Neil Edwards

Wednesday 15 May 2024 

Caroline Saunders 
Senior Coroner (Gwent) 

Dear Ms Saunders 

Re: Regulation 28 Report received by Aneurin Bevan University Health Board further to the 
inquest touching on the death of Neil Francis Edwards which concluded on 8 March 2024 

Thank you for your Regulation 28 Report dated and received by the Health Board on 20 March 
2024. 

I am writing to provide you with the Health Board’s response to the Regulation 28 Report to 
Prevent Future Deaths, which was issued following the inquest into the death of Mr Neil Francis 
Edwards. 

As requested, the information presented below is intended to describe the actions which have 
been taken/are being taken by Aneurin Bevan University Health Board to mitigate the risk of future 
deaths. You require the Health Board to provide you with the following information: 

1.  Confirmation as to whether it remains the policy of ABUHB to investigate deaths arising 

from in-patient falls.  

The Health Board has a  Falls Policy in place for Hospital Adult inpatients. The Falls Policy must be 
implemented  at  all  levels  within  the  organisation  to  ensure  a  safe  and  consistent  approach  is 
adopted. The aim is to reduce avoidable, injurious falls whilst ensuring appropriate management of 
patients  who  experience  a  fall,  to  include  collaboration  with  intermediate  care  and  the  frailty 
programme.   

In order to discharge the requirements of the policy the Health Board has in place a Falls Review 
Panel (FRP) which meets monthly to review incidents of injurious inpatient falls.  All inpatient falls 
that result in a fracture need to be reviewed by the panel and there is a focus on identifying learning 
and  agreement  of  appropriate  actions  in  support  of  the  reduction  of  incidents.  The  incidents 
discussed are those identified as high severity due to associated fractures.  

Falls are reported via the Health Board’s incident reporting procedures, namely by completing an 
incident report via our electronic ‘RL Datix Incident’ reporting system. These reports are circulated 
to  relevant  staff  and  senior  managers  for  review  and  action.  Where  any  concerns  are  identified, 
consideration will then be given to the form and type of post fall investigation required. For cases 
identified where moderate harm or above, these will be managed in line with the Health Board’s 

Bwrdd Iechyd Prifysgol Aneurin Bevan 
Pencadlys, Ysbyty Sant Cadog 
Ffordd Y Lodj, Caerllion, Casnewydd NP18 3XQ 

 01633 436 700   

 BwrddIechydPrifysgol   

 BIPAneurinBevan 

Rydym yn croesawu gohebiaeth yn Gymraeg a byddwn yn ymateb yn Gymraeg heb oedi. 
Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan. 

Aneurin Bevan University Health Board 
Headquarters, St Cadoc’s Hospital 
Lodge Road, Caerleon, Newport NP18 3XQ 

 01633 436 700   

 AneurinBevanHealthBoard  

 AneurinBevanUHB 

We welcome correspondence in Welsh and we will respond in Welsh without delay. 
Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board. 

 
 
 
 
 
 
  
 
  
 
 
 
 
  
   
 
 
  
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 ‘Patient  Safety  Incident  Reporting  and  Management  Policy  (Duty  of  Candour:  Moderate/Severe 
Harm).’  

The aim of the panel is to reduce the number of in-patient falls and the number of in-patient falls 
with a fracture.   

The objectives of the Falls Review Panel are to: 

•  Put processes in place to identify all inpatient falls with fractures and to monitor the number 

of cases and their location.  

•  Review  individual  cases  to  check  whether  appropriate  care  has  been  provided  to  prevent 

falls, including risk assessments and care plans.  

•  Ensure wards put in place appropriate action plans to address any deficiencies identified 
• 

Identify factors that are most often present in falls with fractures and ensure these are part of 
the risk assessment process and training. 

•  Make recommendations on good practice to Falls Bone and Health Steering Group 
•  Make recommendation re specific training needs/actions where themes/clusters are found. 
• 
Identify issues where a specific piece of work is required to assess effectiveness, for example 
the use of pressure sensors in acute wards 

•  Determine  whether  cases  should  be  referred  to  the  Division  for  further  consideration  for 

redress 

•  Support the reporting of a fractured neck of femur from inpatient falls as a Serious Incident 

to Welsh Government, and the timely closure of cases. 

•  Provide summary reports to the Falls Bone and Health Steering Group /Quality and Patient 

Safety Committee as required. 

•  Review National Reports that benchmark ABUHB against similar organisations and National 

Guidance on Falls Prevention and support actions to improve the prevention of falls. 

A representative from the ward where a patient sustained the fracture attends the panel to describe 
the  patient’s  risk  factors  for  falls  and  the  actions  that  were  put  in  place  to  reduce  the  risk  of  the 
patient falling.  The main focus of the Panel is to learn more about what we can do to prevent in-
patient  falls,  the  ward  staff  are  the  experts  in  this and  therefore  all  staff  attending  the  Panel are 
encouraged to share their learning in relation to falls and what can be changed to reduce the number 
and severity of in-patient falls. 

In  line  with  current  processes  each  reported  incidence  of  a  fall  with  fracture  is  subject  to  an 
investigation  by  the  respective  ward,  these  findings  are  presented  to  FRP.  Aligned  with  the 
objectives of the panel, factors for discussion include the circumstances surrounding the incident, 
the status of the patient on admission leading up to and post fall, the contributory factors and overall 
provision of care to include all risk assessments. 

There is an investigation form that must be completed about the fall that is presented to the panel 
and there also needs to be a full copy of the multi factorial falls risk assessment (MFRA) tool and 
Care Plan for the patient to be discussed at the panel too. Other relevant supporting information or 
evidence  (e.g.  bed  rails  assessment)  is  also  encouraged  at  the  meeting  to  enable  a  thorough 
discussion, the incidents are also reviewed in the context of compliance with the ‘Falls Policy for 
Hospital Adult Inpatients’ (ABUHB: 2021). 

The FRP is constituted of a multidisciplinary substantive membership alongside those clinical staff 
presenting the incidents.  It provides a forum for open discussion on the factors identified during the 
investigation,  subsequent  actions  implemented  by  the  ward  and  the  associated  monitoring 
processes.  The  FRP  reviews  the  associated  themes  across  the  cases  presented  which  may  be 

 
 
 
 
 
 
 
 
 
 cross Divisional and the actions requiring implementation with escalation as necessary through the 
Health Boards defined quality, patient, safety governance structures. Documented outcomes of the 
FRP discussions are provided to those present at the panel reviewing the individual cases together 
with  the  substantive  membership  for  onward  cascade  and  to  inform  discussions  and  actions  at 
Divisional level. 

As  I  have  set  out  previously  Falls  incidents  are  identified  through  RLDatix  and  falls  of  moderate 
harm  and  above  are  discussed  weekly  with  Clinical  Executives  to  discuss  what  immediate 
investigation  is  needed.  Falls  data  is  analysed  weekly  and  a  falls  report  is  sent  out  to  all  ward 
managers.  Incident reports with themes and trends, including the number of in-patient falls, key 
variations by Division and the severity of harm are produced for the Patient Quality and Outcomes 
Committee.   

Where it is identified that the fall and therefore NHS care and treatment provided to the patient has 
or may have, contributed to unexpected or unintended, moderate or severe harm or death, this will 
also trigger a formal Duty of Candour review as required by the Health and Social Care (Quality and 
Engagement) (Wales) Act 2020 and a Serious Incident Investigation will be commissioned. 

The Health Board’s Serious Incident Process has been reviewed to improve the scrutiny of incidents. 
Serous Incident meetings are considered mandatory and investigating officers are now appointed 
in advance of the first meeting to ensure the investigating officer can be present and engaged from 
the outset. The Health Board has been delivering Investigating officer training since September 2020 
which  includes  SIs  and  complaints.  The  workshops  are  human  factors  based  and  provide 
Investigating Officers with a range of methodologies to use in their investigations. 

Improved and standardised agendas have been introduced as part of the SI process to ensure that 
the scope of investigation and robust terms of reference are captured and referred back to at the 
end of the process and this will include the involvement of patient families and any concerns they 
may  have,  from  the  outset.  The  standardised  agenda  includes  a  prompt  to  ensure  reporting  to 
external Agencies such as NHS Executive and the HSE. 

Once the investigation has been completed the governance of each report follows a robust three 
stage process:  Divisional Director/Nurse approval of the report and action plan this is then approved 
by the Chair of the Serious Incident process, and finally there is Clinical Executive approval. This is 
in addition to the Patient Safety Incident team scrutiny for quality. 

2.  Confirmation whether, in light of the circumstances described at the inquest, action is 
being taken to ensure that patients who require 1:1 observation are afforded this level of 
care in the future. 

In August 2021, the Health Board developed and then launched a person-centred Enhanced Care 
Framework. The purpose of the framework is to provide personalised, appropriate, consistent and 
high-quality enhanced observation/care for those patients deemed appropriate to receive such care 
requirements.  The  person-centred  Enhanced  Care  Framework  incorporates  an  individual 
management plan and tool kit to aid assessment of a patient’s needs and supports the delivery of 
safe and dignified patient centred care.  

Supported by the patient centred care team the framework has been rolled out across all acute and 
community  wards  to  ensure  patients  requiring  a  level  of  enhanced  observation  and  supervision, 
either through an increase in observation, being cared for in a cohorted environment or requiring 
1:1 nursing care, are identified and appropriate care and observation initiated.  

The Health Board has recently (May 2024) revised and updated the Person-centred Enhanced Care 
Framework. Lessons learned from patient safety incidents, feedback and audits have informed the 
revised  framework.  The  main  focus  of  the  revised  framework  is  to  ensure  patients  receive  the 

 
 
 
 
 
 
 
 
 
 
 appropriate level of enhanced care / supervision that is proportionate to their needs and that this is 
based upon careful risk assessment and care planning.  

The  revised  framework  has  been  developed  by  the  Patient-Centred  Care  Team,  Divisions  of 
Medicine,  Surgery,  Urgent  Care  and  Primary  &  Community  Care  to  ensure  it  is  robust  and 
appropriate to meet the needs of patients requiring enhanced care / supervision.  

The launch of the revised framework will be supported by a bespoke education package to ensure 
all  staff  fully  understand  the  revised  framework.  A  full  communications  programme  will  also  take 
effect to ensure there is widescale awareness of the changes.  

In summary, a number of changes have been made to the Enhanced Care Framework: 

•  Amended the enhanced care framework document to a 7-day document - to keep all relevant 

• 

• 

paperwork together 
Included  collaboration  with  patient  and  family  in  the  enhanced  care  management  plan 
section,  in  addition  staff  must  make  a  record  of  any  conversation  in  the  patient’s  clinical 
records with family members on expected levels of care delivery and involvement, plus carer 
information leaflet to be given.  
Included a blank management plan into the enhanced care document to ensure anything that 
is specific to the patient is included and it is person centred 
Included agreed delegation of care to non-healthcare worker in the management plan 

• 
•  Changed green level of care to yellow following feedback from staff, findings from audit and 

coroner’s reports 

•  Strengthened the mental capacity/best interest and deprivation of liberty section by making it 

clearer what is required by staff 

•  Devised a new risk assessment so it aligns with the enhanced care framework document  
•  Created an 'are you considering enhanced care' flow chart as a staff aid, to highlight least 

restrictive practice and alternative support. 

•  Added the staff requirements when caring for a patient at a red level and 24-hour supervision 

where the patient must not be left unattended. 

•  Whatever level of supervision the patient has been assessed as requiring must be provided. 
For example, if a patient has been assessed as requiring continuous 1:1 direct supervision, 
this must be fully provided at all times. If there is any reason why this cannot be provided this 
will be escalated as appropriate to ensure the patient’s safety is maintained  – this may on 
occasions result in a temporary delay in other non-urgent care delivery tasks as the priority 
must be towards providing enhanced care / supervision to maintain safety.  

•  Enhanced  care  /  supervision  will  be  provided  by  substantive  staff  in  the  first  instance  as 

apposed to non-substantive staff.  

•  Positive progress is being made to appoint Activity Co-ordinators for all acute and community 
wards to ensure meaningful activities are encouraged appropriate to individual needs.  

The implementation and impact of the changes to the framework will be monitored closely to ensure 
optimal patient experience and safety.  Ward Managers will be accountable for ensuring the revised 
framework is followed.  

In order to support safe nurse staffing levels, the Health Board has implemented Health-Roster & 
Safe-Care  across  the  Health  Board.  This  is  a  digital  platform  which  gives  nurses  the  visibility  of 
staffing levels across wards and departments, allowing them to maintain safe and compliant patient 
care based on patient numbers, acuity and dependency. It supports day-to-day operational changes 
to  the  roster  in  real  time,  facilitating  the  redeployment  of  staff  to  support  enhanced  care 

 
 
 
 
  
 
 
 requirements. The system enables a review of daily staffing levels and whether they are deemed 
safe to meet clinical demand.  

Safe-Care  provides  the  functionality  to  enter  acuity  and/or  dependency  data  to  inform  evidence-
based decision making on staffing requirements and workforce. This provides a visual platform of 
establishments, skill mix, patient demand/acuity in real-time to ensure informed decisions are made 
and supports acuity-driven staffing level requirements 

In line with the Nurse Staffing Levels (Wales) Act 2016 the Health Board undertakes a bi-annual 
audit of patient acuity which informs a recalculation of nurse staffing levels.  Any changes outside 
the  bi-annual  audit  to  the  purpose  of  a  ward,  requires  an  additional  recalculation.  By  way  of 
assurance  Board  receives  the  outcome  of  the  recalculations  on  an  annual  basis.  Significant 
investment into nurse staffing levels has been secured since the inception of the Act. 

The  Health  Board has  a  well-established  process to  manage  and escalate  nurse  staffing  deficits 
ensuring all reasonable steps have been followed to maintain nurse staffing levels, these include, a 
Nurse  Staffing  Operational  Framework 
their 
responsibilities, processes and procedures for ensuring appropriate and carefully considered nurse 
staffing in all areas. Staffing deficits across the Health Board are reported weekly to include: 

inform  staff  groups  of 

to  standardise  and 

•  Filled and unfilled Registered Nurse (RN) shifts against planned rosters 
•  Filled and unfilled Health Care Support Worker (HCSW) shifts against planned rosters 
•  Percentage  of  substantive  staff  versus  agency  staff  populating  rosters  to  gauge  quality, 

safety, and continuity of care. 

•  A workforce tracker is presented to the Executive Team detailing progress on recruitment, 

bank and agency usage, turnover, and absenteeism. 

•  Daily  review  of  nurse  staffing  levels  is  undertaken  by  the  divisional  and  site  teams  –  to 

manage and mitigate risk. 

•  A Nursing, Midwifery and SCPHN Workforce Strategy 2023-26 was approved by the Board 
in May 2023. Positive progress has been made against the priority action plans aligned to 
the strategy. 

I trust that this information reassures you with regard to the matters raised, however, if you require 
any further information or assurance, please do not hesitate to contact me. 

Yours sincerely  

Prif Weithredwr | Chief Executive