Recurance · prevention of future deaths reports
Pre-inquest brief
Incomplete or inaccurate transfer of care documentation
The earlier warning
Andrew Roberts · 20 Aug 2015 · John Gittins, North Wales (East and Central)
“That the Transfer of Care Form was not completed by the Doctor who had carried out the examination of the patient and the information contained therein was subsequenily found to be inaccurate.”
judiciary.uk/prevention-of-future-death-reports/andrew-roberts
What was promised
No published response from Betsi Cadwaladr University Health Board was found for the earlier reports.
What recurred
- 14 Sept 2023 · Richard Griffiths · Kate Robertson · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Andrew Roberts · 20 Aug 2015
“That the Transfer of Care Form was not completed by the Doctor who had carried out the examination of the patient and the information contained therein was subsequenily found to be inaccurate.”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.