Response fromBetsi Cadwaladr University Health Board
NHS / Health Body
Action Planned
A task and finish group has been set up to review the current discharge form for suitability to ensure that frequency of observations and medication is clearly defined within the document. Changes to the form, once finalised and approved, will be shared with the North Wales Care Home Forum, with support from the Quality Development Team. (AI summary)
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Dear Mr Gittins,
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Patricia Ann Catterall
I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 11th April 2025, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Mrs Patricia Ann Catterall.
I would like to begin with offering my deepest condolences to the family and loved ones of Mrs Catterall.
In the notice, you highlighted your concern in relation to the level of information provided to care homes during the community hospital discharge and handover process.
In response to the notice, our senior nursing team in the East Integrated Health Community have led work to understand the issue across the Health Board. This work has identified that whilst there is a standardised form for discharge plans into care homes, the level of detail is varied.
A Task and Finish Group has been set up (consisting of Community Hospital Matrons and Discharge Nurses) to review the current form for suitability, and this work will specifically ensure that frequency of observations and medication is clearly defined within the document.
Changes to the form, once finalised and approved, will be shared with the North Wales Care Home Forum, with support from the Quality Development Team (this team supports improvements in quality across commissioned care home services).
The new form, and examples to support learning, will be shared with teams and will be included on Team Meeting Safety Briefs.
Ein cyf / Our ref:
Eichcyf / Your ref: :
Gofynnwch am / Ask for:
E-bost / Email: Dyddiad / Date: 04 June 2025 John Gittins HM Senior Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN Legal Services, Bron Afon, Bryn y Neuadd Hospital, Llanfairfechan LL33 0HH
---------------------------------------------- Gwasanaethau Cyfreithiol, Bron Afon, Ysbyty Bryn y Neuadd, Llanfairfechan LL33 0HH
Audit questions will be developed to monitor these changes which will be completed by Ward Managers and Matrons and included in the peer reviews across our services. The audit findings will be included in the monthly Matron Reports into local quality groups for assurance.
Our aim is to have this work completed by the end of June 2025.
I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed and mitigated.
We would be happy to meet with you and discuss our plans in more detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to the family and friends of Mrs Catterall for their loss.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Patricia Ann Catterall
I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 11th April 2025, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Mrs Patricia Ann Catterall.
I would like to begin with offering my deepest condolences to the family and loved ones of Mrs Catterall.
In the notice, you highlighted your concern in relation to the level of information provided to care homes during the community hospital discharge and handover process.
In response to the notice, our senior nursing team in the East Integrated Health Community have led work to understand the issue across the Health Board. This work has identified that whilst there is a standardised form for discharge plans into care homes, the level of detail is varied.
A Task and Finish Group has been set up (consisting of Community Hospital Matrons and Discharge Nurses) to review the current form for suitability, and this work will specifically ensure that frequency of observations and medication is clearly defined within the document.
Changes to the form, once finalised and approved, will be shared with the North Wales Care Home Forum, with support from the Quality Development Team (this team supports improvements in quality across commissioned care home services).
The new form, and examples to support learning, will be shared with teams and will be included on Team Meeting Safety Briefs.
Ein cyf / Our ref:
Eichcyf / Your ref: :
Gofynnwch am / Ask for:
E-bost / Email: Dyddiad / Date: 04 June 2025 John Gittins HM Senior Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN Legal Services, Bron Afon, Bryn y Neuadd Hospital, Llanfairfechan LL33 0HH
---------------------------------------------- Gwasanaethau Cyfreithiol, Bron Afon, Ysbyty Bryn y Neuadd, Llanfairfechan LL33 0HH
Audit questions will be developed to monitor these changes which will be completed by Ward Managers and Matrons and included in the peer reviews across our services. The audit findings will be included in the monthly Matron Reports into local quality groups for assurance.
Our aim is to have this work completed by the end of June 2025.
I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed and mitigated.
We would be happy to meet with you and discuss our plans in more detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to the family and friends of Mrs Catterall for their loss.