Wales prevention of future deaths reports

Concerns summary The Welsh Ambulance Service experienced significant delays in allocating an ambulance for an urgent call, partly due to hospital handover delays. The number of funded ambulances appeared insufficient.

Concerns summary Widespread non-compliance with medication review targets and a lack of standardised review practices led to insufficient patient advice, increasing the risk of inadvertent overdose from combined medications.

Concerns summary Ambiguity in police officers' recognition and communication of Acute Behavioural Disturbance (ABD) during restraint potentially undermined critical 'Speak Up and Speak Out' principles in emergency situations.

Concerns summary Ambulance service instructions not to call back and inadequate welfare checks during delayed responses risk callers failing to recognize deterioration or feeling unable to re-contact emergency services, missing critical reassessment opportunities.

Concerns summary Insufficient information sharing, poor discharge planning, and delayed documentation transfer between the Health Board and private out-of-area psychiatric units were identified. The absence of written agreements for minimum standards and communication protocols creates a significant risk of future deaths.

Concerns summary The Coal Authority lacked accessible risk information, specific water safety policies, and effective inspection protocols, failing to address deep, fast-flowing water dangers and implement identified safety works.

Concerns summary Significant ambulance handover delays at hospitals are severely impacting emergency response times, causing patients to wait many hours for treatment or conveyance. These delays pose a critical risk to patient safety.

Concerns summary Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to acquire information and means to cause their own death.

Concerns summary A crucial ERCP referral was lost, with no investigation or learning by the Health Board, compounded by delays in electronic referral implementation, risking patient safety.

Concerns summary A deficient investigation and unfinalized transfer of care policy highlight systemic failures. Persistent reliance on paper-based mental health notes prevents wider access to critical patient information, risking future harm.

Concerns summary Human error led to critical first aid advice for a varicose vein bleed not being given during emergency calls, highlighting a risk of future deaths from handlers not following MPDS protocols.

Concerns summary Persistent and unacceptable ambulance delays, compounded by patient offload issues at emergency departments, are linked to a lack of local authority involvement in addressing social care deficiencies affecting patient flow.

Concerns summary Unacceptable and persistent ambulance delays, a problem worsening over ten years despite previous reports, demonstrate inadequate cohesive planning for both short-term pressures and long-term solutions.

Concerns summary Persistent ambulance delays stem from patient flow issues caused by social care deficiencies, leading to hospital handover delays. Insufficient collaboration between ambulance services, health boards, and local authorities continues to risk future deaths.

Concerns summary Significant ambulance response and hospital handover delays, extending over many hours, persist due to multifactorial issues including social care deficiencies and patient flow, posing a continued risk of future deaths.

Concerns summary The health board lacks a robust, documented policy for decision-making and care pathways when patients are referred to the Home Treatment Team.

Concerns summary The health board's internal investigations are too slow, with unrealistic action plans and missed deadlines, significantly delaying learning and preventing the timely implementation of safety improvements.

Concerns summary The Health Board demonstrates an evident lack of strategic direction for investigations and learning, with significant delays in implementing action plans following a death, risking recurrence of similar incidents.

Concerns summary Persistent and significant ambulance handover delays between the Welsh Ambulance Service and Health Board are causing ongoing deaths, with current improvements proving extremely limited.

Concerns summary Persistent staffing shortages lead to extensive waiting lists and assessment delays in mental health services, while interim support for low-risk patients is inadequate and lacks proactive monitoring.

Concerns summary There is a national lack of formal guidance and training for correlating missing person risk assessments with vehicle stop priorities, leading to dangerous mismatches and inappropriate response levels.

Concerns summary Ward understaffing, inadequate ward layout, and ineffective alarm systems prevented required observations for high-risk patients. There was no updated policy for managing enhanced care in single-room environments.

Concerns summary Ongoing insufficient ambulance resources in Gwent consistently result in unacceptable response times for Amber 1 patients, with chronological allocation lacking clinical consideration and ad hoc interventions not supported by policy.

Concerns summary Retailers fail to provide essential safety advice at the point of paddleboard sale, specifically regarding the mandatory wearing of life-saving equipment and appropriate leash usage for varying water conditions.

Concerns summary Nurses lack essential training in the Multifactorial Risk Assessment Process (MFRA) for falls, leading to newly qualified nurses managing patients without this critical safety knowledge.