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.