Wales prevention of future deaths reports

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 Waterfall signage is inadequate, poorly placed, and lacks clear, concise warnings about water dangers, particularly for non-swimmers, contributing to a lack of awareness of potential drowning risks.

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 The distribution of ligature cutters to frontline police officers remains incomplete, posing a risk in emergency situations. Additionally, bespoke training for officers responding to mental health crisis incidents is not widely available.

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 Inadequate and unclear signage at a waterfall location fails to explicitly warn visitors of drowning risks. Furthermore, responsibility for safety in this multi-jurisdictional area is poorly defined.

Concerns summary Crisis team actions were poorly monitored and falsely marked as complete, and significant procedures were communicated inappropriately. A lack of clear re-entry routes for vulnerable discharged patients revealed poor inter-service information sharing.

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 Longstanding ambulance delays, caused by high-acuity incidents and significant hospital handover issues, pose a continuing risk of future deaths for patients awaiting emergency care.

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 Multiple prescribing and dispensing errors occurred due to an electronic prescribing tool that allowed bypassing allergy checks and a lack of specific knowledge about constituent drugs among prescribers and pharmacists.

Concerns summary Highway safety risks exist for pedestrians crossing a 60mph road from a canal towpath, compounded by quiet electric cars, earphone use, and sun glare, increasing accident reoccurrence.

Concerns summary Repeated failures to conduct Multifactorial Risk Assessments for a known falls risk patient, despite multiple falls and transfers, were not addressed by previous action plans or staff accountability.

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 Clinicians lacked access to comprehensive patient records from community care and the unit's internal records were fragmented, impairing assessment, observation setting, and safeguarding measures.

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 A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading of prescribed medication, posing a significant risk to prisoner safety.

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.