Comprehensive service review of main theatres at the University Hospital of Wales
Following an internal staff survey that raised significant concerns, the Health Board initiated a comprehensive service review of the main theatres at the University Hospital of Wales.
The service review was conducted by two senior colleagues who were appointed on the basis that they had no conflict of interest and had no previous line management responsibility of theatres.
The service review was completed on Tuesday, 29 April 2025 and involved over a third of theatres staff sharing their views and experiences. It uncovered a number of concerning themes, ranging from failures of leadership practice, variable compliance with policies and procedures and poor culture, all of which impact upon behaviours and psychological safety of colleagues.
In relation to patient safety, the main areas of concern relate to compliance with the World Health Organisation surgical safety checklist and the process for obtaining patient consent. As a Health Board, we have already taken mitigating actions and improvements have been implemented.
The Health Board will now consider the findings, recommended actions and implications of the service review as it develops a management response and a detailed action plan to make urgent improvements and address quality and safety issues.
Colleagues directly involved in theatres will receive a copy of the report and will be supported by a series of face-to-face briefings with the Chief Operating Officer and other senior colleagues.
While very disappointing and concerning, the Health Board conducts more than 30,000 surgical procedures in Cardiff and the Vale of Glamorgan every year and the number of incidents affecting patients is proportionately very small.
However, this does not diminish the responsibility we hold to ensure we seek continuous improvement, and we want to assure the public that safety measures remain a top priority for the Health Board.
On a positive note, we are pleased that the report did acknowledge and praise many of the highly skilled, experienced and knowledgeable individuals who work within the theatres department. Many of them you will have seen on Saving Lives in Cardiff.
As an executive team, we are committed to improving the working environment and culture and addressing all issues raised. It is important to us as a Health Board that we retain the trust and confidence of patients and their loved ones who put their health in our hands and rely upon us to do no harm.
We are very sorry for the distress and concern this will cause, and we want to reassure the public that we will take the necessary steps to address the concerns raised.
Suzanne Rankin, Chief Executive
Paul Bostock, Chief Operating Officer