North Wales (East and Central)

Action Planned (AI summary) Betsi Cadwaladr UHB acknowledges concerns about pressure on the Emergency Department at Ysbyty Glan Clwyd. They are undertaking a programme management approach organized into three phases to strengthen planning, leadership and governance across the Health Board and are working with operational and clinical teams.

Action Planned (AI summary) Betsi Cadwaladr University Health Board is undertaking an addendum investigation regarding the transfer of care, and a strategic outline case for an Electronic Patient Record system(s) is being developed on a Health Board wide level to address the issue of fragmented care records; the deadline for the strategic outline case is the end of January 2024.

Action Planned (AI summary) Following an internal audit, the Welsh Ambulance Service will issue a reminder to all call handlers regarding the use of Post-Dispatch Instructions (PDIs), specifically related to haemorrhage/laceration calls, and will undertake a further targeted audit in February 2024.

Action Planned (AI summary) The Health Board has reminded ward managers about paper-based assessment forms while awaiting a national update to the Welsh Nursing Care Record. They are also finalising an updated Bed Rails Procedure and are working to comply with a National Patient Safety Alert regarding bed rails.

Action Planned (AI summary) Adferiad is seeking a range of updated automated communication routes for the service (such as a text reminder service) and as we proceed with this initiative, we will, of course, continue to have regard to your concern. The Health Board has re-issued communication detailing the referral process to liaison services and will share it with clinical teams across the Health Board to ensure there is clarity and consistency across all areas. The MHLD Liaison Psychiatry Services in Acute Hospitals Delivery Framework will also be reviewed.

Action Planned (AI summary) The Health Board will review and ratify its Home Treatment Team Operational Policy by 31 January 2024, incorporating the coroner's comments. An interim addendum has been created to address immediate concerns.

Action Planned (AI summary) The Health Board is re-evaluating the incident process with a new procedure document to be developed by the end of August 2023, addressing overdue investigations with weekly meetings, and implementing training programmes after procedure approval. They have also commissioned a Patient Safety Improvement Programme.

Action Planned (AI summary) Tesco will add a sticker to the front of their paddleboard packaging with safety information and a QR code linking to British Canoeing's website, and will share information with other retailers via the British Retail Consortium's Product Safety Committee. They have made arrangements for stores to receive and affix the stickers to units delivered in 2022. The Department for Business and Trade has referred the report to Hertfordshire Trading Standards, asked the Office for Product Safety and Standards (OPSS) to write to the British Retail Consortium and major retailers, liaise with enforcement partners and manufacturers, and write to the British Standards Institute to consider industry standards relating to paddleboards.

Action Planned (AI summary) TLC Homecare and Nursing Plus is implementing measures including staff training, an automated review system, and a more regular client review process to better monitor care provision and address deviations to care plans.

Action Planned (AI summary) BCUHB is considering adopting the SNAP protocol for paracetamol overdose treatment but requires local review and approval. The Health Board is reviewing historic action plans from serious incident investigations and tracking actions through their Datix patient safety system.

Action Planned (AI summary) Pendine Park will introduce a programme of testing door pressures where mobile residents encounter doors and will continue to work with GPs and other health professionals to support any resident that has a history of falls using the North Wales Prevention and Management of Falls in Care Homes Pathway. They also aim to continue to be suitably staffed.

Action Planned (AI summary) The First Minister of Wales has consulted with current and former ministers and the family of the deceased to make changes to the process for ministers leaving the Cabinet. A new section will be added to the Welsh Government Ministerial Code to ensure the well-being of ministers is taken into account during reshuffles and that they are aware of available support services.

Action Planned (AI summary) The Trust has started an investigation of physical options to address gaps in the parapet and will submit a final design for approval after an informal public consultation.

Action Planned (AI summary) The Health Board is implementing an Unscheduled Care Plan in 2017/18 to improve waiting times for hospital admissions and reduce bed occupancy. The plan includes targets for each section and will be overseen by a Health Board-wide Transformation Group, with progress monitored monthly and by Welsh Government.