South Wales Central

Concerns summary Missing documented observations and pain scores before discharge, alongside absent formal guidance for prescribing oramorph to discharging patients, led to inconsistent and potentially inappropriate medication.

Concerns summary Patient discharge after an overdose failed to include psychiatric liaison assessment, passing critical responsibility to the family. Inadequate history-taking led to underestimated risk, and insufficient GP medication reviews created an overdose risk.

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 A severe lack of ambulance resources caused a critical three-hour delay in dispatching a vehicle to a rapidly deteriorating patient, despite urgent clinical priority.

Concerns summary External consultants had insufficient input into mental health patients' physical care, bureaucratic processes delayed rectifying ligature points, and the system for managing dangerous patient items was ineffective.

Concerns summary Errors in assessing head injury urgency and significant delays in transferring patients to neurosurgical centers, compounded by a lack of specialist radiologists and inadequate electronic radiology transfer systems, posed serious risks.

Concerns summary Seriously underestimated ambulance demand and unrealistic A&E turnaround targets led to severe ambulance shortages. Unreliable welfare call systems and failure to involve police for checks further delayed critical intervention.

Concerns summary An auxiliary nurse's recording of a patient's neck pain was not escalated to a doctor for further assessment, potentially delaying diagnosis of a cervical spine fracture.

Concerns summary Inconsistent application and recording of enhanced observations for at-risk mental health patients, coupled with a lack of training and written guidelines, compromised suicide and self-harm prevention.

Concerns summary Inadequate care and risk assessments failed to address environmental safety hazards like open doors and stair-gate suitability, with unclear responsibility for control measures.

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 Nursing staff failed to use a fluid balance chart or monitor urine output, hindering detection of critical issues. A nurse was untrained in male catheterisation, and there was a general lack of understanding and training in managing long-term indwelling catheters.

Concerns summary There was a lack of a robust system to ensure mental health patients, especially those with psychotic episodes, were seen and re-engaged, leading to discharge without adequate follow-up after an initial appointment failure.

Concerns summary Landlords in Wales are under no legal obligation to install smoke alarms in rented properties, contrasting with England's regulations, and current "best practice" recommendations carry no enforcement.

Concerns summary Clear failures in neurological monitoring, with substantial observation gaps and delayed action on elevated vital signs, were identified. There was also a lack of appropriate management to ensure nurses adhered to observation guidelines.

Concerns summary Despite an identified risk of smoking in bed, carers regularly assisted the deceased to smoke, due to a lack of management oversight and a clear prohibition policy.

Concerns summary Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led to poor DVT management.

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 Fire Service departed a dangerous flood scene without closing the road or leaving warning signs, as their protocols and equipment do not permit road closures, relying solely on other authorities.

Concerns summary An eight-hour ambulance delay for a patient with a fractured hip was caused by insufficient clinician capacity for 999 calls and widespread ambulance unavailability due to extensive hospital handover delays.

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.