Carmarthenshire & Pembrokeshire

Concerns summary Cockpit fire/smoke procedures need a full review for oxygen fire recognition and protective equipment. International civil aviation investigation protocols require amendment for state participation and final report timelines.

Concerns summary Unregulated online pharmacies easily sell prescription-only and controlled drugs, lacking patient verification, dosage guidance, and safeguards against misuse, exposing vulnerable individuals to unsafe medications.

Concerns summary The In-Patient Medication Administration Record and A&E Record Card fail to document medication prescription times, only administration. This lack of recorded prescription times hinders checks for timely delivery and cross-referencing.

Concerns summary Crisis team actions were poorly monitored and falsely marked as complete, and significant procedures were communicated inappropriately. A lack of clear re-entry routes for vulnerable discharged patients revealed poor inter-service information sharing.

Concerns summary A vehicle should have been taken out of service due to multiple safety defects, including worn tyres and a fractured arm pivot, but remained in use after an inspection.

Concerns summary There was no overarching risk management plan for patient care, coupled with deficiencies in record-keeping, including outdated strategies and poor preservation of handover information.

Concerns summary The evidence revealed general concerns indicating a risk of future deaths without specifying particular issues.

Concerns summary Concerns exist regarding the content of police training for restraint and Appropriate Adult responsibilities. Criteria for identifying and transporting individuals to a place of safety under MHA 1983 also require review.

Concerns summary Insufficient dietetic staff, lack of mandatory training for nutritional assessment tools, and nursing staff's failure to act on doctor referrals to dietetics led to inadequate patient nutrition.

Concerns summary The junction lacks adequate road markings, early warning signs, and properly positioned speed limit signs. Filter lanes are too short, and there's no westbound filter, increasing road safety risks.

Concerns summary The police STORM report was not consistently updated, leading to uncertainty about completed actions, potential loss of evidence, and duplicated work, highlighting a need for better training.

Concerns summary Inconsistent police training and guidance regarding PAVA spray use and forcible mouth searches for detained persons with objects in their mouths, conflicting with FFLM recommendations, indicates a systemic failure to implement past lessons.

Concerns summary Referrals to consultants were inappropriately handled by middle-grade doctors, and essential liver function tests were declined due to a rigid demand management policy, lacking a mechanism for clinical override.

Concerns summary Windows in Morlais Ward service user areas are not ligature-free, posing a safety risk, and planned remedial work has not yet been completed.

Concerns summary Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.

Concerns summary Three deaths at the Millpond indicate significant safety concerns, highlighting the need for fencing, improved lighting, clear warning notices, and readily available flotation equipment.

Concerns summary The Welsh Assembly Government's advice on reducing cot death is confusing, specifically regarding the ambiguous "very tired" criterion for parents considering bed-sharing.

Concerns summary There was a breakdown in information transfer between child and adult mental health teams, coupled with ward understaffing and critical training needs regarding Section 136 procedures, absconding, and powers of detention.

Concerns summary Communication failures post-handover, lack of falls risk assessment, unavailability of a low bed, and inadequate staffing levels for high-need patients contributed to risks.

Concerns summary The inquest revealed unstated circumstances that pose a continued risk of future deaths if action is not taken.

Concerns summary CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.

Concerns summary Citalopram was inappropriately given on repeat prescription, contravening guidelines. Moreover, long ten-month waiting times for psychotherapy make it an unviable treatment alternative.

Concerns summary Insufficient information sharing about vulnerable individuals with the Fire Service and a lack of training for Local Authority staff on home fire safety checks increase fire risks for the elderly.