This Extended Adult Practice Review was commissioned by the Chair of the North Wales Safeguarding Adults Board in April 2016 in order to consider what lessons could be learnt following the sad death of Patient A in March 2015 . An independent Chair was appointed and two independent Reviewers with a specialist background in Health Care were commissioned to undertake the review.
The review was undertaken following a Protection of Vulnerable Adults (POVA) referral to Conwy County Borough Council. The subsequent POVA investigation concluded that, on balance of probability, Patient A had suffered significant harm as a result of non-intentional neglect. Conwy County Borough Council made an Adult Practice Review referral on 18/3/16 to the North Wales Safeguarding Adults Board.
Key themes of learning were identified through the review process and recommendations were made regarding:
Communication
Referral pathways for Clinical Concerns
Clinical Examination and treatment
Care Coordination and Continuity of Care
Strategic Issues
These recommendations will be taken forward through an action plan in order to ensure key learning will be taken forward by partners with the North Wales Safegurding Board and progress will be overseen by the Board.
The North Wales Safeguarding Adults Board have followed the process detailed in the Social Services and Well-being (Wales) Act 2016 – Working Together to Safeguard People (Volume 3 – Adult Practice Reviews).
You will find the report in the APR Section of the Website
