Ambulatory Care services, consultant triage, virtual assessment, multidisciplinary frailty assessment, and more. They have also implemented a system of regular checks for patients delayed in ambulances.
Edwina Moses
Partially Responded
2016-0462
22 Dec 2016
South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A poor system for requesting and securing one-to-one nursing cover led to frequent unavailability and staff confusion. This resulted in inadequate staffing levels, leaving frontline nurses unable to safely care for vulnerable patients.
Action Taken
(AI summary)
The University Health Board has reviewed the process around enhanced observation, including risk assessments and staffing level monitoring, and introduced an audit process to monitor adherence to increased nursing observation guidelines.
David Cooper
Partially Responded
2016-0459
21 Dec 2016
South Wales Central
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There was also a lack of 'joined-up' thinking and insufficient systems for booking one-to-one care for high-risk patients.
Action Taken
(AI summary)
The University Health Board established a Falls Management Group, reviewed policies and training requirements, introduced National Patient Safety Agency's Risk Assessments, devolved falls management to Directly Managed Units, and will continue to meet as a scrutiny panel with a Consultant Physician leading the group.
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.
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.