Carmarthenshire & Pembrokeshire

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There was no overarching risk management plan for patient care, coupled with deficiencies in record-keeping, including outdated strategies and poor preservation of handover information.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