South Wales Central

Concerns summary Significant and prolonged handover delays between ambulance crews and hospital staff led to critical delays in ambulance dispatch and availability, worsening since new guidance.

Concerns summary Poor design of the school service road and bus bay, coupled with insufficient staff supervision, created a highly dangerous situation for children crossing the road, stemming from a lack of accountability in the school's construction.

Concerns summary There were no local protocols or specific training for intercostal drain insertion, and recommended real-time ultrasound guidance was unavailable, raising significant safety concerns for patients.

Concerns summary A poor system for requesting and securing one-to-one nursing cover led to frequent unavailability and staff confusion. This resulted in inadequate staffing levels, leaving frontline nurses unable to safely care for vulnerable patients.

Concerns summary Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There was also a lack of 'joined-up' thinking and insufficient systems for booking one-to-one care for high-risk patients.

Concerns summary Inadequate falls risk assessment, inconsistent 1:1 supervision, understaffing, and untrained staff performing neurological observations contributed to multiple falls and missed assessments.

Concerns summary Current legislation exempts older, powerful vehicles from essential safety requirements like helmets or seatbelts, posing significant risks to riders and other road users.

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 There is no formal backup plan for PCI procedures when primary hospitals lack capacity, and no agreed pathways for accessing critical care beds outside Wales or for unconscious STEMI patients.

Concerns summary Insulin pump guidance inadequately highlights misuse dangers from incorrect cartridge insertion, and patient education fails to emphasize the rapid life-threatening nature of hyperglycaemia.

Concerns summary Hostel staff lacked specific training on monitoring and safeguarding residents found after illicit drug use, instead only focusing on overdose recognition, leaving at-risk individuals unmonitored.

Concerns summary A lack of acute mental health facilities in Powys forces patients to be moved far from home, causing discontinuity of care and negatively impacting patient engagement, thus increasing self-harm and suicide risk.

Concerns summary An ambulance response was critically delayed by over two hours, and no follow-up calls were made to the patient's family. This was attributed to an absence of clear planning for high call volumes, risking future service failures.

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.

Concerns summary Ambulance response was delayed, only arriving after police expedited the call, indicating potential issues with emergency service dispatch or prioritization.

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 Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was accidentally disconnected, highlighting a lack of clear labelling protocols.

Concerns summary Inconsistent practices for monitoring district nurse compliance with delegated INR testing across GP surgeries create a risk of unmonitored over-anticoagulation.

Concerns summary Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy for a dementia patient, missing a critical hospital admission opportunity.

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.