South Wales Central

Concerns summary Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to acquire information and means to cause their own death.

Concerns summary Police officers have limited access to qualified mental health advice and clinical records when responding to mental health crises, as urgent support teams are not readily available and a promised service is unimplemented.

Concerns summary The distribution of ligature cutters to frontline police officers remains incomplete, posing a risk in emergency situations. Additionally, bespoke training for officers responding to mental health crisis incidents is not widely available.

Concerns summary Multiple prescribing and dispensing errors occurred due to an electronic prescribing tool that allowed bypassing allergy checks and a lack of specific knowledge about constituent drugs among prescribers and pharmacists.

Concerns summary Clinicians lacked access to comprehensive patient records from community care and the unit's internal records were fragmented, impairing assessment, observation setting, and safeguarding measures.

Concerns summary A&E consultants and agency nurses lacked adequate training in paediatric sepsis identification and management, including using risk stratification tools and appropriate terminology. Failures were noted in considering alternative antibiotic administration methods.

Concerns summary Motorcyclists using Trelai Park as an unfettered racing area pose a significant safety risk to the general public, particularly children and the elderly.

Concerns summary Patients on finite oxygen supplies risk being unmonitored; oxygen administration training is incomplete, and there are no formal procedures for tracking oxygen expiry times. The root cause analysis was also deficient.

Concerns summary Missed opportunities for a CT scan and lack of a system for overnight consultants to authorise scans contributed to delayed diagnosis and potentially preventable death.

Concerns summary Gateway assessors had incomplete access to patient notes, potentially resulting in inadequate assessments and treatment plans due to missing critical information.

Concerns summary The improvement plan failed to address specific issues, and there's no dedicated pathway for urgent clinical discussions between external healthcare professionals and ambulance staff to ensure proper assessment of response urgency.

Concerns summary Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which led to an overdose.

Concerns summary Care plan reviews lacked documentation, making it impossible to confirm outcomes or whether previous suicide attempts were considered. Additionally, Nomad trays might be unsuitable for certain patients, impeding medication benefits.

Concerns summary Mental health guidance lacks provisions for reviewing Section 17 leave upon ward transfer, and there's a need for better communication to clinicians and consideration of two escorts for patient safety.

Concerns summary The surgical team was unaware of the patient's thrombosis history. Deteriorating NEWS scores did not trigger timely clinician review, highlighting a failure in information sharing and effective care escalation.

Concerns summary An untrained doctor performed a FAST ultrasound without supervision, and records were not stored. There was also inadequate escalation of care for symptomatic patients with identified Abdominal Aortic Aneurysm.

Concerns summary Outdated guidelines and failure to follow national guidance for Naso Gastric tube insertion, including PH testing and X-rays, compromised patient safety, compounded by inconsistent practice and lack of specific ITU guidance.

Concerns summary Surgery for a neck of femur fracture was delayed beyond NICE guidelines due to theatre staff and resource availability issues, despite the recognised risk of serious complications from prolonged waiting.

Concerns summary Failures in conducting routine neurological and NEWS observations, including missed checks and an incorrectly calculated score, resulted in the deceased not receiving a necessary medical review.

Concerns summary An inappropriate healthcare professional conducted the mental health assessment for a vulnerable older person, and the assessing professional lacked critical access to the detainee's medical records.

Concerns summary A "challenging" A470 road stretch with a history of serious collisions lacks adequate warning signs for an approaching left bend. An advanced warning sign is needed to reduce future fatality risks.

Concerns summary A significant lack of awareness among health professionals regarding the dangerous interaction between Miconazole Gel and Warfarin, combined with unclear information resources, risks uncontrolled bleeding.