Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0492, written 6 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Oct 2025 |
|---|---|
| Reference | 2025-0492 |
| Deceased | Steven Turzynski |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Chief Executive Of Aneurin Bevan University Health Board 2 Chief Executive Of Velindre University Nhs Trust 1 CORONER I am Caroline SAUNDERS, Senior Coroner for the coroner area of Gwent 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 07 August 2024 I commenced an investigation into the death of Steven Paul TURZYNSKI aged 70. The investigation concluded at the end of the inquest on 25 September 2025. The conclusion of the inquest was recorded as: Death from Natural Causes The medical cause of death was: 1a) Pneumonia 1b) Metastatic Squamous cell Carcinoma of the Lung 2) Oropharyngeal Cancer (treated) Steven Paul Turzynski died from the effects of lung cancer at the Grange University Hospital, Llanfrechfa on 29/7/2024. 4 CIRCUMSTANCES OF THE DEATH Steven Paul Turzynski was a 70-year-old man who had successfully undergone treatment for oropharyngeal cancer in 2019. The nature of the cancer affected Steven’s ability to eat and to enjoy food. In January 2023, Steven was diagnosed with lung cancer. His treatment thereafter further affected his ability to maintain adequate nutrition. Steven’s dietetic care was shared between Aneurin Bevan University Health Board and Velindre University NHS Trust. Steven was under the care of dietitians in both departments at the same time. However, through the course of his treatment from November 2023 until his death in August 2024, there was very little communication between the two teams and no sharing of information or discussion about treatment plans. Steven required ongoing nutritional support and was on occasion receiving different advice from these two teams. The poor communication was further hampered by an inability for the respective teams to access each other’s records. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The inquest was told that adequate nutrition could not be determined merely from recordings of a person’s weight or their alleged intake, but required an assessment of frailty and cachexia, matters which needed to be assessed in person. Throughout this time, Steven had only 2 face to face appointments with members of the dietetics department By the time of his death Steven was suffering from significant undernutrition. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Steven Paul Turzynski died from the effects of cancer, which was also responsible for his nutritional status. However the almost absent communication between the two dietetic teams and the lack of adequate assessment during the last 12 months of Steven’s life contributed to his poor nutritional state. I was informed at the inquest that the need for a face to face appointment is entirely a matter for the individual dietician. However, this decision making is not governed by guidelines nor is it monitored and can lead to an over-reliance of telephone assessments. Adequate nutrition for patients who have cancer is a significant element of their care and inadequate nutrition can contribute to an early death. Kindly inform me whether your organisations have taken steps to improve co-working within disciplines when sharing the care of patients who require hospital and community dietetic care. Kindly inform me whether action will be taken so that when care is shared, the respective teams can access each other’s records. Kindly inform me whether there are plans for setting guidelines or monitoring the adequacy of dietetic assessments over the phone, and a minimum standard set for face to face consultations. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by December 01, 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family And/Or Next Of Kin Of Steven Paul Turzynski Regulation 28 – After Inquest Document Template Updated 30/07/2021 I have also sent it to Health Inspectorate Wales who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 06/10/2025 Caroline SAUNDERS Senior Coroner for Gwent Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Executive Director of Nursing | Gweithredol Cyfarwyddwr Nyrsio Private & Confidential Caroline Saunders Senior Coroner for Gwent Dear Ms Saunders Thursday, 27 November 2025 Response to Regulation 28 Report received following the inquest touching on the death of Steven Paul Turzynski Thank you for your letter and accompanying report, which the Health Board received on 6 October 2025. This letter provides the Health Board’s formal response to the Regulation 28 Report to prevent future deaths following the inquest into the death of Mr Steven Paul Turzynski. To provide assurance that meaningful and lasting improvements are being achieved across the Health Board, we have implemented a strengthened governance framework dedicated to nutrition and hydration. This framework enhances organisational coordination, ensures accountability for quality improvement, and embeds systematic oversight within our Quality Management System. At its core, the framework consists of a Strategic Nutrition and Hydration Group, supported by two operational sub-groups. Each group has clearly defined roles, multi-professional membership, and a direct reporting route from frontline practice to board assurance, ensuring that clinical and operational perspectives are aligned. The Strategic Group provides senior clinical leadership and organisational assurance. Chaired by the Assistant Director for Allied Health Professions and Health Science, it includes senior representatives from Nursing, Medicine, Finance, Digital, and Quality & Patient Safety. The inclusion of Llais within its membership ensures that the views and experiences of patients and service users inform all improvement activity. Meeting every two months, the group reviews incident themes, monitors risk registers, and oversees progress against strategic improvement priorities. It also acts as an expert reference group for the wider organisation on all matters relating to nutrition and hydration safety. Two operational groups report into this structure: Food Standards Group – responsible for operational oversight of food service delivery, dietary standards and compliance with the All-Wales Nutrition and Catering Standards for 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. Food and Fluid Provision for Hospital Inpatients. It meets monthly to review incidents, drive service improvements, and escalate key issues to the Strategic Group Clinical Standards Group – overseeing clinical practice in relation to nutrition and hydration across acute, community, maternity, paediatric and older adult services. The group monitors, compliance and leads on risk-assessment processes and ensures that clinical standards are applied consistently across all care settings This governance model has already accelerated the delivery of targeted improvements, such as enhanced nutritional screening, included in our ward accreditation programme, monitoring of fluid balance, strengthened escalation processes for patients at risk of malnutrition, and improved documentation standards. These developments are now being embedded into routine practice through the Quality Management System, supporting a proactive and transparent approach to preventing avoidable harm. The Health Board has also recently created and successfully appointed the first Consultant Dietitian post in Wales with a specific remit for Nutrition and Hydration. This senior clinical leader will embed Nutrition and Hydration at the core of our clinical care and strategically in our policies and clinical pathways. In summary, this framework provides the Health Board with strong clinical leadership, effective operational alignment, and meaningful service-user involvement in the ongoing improvement of nutrition and hydration care. It offers a clear mechanism for ensuring that learning from incidents leads to sustainable, system-wide change. The information below outlines the specific actions undertaken and those in progress to reduce the likelihood of similar circumstances arising in the future. These are detailed within the accompanying multi-professional improvement plan appended to this letter. 1. Communication and Information Sharing Between Health Boards Assurance Statement Aneurin Bevan University Health Board (ABUHB) and Velindre University NHS Trust (VUNHST) recognise the coroner’s concern that inadequate communication between each organisations dietetic teams contributed to suboptimal nutritional management. Both organisations are committed to strengthening the safety and consistency of information exchange for all patients whose care is transferred across organisational boundaries. Planned / Ongoing Actions Joint Transfer of Care Standard Operating Procedure (SOP): A collaborative SOP is being developed between ABUHB and VUHNHST to define clear referral, handover, and documentation standards for patients receiving shared dietetic care. The SOP will outline required content for transfer summaries, response timeframes, and points of professional contact Shared Access to Clinical Records: Both organisations are reviewing long term digital interoperability options with potential single patient care records, dependant on Digital Health & Care Wales support. In the interim, read only access to ABUHB clinical system (CWS) has been granted to VUHNHST dieticians and WCP access will be granted to appropriate cohort of ABUHB Dietitians Multidisciplinary Interface Meetings: Quarterly meetings will be held between ABUHB and VUHNHST dietetic leads to discuss and review any shared oncology cases, clinical incidents, resolve communication issues, and identify opportunities for process improvement How these actions address the concern These steps ensure that dietitians in different hospitals can share information across organisational boundaries, understand who is responsible for each patient, and provide consistent nutritional advice. Patients will no longer receive conflicting information as both teams will have shared visibility and direct contact pathways. Cross site interface meetings will facilitate shared learning and information sharing. 2. Clinical Standards and Governance for Mode of Dietetic Assessment Assurance Statement The Health Board acknowledges the coroner’s concern regarding the absence of guidance for determining when dietetic assessments should be conducted face-to-face versus by telephone. The organisation, in collaboration with Velindre, is updating and enhancing existing clinical standards to guide assessment practice and ensure equity and quality of nutritional care Planned / Ongoing Actions Dietetic Assessment and Consultation Guideline: Development of an operating protocol to define clinical criteria for the mode of assessment. This will include consideration of disease complexity, nutritional risk, treatment phase, and patient preference. ABUHB booking process being adapted to facilitate face to face review as an initial assessment. Decision-Making Tool: Decision-making tool to be introduced, requiring clinicians to record their rationale for remote versus in-person assessment in the patient’s notes, promoting transparency and auditability How these actions address the concern Where a patient is unable or unwilling to travel for an in-person review, a face-to-face assessment will still be arranged through a home visit or other clinically appropriate alternative setting to ensure that frailty, weight loss and nutritional risk are directly assessed. 3. Monitoring, Audit and Continuous Improvement Assurance Statement The Health Board is committed to ensuring that the above improvements are sustained through regular audit, shared learning, and oversight via established quality governance structures. Planned / Ongoing Actions Annual Joint Audit: ABUHB and VUNHST will jointly audit adherence to the Dietetic Transfer of Care Standard Operating Procedure and Assessment Protocol, with findings reported to each organisation’s Nutrition & Hydration Group and/or Quality & Patient Safety assurance group Exception and Learning Reporting: Any deficiencies or recurrent communication failures will be logged through Datix and reviewed at joint governance meetings. Themes and learning will be fed into professional development sessions Workplan Integration: Requisite improvement actions will be included within the ABUHB Nutrition & Hydration Group workplan, with progress reviewed bi-annually and updates shared with VUHNHST governance partners Quality Assurance: Peer review and clinical supervision sessions will be embedded into dietetic governance structures within ABUHB, focusing initially on oncology cases Spreading the learning: Dietetics service will present learning from this case at the ABUHB patient quality & safety learning and improvement forum How these actions address the concern A system of disseminating learning from incidents and regular compliance audits will ensure all staff follow consistent standards when providing dietetic care, regardless of where they work. Lessons learnt from this case will be embedded into professional development and ongoing supervision so that improvements are maintained long term Governance and monitoring In parallel with the joint work undertaken with VUHNHST, ABUHB continues to strengthen its own internal systems to ensure that exacting standards of nutrition and hydration care are delivered consistently across all divisions. Locally, this includes the development of enhanced digital documentation tools, strengthened escalation frameworks for patients at nutritional risk, and teams. increased learning within supervision reflective clinical and use of At a system level, the Health Board and VUHNHST have committed to working in close partnership to maintain and monitor these improvements. Regular joint meetings between both organisations will review progress against the action plan, share emerging learning, and resolve any cross- boundary issues in real time. An annual joint audit of service quality will also be undertaken to evaluate the effectiveness of the improvement. collaborative arrangements and further opportunities identify for to Together, these local and joint actions provide assurance that improvements are both organisation- led and system-wide, supporting sustained and measurable progress in the safety and quality of dietetic care. We accept and are sorry that there were elements of Mr Turzynski’s care that fell below the standards we would want and expect for our patients and appreciate how devastating this has been for his family and we are committed to ensuring that the circumstances surrounding Mr Turzynski’s end of life nutritional care result in meaningful and sustained improvements in communication, record-sharing and dietetic care. Yours sincerely, Prif Weithredwr | Chief Executive Enc. Action Plan
Pencadlys Ymddiriedolaeth GIG Prifysgol Felindre Velindre University NHS Trust Headquarters 2 Cwrt Charnwood Heol Billingsley Parc Nantgarw Caerdydd/Cardiff CF15 7QZ Ffôn/Phone: (029) 20196161 https://velindre.nhs.wales 28th November 2025 FAO: Ms. C Saunders Gwent Coroners Service Livingstone House Langstone Business Village Langstone Park Newport, NP18 2LH Dear Ms Saunders, Re: Regulation 28 Response I am writing to provide Velindre University NHS Trust’s formal response to the Regulation 28 Report issued on the 6th October 2025 following the inquest into the death of Mr. Steven Paul Turzynski. I would like to start by thanking you for raising these extremely important matters with the Trust and to apologise for the failings identified through the inquest process. Velindre University NHS Trust both acknowledges and accepts the concerns raised relating to the adequacy of nutritional assessment, communication between dietetic teams, and the need for strengthened standards for face-to-face consultations for patients receiving cancer treatment. We fully recognise the significant role that appropriate nutritional support plays in ensuring safe and effective cancer care, and the serious implications when those standards are not met. The Trust has undertaken a comprehensive review of practice and implemented targeted Mae Ymddiriedolaeth GIG Prifysgol Felindre yn hapus i dderbyn gohebiaeth yn y Gymraeg neu’r Saesneg. Velindre University NHS Trust is happy to receive communication in Welsh or English. Pencadlys Ymddiriedolaeth GIG Prifysgol Felindre Velindre University NHS Trust Headquarters 2 Cwrt Charnwood Heol Billingsley Parc Nantgarw Caerdydd/Cardiff CF15 7QZ Ffôn/Phone: (029) 20196161 https://velindre.nhs.wales improvement actions. We continue to work closely with Aneurin Bevan University Health Board (ABUHB), reflecting the joint nature of this Prevention of Future Deaths (PFD) Report, to ensure that safe, consistent and coordinated dietetics care is provided across organisational boundaries. I have attached the Trust’s improvement plan that has been developed in conjunction with ABUHB for reference. For ease of reading I have detailed below the specific actions undertaken and those in progress to reduce the likelihood of similar circumstances arising in the future: Development & Improvement To ensure sustained system-wide improvements, Velindre Cancer Service has strengthened its governance arrangements relating to dietetic care, including enhanced reporting mechanisms, improved visibility of service risks, and increased oversight of multi-professional clinical standards. We have implemented a series of measures to improve co-working and communication between hospital and community dietetic services, including: • A joint communication protocol and Multi-Disciplinary Team checklist to standardise the processes for shared care patients • Quarterly joint dietetic meetings with ABUHB to support shared learning and early escalation of any potential risks or issues • Review and confirmation of Upper Gastrointestinal and Head & Neck clinical pathways • Development of an interim shared care transfer document until the All-Wales standard is formally approved Mae Ymddiriedolaeth GIG Prifysgol Felindre yn hapus i dderbyn gohebiaeth yn y Gymraeg neu’r Saesneg. Velindre University NHS Trust is happy to receive communication in Welsh or English. Pencadlys Ymddiriedolaeth GIG Prifysgol Felindre Velindre University NHS Trust Headquarters 2 Cwrt Charnwood Heol Billingsley Parc Nantgarw Caerdydd/Cardiff CF15 7QZ Ffôn/Phone: (029) 20196161 https://velindre.nhs.wales • Active engagement with the Welsh Dietetic Leaders Advisory Group (WDLAG) to strengthen cross-boundary referral processes The above steps will ensure that dietitians in different hospitals can share information across organisational boundaries, understand who is responsible for each patient, and provide consistent nutritional advice. Patients will no longer receive conflicting information as both teams will have shared visibility and direct contact pathways. Cross site interface meetings will facilitate shared learning and information sharing. We also recognised following the inquest the risk of not seeing patients face to face and we have developed plans and guidelines to ensure the adequacy of dietetic assessments over the phone, and a minimum standard set for face-to-face consultations. The steps we have taken to date include benchmarking locally, regionally and nationally to help inform the development of a draft Standard Operating Procedure which, following approval, will be evaluated to ensure that it is embedded into practice. Governance and Monitoring To provide assurance of ongoing monitoring, evaluation and sustained improvements any Improvement work is overseen through the Velindre Cancer Service Quality & Safety governance structure. Progress is monitored via the Trust’s electronic regulatory and assurance tracker and is reported to the Executive Management Board and Quality, Safety and Performance Committee. Monthly joint meetings with ABUHB ensure close alignment and shared accountability in relation to our shared improvement actions. We have written to Mr Turzynski’s partner to express our sincere apologies that the care provided did not meet the standards to which we are committed, and we have offered the opportunity to meet with the clinical team. I hope that this response provides you with the assurance required that the action we have taken is robust enough to prevent future deaths related to dietetic support and provision. Mae Ymddiriedolaeth GIG Prifysgol Felindre yn hapus i dderbyn gohebiaeth yn y Gymraeg neu’r Saesneg. Velindre University NHS Trust is happy to receive communication in Welsh or English. Pencadlys Ymddiriedolaeth GIG Prifysgol Felindre Velindre University NHS Trust Headquarters 2 Cwrt Charnwood Heol Billingsley Parc Nantgarw Caerdydd/Cardiff CF15 7QZ Ffôn/Phone: (029) 20196161 https://velindre.nhs.wales Please do not hesitate to contact me if I can provide any further information. I am truly sorry for the issues that have been found and for the impact that these have had on Mr. Turzynski and his family. I hope to assure you that, as a Trust, we are committed to continuously striving to improve the care that we provide to all our patients. Yours sincerely, Prif Weithredwr Interim Chief Executive Officer Encl: Velindre Cancer Service Dietetic Provision Improvement Plan Mae Ymddiriedolaeth GIG Prifysgol Felindre yn hapus i dderbyn gohebiaeth yn y Gymraeg neu’r Saesneg. Velindre University NHS Trust is happy to receive communication in Welsh or English. Dietetic Provision Improvement Plan Velindre Cancer Service (VCS) Action plan approval: Name VCS Triumvirate Private Trust Quality Safety & Performance Committee Private Trust Board Progress Key: Off target - Risk Delayed/behind schedule Not started Date 4/11/25 13/11/2 27/11/25 In progress On track Completed and evidenced Dietetic Provision Improvement Plan v0.2 November 2025 Regulation 28 Recommendation 1 - To improve co-working within disciplines when sharing the care of patients who require hospital and community dietetic care Action taken Proposed action Safety action owner Professional Head of Nutrition and Dietetics Target completion date Evidence 31/01/2026 TOR for meeting Meeting notes Clinical pathways To continue monthly Dietetic professional meetings, with the next meeting arranged for 17/11/2025 Meetings undertaken on 28/07/2025 and 06/10/2025 between Dietetic departments at VCS and ABUHB. Upper Gastrointestinal and Head & Neck clinical pathways reviewed, further developed and confirmed. Clinical Pathways have been implemented across Dietetics at VCS and ABUHB. To be completed 1. Safety action description (SMART) To schedule and conduct meetings with ABUHB to review and discuss the current Head and neck and Upper Gastrointestinal patient pathways, identify gaps and/or improvements, and agree on next steps for pathway optimisation. 2. To provide assurance that pathways developed under safety action #1 are completed and embedded into practice. Dietetic Provision Improvement Plan v0.2 November 2025 Regulation 28 To ensure the pathways are robust and meet the needs of our patients, we will regularly audit the pathways implemented. Professional Head of Nutrition and Dietetics To ensure the pathways are fully embedded into practice, the target date for auditing is 30/05/2026 This will be recorded and tracked on our internal audit governance system (AMaT) and will be reported through internal governance at quality and safety board meetings. Draft MDT checklist will go through the internal ratification process and be implemented. To ensure the checklist is robust and fit for purpose, it is necessary to undertake an audit of the checklist. This will be recorded and tracked on our 3. To improve multi- disciplinary communication and working processes between VCS and ABUHB by introducing a shared communication protocol/checklist and establishing when urgent joint MDT meetings are required. Collaboration across multi-professional teams and both organisations to develop and implement an MDT checklist for complex nutritional care patients. Dietetic Provision Improvement Plan v0.2 November 2025 Regulation 28 Head of Therapies 30/11/2025 MDT checklist To ensure the checklist is embedded the target date for auditing is 30/05/2026 internal audit governance system (AMaT) and will be reported through internal governance at quality and safety board meeting. This will be based on Quality Improvement (QI) methodology, ensuring the audit cycle is completed and learning is shared widely across the Trust. To utilise local transfer form between VCS and ABUHB 30/11/2025 Transfer form Professional Head of Nutrition and Dietetics To utilise the All- Wales transfer 30/11/2026 4. Formulise an agreed method of communication for the transfer of patient care with all health boards leads in Wales – all Wales transfer documentation, to be used for transfer between ABUHB and VCS. In the interim to use a standardised email transfer template. A transfer document has been developed with VCS and ABUHB, to be used for shared care patients, until the All-Wales document has been agreed. Discussion of cross boundary referral concerns and options at Dietetic Provision Improvement Plan v0.2 November 2025 Regulation 28 5. To ensure replication of safety action #1,3 &4 above, across all VCS commissioned health boards in Wales. Head of Therapies 31/03/2026 the Welsh Dietetic Leaders Advisory group (WDLAG) to ensure comprehensive handover of patient role 07/10/2025 Meeting date arranged between Head of Therapies at VCS and AHP Clinical Directors within local Health Boards to address pathway review and enhanced communication 07/11/2025 form once agreed with WDLAG. To start replication of care, standardised process and protocols to ensure the safety actions meet quality standards of care across all UHB's commissioned to provide a service to VCS. Dietetic Provision Improvement Plan v0.2 November 2025 Regulation 28 Recommendation 2 - To improve accessibility of patient records across Trust and Health Board Safety action owner Professional Head of Nutrition and Dietetics Target completion date Evidence 10/10/2025 Starters checklist and database of CWS access Head of Therapies 30/11/2025 Meeting summary Safety action description (SMART) 1. To ensure all Dietitians have access to Clinical WorkStation (CWS) to enable full notes to be accessible between VCS and ABUHB. 2. To schedule formal communication with the Chief AHP digital advisor in Digital Health Care Wales (DHCW) and Head of Dietetics at ABUHB, to review and discuss digital systems across Wales, identify any gaps or improvements, and agree on next steps for pathway optimisation. Action taken Proposed action We are 100% compliant with our Dietitians at VCS having access to 'read only' notes on CWS. Accessing this system has been embedded into day-to- day practice. Meeting held with Chief AHP digital advisor, VCS and ABUHB 22/08/2025. Shadowing session held at VCS with Chief AHP digital advisor to review current processes and systems and to make key improvements/ recommendations 28/10/2025. All new starters within the Dietetic department will have access and training to CWS which will be recorded on our training needs analysis records kept for all staff. Risk to be raised with Local health Boards, in liaison with DHCW, re: multiple number of digital systems in use across NHS Wales. There is focused work ongoing regarding the use of digital systems across Wales, and we are collaborating with DHCW to help inform these conversations. Dietetic Provision Improvement Plan v0.2 November 2025 Regulation 28 3. To ensure replication of safety action #1 & 2 above, across all VCS commissioned health boards in Wales. Meeting date arranged between Head of Therapies at VCS and AHP Clinical Directors within local Health Boards to formalise digital access 07/11/2025 Head of Therapies 31/03/2026 Recommendation 3 - To set guidelines/monitoring for dietetic assessments over the phone, and a minimum standard set for face-to-face consultations. Target completion date Evidence 30/11/2025 SOP document Safety action owner Professional Head of Nutrition and Dietetics Safety action description (SMART) 1. To develop a Standard Operating Procedure (SOP) to ensure standards/ guidance are set for Dietitians to consider when making clinical decision regarding telephone review and face to face sessions. Action taken Proposed action Benchmarking has been undertaken locally, regionally, and nationally to help inform the development of the SOP. Draft SOP/standards have been written To finalise the Standard Operating Procedure (SOP) for dietetic provision of care and submit it through the Velindre Cancer Service (VCS) internal governance process for approval. Dietetic Provision Improvement Plan v0.2 November 2025 Regulation 28 To implement the approved Standard Operating Procedure (SOP) for dietetic provision of care across all relevant teams within Velindre Cancer Service (VCS), ensuring all staff understand and adopt the new process. In order to ensure the SOP is robust and meets the needs of our patients, to undertake an audit of the SOP once implemented. This will be recorded and tracked on our internal audit governance system (AMaT) Professional Head of Nutrition and Dietetics To ensure the SOP is embedded the target date for auditing is 30/05/2026 2. To provide assurance that the SOP developed under safety action #1 is robust and embedded into practice. Dietetic Provision Improvement Plan v0.2 November 2025 Regulation 28 and will be reported through internal governance at quality and safety board meeting. This review will be based on Quality Improvement (QI) methodology, ensuring the audit cycle is completed and learning is shared widely across the Trust. Dietetic Provision Improvement Plan v0.2 November 2025 Regulation 28
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