Wales prevention of future deaths reports

Concerns summary Critical ambulance delays, exacerbated by significant hospital handover issues and a lack of social care, lead to patients awaiting discharge, blocking emergency departments and severely jeopardizing lives.

Concerns summary The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete records. Learning from the investigation was poorly shared and lacked context, hindering genuine organizational change.

Concerns summary During hospital admission, there was a prolonged failure to address the patient's inadequate nutritional intake, including neglecting family concerns, not monitoring diet, and delaying proper nutritional intervention despite signs of malnutrition.

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 Unregulated online pharmacies easily sell prescription-only and controlled drugs, lacking patient verification, dosage guidance, and safeguards against misuse, exposing vulnerable individuals to unsafe medications.

Concerns summary Reduced visibility, permissible right turns from a parking bay, and speed limits on a particular road create a high risk of collisions. Planned speed reductions may not fully mitigate this.

Concerns summary The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in missed critical patient information.

Concerns summary Obstructed visibility at a road junction and high traffic speeds following a speed limit change create an ongoing risk of serious collisions and potential fatalities.

Concerns summary The Perinatal Mental Health Service suffers from insufficient awareness among health professionals, inadequate staffing levels, and a lack of documented decisions and discussions in patient records at the Single Point of Access.

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 There was an absence of formal documented processes and record-keeping for inter-hospital referrals, discussions, and the subsequent advice and actions taken.

Concerns summary Ambulance call handlers failed to clinically override the dispatch system's categorization, maintaining a low priority despite clear evidence of the patient's severe, deteriorating, and unmonitored condition.

Concerns summary The easy accessibility of electric motors and parts enables the conversion of pedal bicycles into high-powered, throttle-controlled scooters, posing dangers to both riders and the public.

Concerns summary Cheshire Police had confused report management with no officer acknowledgement system and significant delays in delivering critical ANPR/Vehicle Finder system training to control room staff.

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 A dangerous 5.75-mile stretch of the A48 road, with varying speeds and no dedicated cyclist safety infrastructure, has a high number of fatal and serious collisions, particularly for cyclists.

Concerns summary There was a lack of documented post-leave assessments for a patient with a known risk of ingesting vegetation, alongside staff confusion regarding assessment requirements and documentation standards.

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 A taxi firm's training on driver duty of care and safety protocols for vulnerable passengers is inadequate, as a driver would repeat leaving a passenger in an unsafe location and police contact protocols were not followed.

Concerns summary The Medical Priority Dispatch System (MPDS) for ambulance calls, designed years ago, is failing to meet current response targets due to resource issues, raising concerns that lives are being put at risk by outdated prioritization.

Concerns summary A clinician prescribed a sedative without reviewing the patient's full medical records, leading to unawareness of her enhanced falls risk and demonstrating a risk of prescribing without adequate patient context.