Cardiff Vale University Health Board
NHS / Health Body
Action Planned
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. (AI summary)
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Dear Mr Morse
Re: Regulation 28 Report to Prevent Future Deaths – Robert Maxwell Smith
Thank you for your report dated 21 May 2025 concerning the tragic death of Mr. Robert Maxwell Smith. We acknowledge the concerns raised during the inquest and are committed to taking appropriate actions to prevent future occurrences.
Response to Coroner’s Concerns:
Guidance on Information Sharing and Gathering:
We recognise the need for clearer guidance for clinicians and nursing staff regarding information sharing and gathering with family members. During June and July 2025, we have worked with families, carers, service users and clinicians to co-produce values-based guidance to ensure that the distinction between information sharing and information gathering is clearly defined and understood. The guidance will include examples of lived experience in the form of quotes from families and service users and will include detailed instructions on when and how to document these interactions on standard forms.
Patient Information Leaflet:
We agree that the current patient information leaflet lacks sufficient detail on the approach to information sharing and gathering. During June and July 2025, we have worked with families, carers, service users and clinicians to co-produce a leaflet which will provide comprehensive information so that patients can easily understand the differences and the circumstances under which information sharing and gathering will occur. This will help ensure that patients are fully informed about the Eich cyf/Your ref: Ein cyf/Our ref: SR-jtf-0725-118 Welsh Health Telephone Network: Direct Line/Llinell uniongychol: 029 2183 6010 Executive Headquarters / Pencadlys Gweithredol
Woodland House
Ty Coedtir Maes-y-Coed Road
Ffordd Maes-y-Coed Cardiff
Caerdydd CF14 4HH
CF14 4HH
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
processes and their rights. We recognise that families, carers, and significant others often play a key role in service users care and we are therefore also developing a family and carer information leaflet.
Action Plan:
Revision of Guidance:
We have established a working group with involvement from families, carers, service users and clinicians to review and revise the existing guidance. The revised guidance will be disseminated to all relevant staff members through training sessions and internal communications. We aim to complete this process by October 2025.
Updating Patient Information Leaflet:
The updated leaflet will be developed by a panel of experts, including mental health professionals, families, carers, and service users, to ensure that it is values based, has clarity and is comprehensive. We plan to have the new leaflet available for distribution by October 2025.
Training and Awareness:
We will conduct mandatory training sessions for all mental health service staff to ensure they are fully aware of the revised guidance and the importance of accurate documentation. These sessions will start in October 2025.
Information Sharing and Suicide Prevention:
We have included information regarding the UK Government, Department of Health information sharing and suicide prevention: consensus statement" within the guidance. This statement emphasises the importance of sharing information within the context of relevant laws and professional judgment to prevent suicide.
Communication to Managers and Staff:
We will discuss the theme of information sharing and gathering at the MHCB (Mental Health Clinical Board) Professional Learning Event and Shared Learning Event in September 2025.
Co-produced Family Engagement Project:
The Mental Health Clinical Board has commissioned a co-produced family engagement project. This project started in May 2025 and aims to support a cultural shift in practice to enhance family engagement and involvement. The project will complement existing initiatives across the Mental Health Clinical Board which prioritise and encourage family engagement, particularly those based on co- productive and compassionate care. Due to the nature of co-production work, whilst there is an anticipated time of two years for the project, this needs to be agreed with the project working group.
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
We are committed to implementing these changes promptly and effectively to enhance the safety and well-being of our patients. We will provide a detailed update on the progress of these actions by the deadline of 16 July 2025.
Thank you for bringing these critical issues to our attention. We are dedicated to improving our services and preventing future tragedies.
Re: Regulation 28 Report to Prevent Future Deaths – Robert Maxwell Smith
Thank you for your report dated 21 May 2025 concerning the tragic death of Mr. Robert Maxwell Smith. We acknowledge the concerns raised during the inquest and are committed to taking appropriate actions to prevent future occurrences.
Response to Coroner’s Concerns:
Guidance on Information Sharing and Gathering:
We recognise the need for clearer guidance for clinicians and nursing staff regarding information sharing and gathering with family members. During June and July 2025, we have worked with families, carers, service users and clinicians to co-produce values-based guidance to ensure that the distinction between information sharing and information gathering is clearly defined and understood. The guidance will include examples of lived experience in the form of quotes from families and service users and will include detailed instructions on when and how to document these interactions on standard forms.
Patient Information Leaflet:
We agree that the current patient information leaflet lacks sufficient detail on the approach to information sharing and gathering. During June and July 2025, we have worked with families, carers, service users and clinicians to co-produce a leaflet which will provide comprehensive information so that patients can easily understand the differences and the circumstances under which information sharing and gathering will occur. This will help ensure that patients are fully informed about the Eich cyf/Your ref: Ein cyf/Our ref: SR-jtf-0725-118 Welsh Health Telephone Network: Direct Line/Llinell uniongychol: 029 2183 6010 Executive Headquarters / Pencadlys Gweithredol
Woodland House
Ty Coedtir Maes-y-Coed Road
Ffordd Maes-y-Coed Cardiff
Caerdydd CF14 4HH
CF14 4HH
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
processes and their rights. We recognise that families, carers, and significant others often play a key role in service users care and we are therefore also developing a family and carer information leaflet.
Action Plan:
Revision of Guidance:
We have established a working group with involvement from families, carers, service users and clinicians to review and revise the existing guidance. The revised guidance will be disseminated to all relevant staff members through training sessions and internal communications. We aim to complete this process by October 2025.
Updating Patient Information Leaflet:
The updated leaflet will be developed by a panel of experts, including mental health professionals, families, carers, and service users, to ensure that it is values based, has clarity and is comprehensive. We plan to have the new leaflet available for distribution by October 2025.
Training and Awareness:
We will conduct mandatory training sessions for all mental health service staff to ensure they are fully aware of the revised guidance and the importance of accurate documentation. These sessions will start in October 2025.
Information Sharing and Suicide Prevention:
We have included information regarding the UK Government, Department of Health information sharing and suicide prevention: consensus statement" within the guidance. This statement emphasises the importance of sharing information within the context of relevant laws and professional judgment to prevent suicide.
Communication to Managers and Staff:
We will discuss the theme of information sharing and gathering at the MHCB (Mental Health Clinical Board) Professional Learning Event and Shared Learning Event in September 2025.
Co-produced Family Engagement Project:
The Mental Health Clinical Board has commissioned a co-produced family engagement project. This project started in May 2025 and aims to support a cultural shift in practice to enhance family engagement and involvement. The project will complement existing initiatives across the Mental Health Clinical Board which prioritise and encourage family engagement, particularly those based on co- productive and compassionate care. Due to the nature of co-production work, whilst there is an anticipated time of two years for the project, this needs to be agreed with the project working group.
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
We are committed to implementing these changes promptly and effectively to enhance the safety and well-being of our patients. We will provide a detailed update on the progress of these actions by the deadline of 16 July 2025.
Thank you for bringing these critical issues to our attention. We are dedicated to improving our services and preventing future tragedies.