Gwent

Concerns summary A pacemaker clinic failed to refer a visibly unwell patient with high thresholds to cardiology, contributed to a delayed diagnosis. Concerns include lack of referral guidance, limited physiologist knowledge, and inconsistent clinical data communication.

Concerns summary Flawed methods for assessing pavement defect heights result in relevant hazards not being identified and remedial action not being taken, creating a risk of future deaths.

Concerns summary Unsafe practice of routinely downgrading NEWS scores for all COPD patients without knowing individual baseline saturations leads to inadequate clinical assessments.

Concerns summary A lack of consistent guidelines and processes for pre-operative iron administration to chronically anaemic patients, alongside no funding agreement, risks damaging delays in surgery.

Concerns summary Inadequate welfare checks by security guards, stemming from a lack of training on proper procedures and documentation, risked residents not receiving timely medical care.

Concerns summary Inadequate communication between dietetic teams and insufficient monitoring of telephone-based nutritional assessments for cancer patients led to poor nutritional status and potentially earlier death.

Concerns summary Significant delays in ambulance dispatch were caused by prolonged handover times at emergency departments, potentially impacting patient care despite not affecting the specific outcome in this case.

Concerns summary The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by preventing comprehensive mental health assessments, despite not altering the outcome in this instance.

Concerns summary During hospital admission, there was a prolonged failure to address the patient's inadequate nutritional intake, including neglecting family concerns, not monitoring diet, and delaying proper nutritional intervention despite signs of malnutrition.

Concerns summary Ambulance call handlers failed to clinically override the dispatch system's categorization, maintaining a low priority despite clear evidence of the patient's severe, deteriorating, and unmonitored condition.

Concerns summary There was a lack of documented post-leave assessments for a patient with a known risk of ingesting vegetation, alongside staff confusion regarding assessment requirements and documentation standards.

Concerns summary Critical fluid balance monitoring for a patient with severe cardiovascular and renal issues, complicated by sepsis, was entirely neglected by both nursing and medical staff.

Concerns summary Incorrect NEWS score calculation and subsequent failure to follow observation protocols led to missed recognition of a deteriorating patient, delaying senior medical review and putting lives at risk.

Concerns summary Persistent lengthy ambulance response delays for critical emergencies are caused by acute hospitals failing to promptly release ambulances, despite ongoing efforts, directly contributing to patient deaths.

Concerns summary An extreme 9-hour ambulance delay for a patient with a life-threatening emergency, partly caused by hospital handover issues, resulted in her death before paramedics arrived.

Concerns summary The Trust failed to investigate all inpatient falls, including the one contributing to death, preventing learning and reassurance about future prevention measures.

Concerns summary Ambiguity in police officers' recognition and communication of Acute Behavioural Disturbance (ABD) during restraint potentially undermined critical 'Speak Up and Speak Out' principles in emergency situations.

Concerns summary There are no guidelines for the delegation of nursing duties to family members, leading to unacceptable care levels and a lack of clear supervision or intervention by the nursing team.

Concerns summary The health board failed to provide a strategy for family engagement and 24-hour crisis support, despite national recommendations, suggesting these crucial guidelines are not fully integrated into practice.

Concerns summary An inefficient internal postal system for communication between departments caused significant delays in escalating urgent changes in a patient's condition, specifically dysphagia, to the relevant team.

Concerns summary Critical road hazard warning signs near a dangerous bend were overgrown or missing, and no remedial action was taken despite police notification of the problem.

Concerns summary Ward understaffing, inadequate ward layout, and ineffective alarm systems prevented required observations for high-risk patients. There was no updated policy for managing enhanced care in single-room environments.

Concerns summary Ongoing insufficient ambulance resources in Gwent consistently result in unacceptable response times for Amber 1 patients, with chronological allocation lacking clinical consideration and ad hoc interventions not supported by policy.

Concerns summary Significant delays in providing Cognitive Behavioural Therapy and inadequate follow-up by the Community Psychiatric Nurse after discharge, including limited contact attempts, were identified.

Concerns summary Nurses lack essential training in the Multifactorial Risk Assessment Process (MFRA) for falls, leading to newly qualified nurses managing patients without this critical safety knowledge.