South Wales Central

Concerns summary Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical information, and police training suggested a two-officer crew for safety.

Concerns summary The hotel room lacked secondary security for its easily disengaged door locks, and the pool had no physical barrier, allowing unsupervised access by a vulnerable child.

Concerns summary There is a lack of specific practice tools for family and care staff to recognise and escalate acute health deterioration in people with learning disabilities, despite national recommendations for such tools.

Concerns summary The investigation into a domestic explosion was compromised by police disposing of critical debris. There was no understanding of evidence preservation or protocol between police and HSE for such events.

Concerns summary Deteriorating hospital infrastructure and critical care capacity issues pose a significant risk, as safeguards against moving critically ill patients may fail under pressure.

Concerns summary The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of over-sedation due to clinicians applying it without adequate guidance.

Concerns summary Nursing staff demonstrated a lack of knowledge regarding podiatry referrals for pressure wounds and failed to follow a Tissue Viability Nurse's dressing recommendations, leading to unaddressed issues.

Concerns summary Persistent delays in cancer diagnostic, staging, and treatment pathways, especially for staging scans, are adversely affecting patient survivability rates and prognoses, making treatable cancers irresectable.

Concerns summary Over-administration of analgesia during labour rendered the mother comatose, masking labour progression, and current national guidelines lack explicit detail on safe analgesia levels and supervision.

Concerns summary The care home lacks effective staff training on falls risk identification, documentation, and mitigation, with assessments often missing professional counter-signatures and a clear falls prevention policy.

Concerns summary Long-standing, systemic ambulance handover delays in Wales persist at intolerable levels, with risks remaining due to a disconnect between ambulance service rostering expectations and actual hospital capacity.

Concerns summary The absence of lifeguards at a dangerous breakwater during high-risk periods, despite historical effectiveness, and insufficient evidence that new deterrence measures are working, poses an ongoing risk.

Concerns summary Mental health services lack clear guidance for clinicians on family information sharing and gathering, leading to inconsistent practices. Patient information leaflets also fail to adequately explain these processes.

Concerns summary Nursing staff and healthcare workers at St David’s hospital lack confidence and adequate training in falls risk assessments, enhanced supervision, and proper documentation, risking future deaths.

Concerns summary Online suicide forums and social media platforms provided information on self-harm and misleading professionals, raising concerns about the adequacy of The Online Safety Act 2023 in preventing access to such harmful content.

Concerns summary Discharge decisions were made without essential multi-disciplinary meetings or consulting care coordinators, despite clear warnings of high suicide risk, indicating a systemic failure in communication and risk management.

Concerns summary Delays in implementing a "Failed Discharge" policy mean patients are not being appropriately referred for specialist review, increasing risks of re-attendance and errors in emergency departments.

Concerns summary Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, and are reluctant to offer simultaneous support for addiction and mental health.

Concerns summary Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due to significant delays in discharging medically fit patients.

Concerns summary Welsh housing legislation requiring only two hard-wired smoke alarms in rented properties is insufficient, as alarms failed to activate in a contained bedroom fire, posing a risk to life. Crucial items were also prematurely removed from the fire scene, hindering investigation into the cause.

Concerns summary Significant ambulance response delays, exceeding the expected survivability of severe injuries, were caused by ambulances being held up at Emergency Departments, preventing them from attending new calls.

Concerns summary The alarm system allows silencing without patient checks, especially during night shifts, and monitors are not continuously checked. This creates a significant risk of patients remaining unmonitored for extended periods.

Concerns summary Police officers face severely limited access to qualified mental health advice and patient records when responding to mental health crises, due to withdrawn triage support and unimplemented alternative services.

Concerns summary Extensive and repeated delays in urgent gynaecology appointments, relying only on written correspondence, resulted in a significant 24-month diagnostic delay. There were missed opportunities to escalate urgency upon re-referral.

Concerns summary Mental health practitioners lack easy access to complete patient records across Wales and NHS England. Acute and home treatment teams also suffer from a lack of clinical psychologists and lengthy psychotherapy waiting lists.