Wales prevention of future deaths reports

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.

Concerns summary The family and patient lacked understanding of specific sepsis signs, delaying emergency intervention. Distributing information cards on sepsis to at-risk patients in the community could prevent future delayed recognition and response.

Concerns summary Medication cupboard keys were left in easily accessible, unlocked locations nearby, compromising medication security and creating a significant risk of service users accessing and misusing drugs.

Concerns summary There was a critical failure in emergency response, with ambulance services delaying attendance for a gravely ill patient deemed low priority despite severe pain. Out-of-hours GP services also failed to provide adequate advice, pain relief, or expedite hospital admission.

Concerns summary Ambulance availability is critically low for inter-hospital transfers due to bed blocking and a lack of community care. Implementation of crucial reviews for intra-hospital transfers, vascular emergency pathways, and an ambulance handover plan has been unacceptably slow.

Concerns summary The A48 'Forage roundabout junction' is deemed dangerous, requiring urgent changes to enhance road user awareness and implement traffic calming measures to prevent further fatalities.

Concerns summary A dangerous road junction with poor visibility, exacerbated by school traffic, requires safety improvements to prevent further deaths from high-speed driving.

Concerns summary The deceased fell between two non-communicating care teams (mental health and ENT), leading to insufficient support and an inability to resolve his complex health problems.

Concerns summary A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory policy. This indicates a failure in training regarding the revised ACCT procedures for prisoners at risk of self-harm.

Concerns summary The ambulance categorization process failed to account for the clinical risks of a long lie for an elderly patient. A 12-hour delay in ambulance arrival for a serious condition contributed to the patient's death, highlighting systemic risks.

Concerns summary Obstructed visibility from a hedge at a road junction (Green Lane onto A525) creates an ongoing risk of future vehicle collisions and potential loss of life.

Concerns summary Emergency call handling failed to appropriately categorise a time-critical overdose due to protocol shortcomings and clinical misjudgment, leading to significant delays and inconsistent response vehicle deployment.

Concerns summary A critical shortage of residential and nursing placements in Gwynedd prevents elderly patients from accessing appropriate care as their needs evolve, posing a risk to their well-being.

Concerns summary A significant 3-hour delay in ambulance response for a severely injured elderly patient highlights ongoing issues in timely emergency medical care, potentially risking future deaths.

Concerns summary A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged without adequate information or support regarding complex medical conditions.

Concerns summary Communication errors led to delayed ambulance calls and incorrect patient preparation. The hospital lacks robust processes for documenting/chasing emergency ambulances, clear NBM protocols, and joint registrar consultation for common conditions like bowel obstructions.

Concerns summary Urgent investigations into an artificial stall warning for the Hawk Mk 1 aircraft, which can stall without warning, are stalled. The training simulator also inaccurately models the aircraft with a smoke pod.

Concerns summary The prison control room delayed relaying critical information to the ambulance service, and a lack of direct communication between emergency operators and prison first responders hindered resuscitation efforts.

Concerns summary Immigration Officers receive an introduction to pursuit policy but lack specific training in pursuit procedures and decision-making during stressful pursuit situations.

Concerns summary The university's examination results system is complex and misleading, with provisional passes and pending marks causing confusion. There is also no system for personal tutors to proactively contact vulnerable students before releasing failed results.

Concerns summary University students face lengthy delays accessing mental health support, even when expressing suicidal ideation and having known risk factors like ASD.

Concerns summary The Health Board consistently fails to implement its own action plan recommendations and address concerns within set timeframes, leading to ongoing risks to patient lives.