Nancy Price

Bloc 5, Llys Carlton, Parc BusnesLlanelwy, 
Llanelwy, LL17 0JG 

---------------------------------- 

Block 5, Carlton Court, St Asaph Business 
Park, St Asaph, LL17 0JG 

Dyddiad / Date: 21 June 2023  

Kate Robertson 
Assistant Coroner 
North Wales (East and Central) 
Coroner's Office 
County Hall 
Wynnstay Road 
Ruthin LL15 1YN 

Dear Ms Robertson,  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 
Nancy Carolyn Price  

I write in response to the Regulation 28 Report to Prevent Future Deaths dated 26 April 
2023,  issued  by  yourself  to  Betsi  Cadwaladr  University  Health  Board,  following  the 
inquest touching the death of Nancy Price.  

I would like to begin by offering my deepest condolences to the family and friends of Mrs 
Price for their loss, and to apologise to them and to yourself for the failures that were 
identified during the inquest which led to your Notice.  

In  the  Notice,  you  highlighted  concerns  regarding  the  Health  Board’s  strategic 
management of investigations and improvement actions.  

I am aware that we have responded to a Notice form you on 09 May 2023 on the matter 
of investigations and actions, and we also have a further Notice to respond to along the 
same subject. I am also aware you met with our deputy director of nursing responsible 
for patient safety and the head of patient safety on 09 June 2023 to discuss investigations 
and actions.  

For  this  response  I  would  therefore  wish  to  focus  on  reiterating  the  plans  we  have  in 
place, as advised to you in other correspondence:  

  We are  re-evaluating  the  incident  process  to  identify  how  it  can  be  streamlined 
and  a  new  procedure  document  will  be  developed  setting  out  roles  and 
responsibilities. This will be complete by the end of August 2023.  

  We  are  working  to  address  those  investigations  currently  overdue.  A  weekly 
improvement and scrutiny meeting, chaired by the Deputy Directors of Nursing, is 
held  with  clinical  directors  from  our  services  to  monitor,  track  and  support  the 
completion of serious incidents. 

  We  will  be  strengthening  the  performance  and  accountability  process  with  our 

services to include overdue investigations. 

Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: 
Swyddfa'r Gweithredwyr / Executives’ Office 
Ysbyty Gwynedd, Penrhosgarnedd 
Bangor, Gwynedd LL57 2PW 

Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
  

In April 2022 we migrated to the new national “Once for Wales” Datix system for 
managing incidents. We are now utilising this system for the recording of actions 
following  an  investigation.  All  actions  arising  from  a  completed  serious  incident 
investigation  will  be  added  to  this  system  on  final  approval  of  the  investigation 
report  by  the  Patient  Safety  Team,  in  addition  to  any  that  have  already  been 
identified from the rapid review or Rapid Learning Panel. 

  Our divisionally-based Quality Governance Teams will support our services locally 
with  understanding  their  open  and  overdue  investigations  and  actions,  and  will 
support services to collate evidence of action completion. The Patient Safety Team 
have the role of monitoring performance and assuring the completion of actions. 
  A new Organisational Learning Forum has recently been established. It is chaired 
by the Deputy Director of Nursing who leads on the patient safety agenda. This 
monthly meeting considers learning from across the organisation that arises from 
incidents, complaints, mortality reviews and other processes and is attended by 
clinical directors from all services with an aim of sharing learning. 

  We  have  moved  resources  to  strengthen  our  approach  to  learning,  and  a  new 
Organisational Learning Manager has been appointed. We have also appointed a 
Director  of  Nursing  for  Quality  Assurance  and  Learning  who  is  supporting  the 
Organisational Learning Forum mentioned above.  

  We  are  strengthening  the  sharing  of  learning  by  developing  a  digital  learning 
portal, a new lessons learned on a page template and a new learning bulletin. 
  We will be strengthening the assurance of learning by developing a new Quality 

Assurance Framework and a strengthened quality assurance team.  

  Over the next few months, our Organisational Learning Manager is engaging with 
staff across the organisation to understand how we can better support learning. 
This will develop  into  a  new  approach  to  learning  with  a  framework and  toolkit, 
which will include the actions already mentioned. 

  We are looking at best practice both within NHS Wales, across the border and in 
the  private  sector. We  are  hopeful to be  getting  national support from  the  NHS 
Wales  Executive  to  co-pilot  an  innovative  new  learning  model  for  the  NHS  in 
Wales. 

  We  are  reviewing  our  training  for  those  undertaking  investigations  and  writing 
action  plans  and  will launch  new  training  programmes following  approval of the 
new procedure outlined above.  

  To  support  the  delivery  of  safety  and  quality  improvements  across  the 
organisation, we have commissioned a Patient Safety Improvement Programme. 
This patient safety initiative aims to support a culture of safety, continuous learning 
and sustainable improvement across the healthcare system. The programme will 
focus on the reduction of avoidable harm through safe and reliable care processes. 

As we wrote in our response to your earlier Notice, you will be aware the Health Board 
has been placed into Special Measures and one domain of this is clinical governance, 
patient safety and experience and a second domain is learning from incidents.  

 
 
 
 
 
 
 
 
 
 
 The  actions  we  have  detailed  above  form  part  of  our  plans  for  Special  Measures, 
particularly  the  review  of  our  incident  process  and  ensuring  the  timely  completion  of 
investigations and the timely completion of action plans with evidence. This work is one 
of our immediate priorities for the first six months of Special Measures. 

As part of this Special Measures process we are awaiting an expert independent review 
into Patient Safety, and a further expert independent review into Clinical Governance will 
be commencing shortly. We will using the findings of these reviews to help identify and 
make further improvements to our processes.   

We  would  be  happy  to  meet  with  you  further  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 Price for 
their loss and I reiterate my sincere apologies to them and to you for the concerns rightly 
identified at the inquest.  

Yours sincerely 

Cyfarwyddwr Meddygol Gweithredol / Dirprwy Prif Weithredwr Dros Dro 
Executive Medical Director / Acting Deputy Chief Executive  

cc  

, Executive Director of Nursing and Midwifery 

, Deputy Director of Quality