Joseph Page

(1) In the Emergency Department; and whilst patients were awaiting admission to a Ward, their PODS remained with them unsecured in a bay (or similar) . Exposing the medication to potential further uselmis-use by the patient; another patient or relative, or theft and mis-use (2) On ward B5, the policies in place at the time in relation to PODS were not followed, allowing Mr Page's medication to remain unsecured on the Ward, exposing the medication as in (1) above. (3) received evidence that the Patient Property Policy and Medicines Code were in the process of being updated to address (1) & (2) , but this exercise not expected to be completed until March 2019. Thereafter, & on the evidence ofl it was not clear when implementation of the updated policies would take effect (4) Whilst the specific events that unfolded in relation to Mr Page on the morning of 23.3.18 may have been unforeseeable, the current arrangementslpolicies in place for the receiving, utilising and storing of PODS at UHW, Cardiff, could give rise to a risk of future deaths in a variety of different ways: (5) Once completed the exercise of implementing the new Policy & Code needs to be thorough and extensive to ensure that all doctors & nurses throughout the Cardiff & Vale University Health Board (whether full time, part-time or Agencyllocum) not only are aware of the revised PolicyiCode, but clear on its interpretationllrequirements