North Wales (East and Central)

Concerns summary A deficient investigation and unfinalized transfer of care policy highlight systemic failures. Persistent reliance on paper-based mental health notes prevents wider access to critical patient information, risking future harm.

Concerns summary Human error led to critical first aid advice for a varicose vein bleed not being given during emergency calls, highlighting a risk of future deaths from handlers not following MPDS protocols.

Concerns summary The absence of bed rail assessments from the Welsh Nursing Care Record risks these critical safety evaluations being missed, potentially leading to patient falls and future deaths.

Concerns summary The agency failed to adequately assess vessel stability after significant modifications, relying on inadequate checks and skipper assurances, leading to a risk of other unassessed modified vessels operating unsafely.

Concerns summary An addiction support service lacked robust communication and record-keeping policies, relying solely on written correspondence, which led to service users being disengaged and facing long waiting times.

Concerns summary The health board lacks a robust, documented policy for decision-making and care pathways when patients are referred to the Home Treatment Team.

Concerns summary The health board's internal investigations are too slow, with unrealistic action plans and missed deadlines, significantly delaying learning and preventing the timely implementation of safety improvements.

Concerns summary Persistent and significant ambulance handover delays between the Welsh Ambulance Service and Health Board are causing ongoing deaths, with current improvements proving extremely limited.

Concerns summary Retailers fail to provide essential safety advice at the point of paddleboard sale, specifically regarding the mandatory wearing of life-saving equipment and appropriate leash usage for varying water conditions.

Concerns summary The nursing and care provider lacked a formal system to trigger multi-disciplinary reviews for patient deterioration or to monitor whether care plans were being met, despite clear signs of refusal for essential care.

Concerns summary Obstructed visibility from a hedge at a road junction (Green Lane onto A525) creates an ongoing risk of future vehicle collisions and potential loss of life.

Concerns summary The health board experienced significant delays in fully implementing a new Standard Operating Procedure for irregular scan reports and auditing its effectiveness, allowing known patient risks to continue.

Concerns summary Advance Nurse Practitioners failed to routinely review elderly care home patients' medication regimes during multiple visits, missing critical errors due to time constraints, posing a significant risk to patient safety.

Concerns summary The Health Board consistently fails to implement its own action plan recommendations and address concerns within set timeframes, leading to ongoing risks to patient lives.

Concerns summary The Health Board failed to implement a beneficial medical protocol and delayed approving critical risk mitigation procedures for diagnostic results, despite setting their own deadlines, thereby putting lives at risk.

Concerns summary Falls prevention measures were inconsistently implemented, and staffing pressures led to errors in care. The resident's room placement also increased the risk of falls during toilet access.

Concerns summary Mental Health Services failed to adequately protect a patient with an immediate self-harm plan, making no attempt to contact her or reinforce available crisis options.

Concerns summary A lack of protocol for assessing locum staff's practical skills and managerial reluctance to thoroughly check references created risks that locums might perform tasks beyond their capabilities.

Concerns summary The Scout Association failed to implement or ensure understanding of critical safety policies, including risk assessments and leadership oversight, for an organised trip, directly endangering young people.

Concerns summary Paramedics failed to pre-alert the hospital about suspected sepsis due to discretionary policy. They also could not administer vital antibiotics, and did not escalate concerns about patient condition or admission delays.

Concerns summary Lack of appropriate support channels for high-profile individuals removed from government positions, especially concerning media interest and potential mental vulnerabilities.

Concerns summary Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for those with swallowing difficulties, compounded by inadequate management oversight.

Concerns summary The aqueduct's parapet upright spacing is dangerously wide for current standards, creating a fall risk, and inspection procedures for upright embedment are subjective and inadequate to ensure structural integrity.

Concerns summary The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures outstanding for too long.

Concerns summary A root cause analysis identified numerous care and service delivery problems, missed opportunities, and a lack of staff understanding. Significant improvements are needed in mental health teams' risk assessment and escalation training.