Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate transfer assessment and documentation
The earlier warning
Richard Griffiths · 14 Sept 2023 · Kate Robertson, North Wales East and Central
“The Health Board's Transfer of Care document at the time the transfer occurred did not include any detail or process as to how the transfer should occur.”
judiciary.uk/…/richard-griffiths-prevention-of-future-deaths-re…
What was promised
Stated action 1 · response to Richard Griffiths (14 Sept 2023) · stated timescale: end of January 2024
“incidents. The Transfer and Discharge of Care Protocol has been revised to include explicit guidance relating to transfers of care between community teams. This includes the steps to be taken by the care coordinator, supporting administrative staff and the single point of access service (SPOA). Progression of this protocol through the Health Board ratification process is being led by the MH&LD Deputy Director of Nursing and progress is overseen by the MH&LD Policy and Procedure Group. The revised protocol”
judiciary.uk/…/2023-0333-Response-from-Betsi-Cadwaladr-Universi…
What recurred
- 11 Apr 2025 · Patricia Catterall · John Gittins · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Richard Griffiths · 14 Sept 2023
“The Health Board's Transfer of Care document at the time the transfer occurred did not include any detail or process as to how the transfer should occur.”
Later · Patricia Catterall · 11 Apr 2025
“That the process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had been received and assessed”
What happened next
No web check of the stated actions has been published for this chain.