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.

Response Status (last 2 years, 5 reports)
Responded 4 No Response 1
AI Classification
Action Taken 54%
Action Planned 38%
Noted 5%
Disputed 3%
Based on 37 classified responses
PFD Reports Received by Quarter
PFD Reports
29 results
Howell Fisher
Historic (No Identified Response)
2015-0152 21 Apr 2015 Powys, Bridgend & Glamorgan Valleys
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Insufficient staff led to multiple falls for a high-risk patient. There was a critical lack of falls risk assessment and handover information between hospitals.
Robert Payne
Historic (No Identified Response)
2015-0140 16 Apr 2015 Powys, Bridgend & Glamorgan Valleys
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward transfer lacked documentation, and the fatal fall was unwitnessed.
Brian Francis
Partially Responded
2015-0085 4 Mar 2015 Powys, Bridgend & Glamorgan Valleys
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A flawed consultant attendance logging system meant a patient was not reviewed. Lack of access to community medical records at admission delayed critical anti-coagulation therapy.
Action Taken (AI summary) The Health Board provided an action plan prior to the inquest and has updated it in response to concerns. Actions include enhanced senior clinician review of emergency medical patients, reinforced importance of nursing staff reviewing documentation, and plans to extend electronic GP record access to emergency departments.
Terence O’Connell
Partially Responded
2013-0218 28 Aug 2013 Bridgend, Glamorgan Valleys & Powys
Community health care and emergency services related deaths
Concerns summary (AI summary) A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not being seen, alongside a lack of vital clinical monitoring for two days.
Disputed (AI summary) The care home disputes that there was a communication breakdown between the care home, district nurses, and the out-of-hours GP service, asserting that communication breakdown was between district nurses and the GP out of hours service. The University Health Board has implemented a clear and accurate message sheet, SBAR (Situation, Background, Assessment, Recommendation), for switchboard staff to record out-of-hours requests for District Nurses in greater detail.