Alcohol, drug and medication related deaths

Concerns summary Poor record-keeping meant that information and signposting provided to the patient were unclear, and inadequate communication between services led to conflicting advice regarding benzodiazepine use.

Concerns summary Inadequate policies allowed supervision records to be overwritten and subsequently destroyed, preventing accurate ascertainment of information and raising concerns about proper record retention.

Concerns summary Information sharing procedures between different health services are inadequate, failing to ensure the proper exchange of service user information regardless of treatment pathway, which risks patient safety.

Concerns summary Failures include inadequate MDT input and inaccurate reports, lack of accountability for drug testing, poor documentation of leave decisions and substance misuse, and a deficient post-incident investigation.

Concerns summary A significant number of patients on long-term, high-dose opiate/opioid prescriptions lack support to reduce or stop medication. There is an absence of specialist services for dependence and no clear regional or national strategies to address this widespread issue.

Concerns summary Outdated methotrexate guidelines recommend a sub-therapeutic dose and create ambiguity in responsibilities between healthcare providers, risking fatal delays in toxicity management.

Concerns summary Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.

Concerns summary Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.

Concerns summary Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.

Concerns summary Hospital discharge decisions failed to adequately assess a patient's significant mental health deterioration and suicidal ideation, attributing issues solely to alcohol misuse and not deploying escalated home-based treatment.

Concerns summary Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due to staffing shortages.

Concerns summary Community pharmacists in Wales faced confusion regarding clinical checks and patient confidentiality, and had limited access to crucial drug history via the Welsh Clinical Portal, hindering safe prescribing.

Concerns summary Persistent ambulance delays and resource unavailability continue to put lives at risk, despite ongoing multi-agency efforts to address these long-standing issues.