North Wales (East and Central)

Concerns summary Police training was ineffective in identifying mental health issues, and 'concern for safety' incidents were closed without ensuring the individual's welfare.

Concerns summary Whirlpool's risk assessments for appliance fires were inadequate, with a dismissive approach to field data like reported fires. This prevents timely learning and proactive measures to enhance product safety and save lives.

Concerns summary There is a lack of clarity on when a sick child needs senior paediatrician review before discharge, especially with parental concerns. Additionally, the system for identifying and acting on learning opportunities from readmissions lacks clear, consistently applied criteria.

Concerns summary Persistent issues with ambulance delays, emergency department admissions, resource availability, and patient flow continue to place patients' lives at risk despite previous reports.

Concerns summary Significant and recurring delays in patient handover at Emergency Departments led to late hospital admission and delayed medical treatment, tying up ambulance resources and risking future deaths.

Concerns summary There is no procedure to confirm district nurse referral receipt and action, and significant delays exist in developing and implementing a safe patient discharge procedure from acute hospitals.

Concerns summary A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information was not promptly reviewed, posing a significant risk of delayed diagnosis and treatment in future cases.

Concerns summary Pervasive hospital admission delays due to insufficient beds were exacerbated by increased 'bed blocking' on weekends, stemming from reduced patient discharges. This systemic issue poses a significant risk to timely patient care.

Concerns summary Inadequate mental health care planning resulted in patients being without consultant review for extended periods post-discharge. Increased demand on services also created staff cover deficiencies.

Concerns summary Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for other calls, creating ongoing risks to public safety.

Concerns summary Staff are not rigorously following the Therapeutic Engagement and Observation Policy, leading to missed opportunities for escalating patient observation levels during critical risk periods.

Concerns summary The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for their required work.

Concerns summary The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for reviewing vulnerable residents' risk assessments and care plans.

Concerns summary There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and potentially delaying optimal treatment. A rapid testing and reporting service is urgently needed.

Concerns summary Staff lacked clear guidance on psychiatric assessment pathways for 'exceptional cases', medical records were inaccessible out-of-hours, and there was insufficient engagement with family/carers on care plans.

Concerns summary Hospital staff lacked knowledge of pre-hospital pain relief, there were no clear policies for overnight patient discharge, and senior clinical oversight was unavailable late at night.

Concerns summary Inconsistent criteria for requesting CT scans based on time of day or weekend leads to varying levels of care and risks missed diagnoses for patients 'out of hours'.

Concerns summary An unmitigated tripping hazard poses a significant risk of falls and potential future deaths if not addressed.

Concerns summary The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, potentially hindering patient well-being.

Concerns summary Conwy's Telecare package lacks standard interlinked smoke alarms, and interim safety provisions are unclear. Additionally, the deceased was not offered a free home fire safety check.

Concerns summary Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for other critical calls.

Concerns summary A practicing GP failed to diagnose a patient and misled parents, with new evidence casting doubt on his fitness to practice. Previous GMC action stalled, posing a risk of future deaths.