Wales prevention of future deaths reports

Concerns summary Critical fluid balance monitoring for a patient with severe cardiovascular and renal issues, complicated by sepsis, was entirely neglected by both nursing and medical staff.

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 absence of legal restrictions on newly qualified and young drivers carrying multiple young passengers significantly increases collision risk, leading to concerns about future deaths.

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 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 Incorrect NEWS score calculation and subsequent failure to follow observation protocols led to missed recognition of a deteriorating patient, delaying senior medical review and putting lives at risk.

Concerns summary Persistent lengthy ambulance response delays for critical emergencies are caused by acute hospitals failing to promptly release ambulances, despite ongoing efforts, directly contributing to patient deaths.

Concerns summary The Health Board's investigations are consistently of poor quality, ineffective, and untimely, failing to identify and address care omissions or implement learning promptly, leading to recurring patient safety risks.

Concerns summary The Health Board's investigations into care failings lack accountability for staff and suffer from incomprehensible delays in implementing identified actions, perpetuating ongoing risks to patient safety.

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.

Concerns summary The In-Patient Medication Administration Record and A&E Record Card fail to document medication prescription times, only administration. This lack of recorded prescription times hinders checks for timely delivery and cross-referencing.

Concerns summary Paramedics do not routinely carry flumazenil, an antagonist that could be life-saving in acute circumstances, highlighting a potential gap in emergency medical equipment and protocols.

Concerns summary Critical abnormal blood results were not promptly documented or actioned in the emergency department due to a lack of electronic alert systems and over-reliance on unreliable verbal communication.

Concerns summary Critical staff training on timely escalation and maintaining fluid balance charts is not fully rolled out due to resource issues, nor is it compulsory, leaving a significant learning gap.

Concerns summary An extreme 9-hour ambulance delay for a patient with a life-threatening emergency, partly caused by hospital handover issues, resulted in her death before paramedics arrived.

Concerns summary Oxygen cylinders with a confusing two-valve system led to delayed oxygen delivery during resuscitation. Despite repeated incidents and training, the design remains unsafe for high-pressure medical emergencies.

Concerns summary The Approved Mental Health Practitioner service repeatedly failed to conduct legally compliant Mental Health Act assessments, including insufficient collateral information gathering and inadequate medical attendance, despite family requests.

Concerns summary There is inadequate knowledge within the Health Board, including clinical and nursing staff, regarding the correct use and operation of the Adult Critical Care Service Cymru for urgent patient transfers.

Concerns summary Critical failures included poor communication between healthcare and prison, inadequate discharge planning, lack of staff escort during transfer, and insufficient prison resources or policies for complex patient needs. Staff were also fatigued and felt unable to raise concerns.

Concerns summary The Trust failed to investigate all inpatient falls, including the one contributing to death, preventing learning and reassurance about future prevention measures.

Concerns summary Paramedics are unable to administer rapid-acting analgesics like mucosal fentanyl lozenge due to controlled drug legislation, potentially delaying critical pain relief and extrication.

Concerns summary Significant ambulance and hospital offload delays, far exceeding targets, led to the formation and exacerbation of a pressure sore due to prolonged patient immobility.

Concerns summary A miscommunication due to an inadequate bleep system caused critical delays in administering medication, leading to patient deterioration. The system's inability to electronically convey information risked proper task prioritization.

Concerns summary Junior doctors may not feel able to challenge consultant opinions, risking missed diagnoses. The Health Board also lacked adequate systems for urgent complaints and failed to conduct a full, timely investigation into the death.

Concerns summary The Scouts Association lacks a culture of candour and independent regulatory oversight for safety and safeguarding. A critical internal Fatal Accident Inquiry Panel Report was not completed in a timely manner, hindering learning.