Nancy Price

“An investigation was commenced by the Health Board into the death of [the deceased] [name redacted], a significant time after her death and was completed only on 9 June 2022, some 17 months after her death.”

“the investigation report was due to be shared with vascular services to share learning by June 2022 (once approved) and yet the Report was only shared with vascular services in January 2023”

“one action was to identify any gaps in knowledge with regards to assessment and management of vascular emergencies, including recording of limb colour, sensation and movement, by the end of June 2022”

“strategic management of internal Health Board investigations is lacking leading to investigations that are too slow, actions are not always realistic and, as a result, identification of areas for learning and training are not understood quickly enough, such that deaths will occur or will continue to occur into the future unless rapid action is taken”