South Wales Central

Concerns summary Tracheostomy tube manufacturers may not be keeping pace with population changes, leading to tubes of potentially inappropriate length which could increase dislodgement risk.

Concerns summary The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a significant risk of future deaths, particularly in other Health Boards without such a policy.

Concerns summary Low staffing of Tissue Viability Nurses, inadequate pressure ulcer documentation, and a lack of integrated skin care across services contributed to progression of MRSA-infected pressure ulcers.

Concerns summary Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and could lead to inappropriate treatment courses and poorer outcomes.

Concerns summary The medical practice failed to use computer software for prescription decisions, breached its anti-coagulation register contract, and lacked systems for notifying GPs of missed INR tests or Warfarin withdrawal.

Concerns summary HMP Rye Hill's healthcare was inadequately resourced and unprepared for its re-roll to house sex offenders, resulting in substandard patient care. This raises concerns about similar risks in future national prison re-rolls.

Concerns summary There is no mandatory requirement for surgeons to acknowledge reading relevant Health Board and national clinical guidelines, potentially leading to inconsistencies in surgical practice and patient care.

Concerns summary The free availability and high potency/toxicity of the unlicensed 'designer drug' Acetylfentanyl, sold over the internet, poses a significant risk of future deaths.

Concerns summary Insufficient staff led to multiple falls for a high-risk patient. There was a critical lack of falls risk assessment and handover information between hospitals.

Concerns summary Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward transfer lacked documentation, and the fatal fall was unwitnessed.

Concerns summary Slow Tissue Viability Nurse response and inadequate wound care input, exacerbated by specialist nurses not being hospital-based and an overstretched regional TVN service, led to delayed ulcer assessment.

Concerns summary The hospital failed to conduct an updated falls risk assessment upon Mr. McCabe's admission, relying on an outdated assessment and omitting crucial new information about recent falls and sedative use.

Concerns summary The road layout with obscured views and permitted overtaking, combined with protruding "old style cats eyes," creates a significant highway safety risk requiring double white lines and slim-line catseye replacement.

Concerns summary Patients discharged post-surgery received inconsistent advice, both oral and written, regarding venous thromboembolism risks and critical signs requiring urgent medical attention.

Concerns summary Critical patient history, including IVF treatment abroad and ESBL E. coli infection, was not effectively transferred between hospitals. This led to inappropriate treatment and a lack of necessary barrier nursing, highlighting failures in inter-hospital documentation.

Concerns summary Critical issues include incomplete handovers, slow response times for children, lack of ambulance transfer, outdated national guidance on pre-hospital antibiotics for meningitis, and fragmented hospital care with unaddressed nursing concerns.

Concerns summary A prison doctor lacked ACCT training, ACCT trigger event documentation was subjective and lacked detail for accurate assessment, and procedures for obtaining community mental health records were unclear.

Concerns summary Unilluminated and obscured street lamps caused dangerously poor road illumination, likely impairing the driver's ability to see the deceased on the carriageway.

Concerns summary Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the PER form, leading to inadequate assessment and observation of the prisoner.

Concerns summary Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process clinical details led to inappropriate CPR advice.