North Wales (East and Central)

Concerns summary Persistent, unresolved systemic issues, including ambulance handover delays, emergency department overcrowding, and bed blocking, continue to recur despite previous warnings, placing patients' lives at risk.

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 system for providing radiologist reports to the Emergency Department is unreliable, creating a risk that subtle injuries may be missed and patient safety netting is ineffective.

Concerns summary Pulse oximeter alarm settings are fixed at a routine level rather than being adjusted to individual patient baselines, risking unnoticed significant oxygen desaturation.

Concerns summary Critical information was not consistently recorded in nursing notes, and handovers did not reference these records, risking significant patient details being missed by incoming staff.

Concerns summary Emergency Department doctors and staff lack a digital system to support their 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 Inaccurate and delayed completion of the Transfer of Care Form by a doctor prevented critical patient information from being immediately available to custody nurses.

Concerns summary No systematic medication review occurred as per medical practice, and a lack of cohesion between mental health and general medical treatment meant vulnerable patients' mental health information was disregarded in their physical care.

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 New training on procedures is not mandatory for all staff, and the Acute Liaison Nurse role, crucial for patient support, lacks adequate cover during absences.

Concerns summary There is no documented standard practice for regular fetal heart auscultation after opiate administration or for further maternal examinations following a change in condition during labour.

Concerns summary Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning signs of toxicity.

Concerns summary A patient's declining condition and mobility were inadequately assessed for falls risk upon admission and after hospital discharge, leading to repeated falls due to unupdated 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.