Wales prevention of future deaths reports

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.

Concerns summary Internal hospital referrals were paper-based and not promptly integrated into patient notes, leaving busy clinicians without immediate access to complete patient referral information.

Concerns summary A lack of mandatory radio communication between ground crew and glider pilots meant observed glider problems before launch were not communicated. This ongoing absence of mandatory radio use poses a future risk to lives.

Concerns summary The Health Board failed to implement a beneficial medical protocol and delayed approving critical risk mitigation procedures for diagnostic results, despite setting their own deadlines, thereby putting lives at risk.

Concerns summary Medical centre reception staff failed to adequately assess a distressed patient's urgent mental health needs, not providing an emergency appointment or clinical callback, raising concerns about future risk to patients.

Concerns summary The failure to replace old-style road barriers with modern, safer alternatives creates an ongoing risk of further deaths and serious injuries.

Concerns summary An inadequate nasogastric tube feeding regime resulted in inconsistent calorie intake, compromising the patient's ability to fight infection.

Concerns summary Concerns include uncertainty over toxicology screening, delays in updating critical blood result communication protocols, and systemic failures in investigating and learning from adverse incidents.

Concerns summary Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for patient observations, posing a risk to future patients due to insufficient monitoring.

Concerns summary An uneven pedestrian pavement creates a future fall risk, particularly for elderly individuals with reduced mobility.

Concerns summary A vehicle should have been taken out of service due to multiple safety defects, including worn tyres and a fractured arm pivot, but remained in use after an inspection.

Concerns summary Mental Health Services failed to adequately protect a patient with an immediate self-harm plan, making no attempt to contact her or reinforce available crisis options.

Concerns summary Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess patient fall risk correctly, and were unaware of learning opportunities.

Concerns summary The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious incident reviews, which limits learning and partnership working for community-supervised patients.

Concerns summary An opportunity was missed to assess an elderly driver's fitness after a previous collision, highlighting the need for robust driver referral schemes to take unsafe drivers off the road.

Concerns summary Delays in emergency department arrival for acute stroke patients may delay critical treatment, raising concerns about stroke patient categorisation, specific time targets, and ambulance service resources.

Concerns summary Excessive ambulance waiting times (2 hours) without informing the family of estimated arrival, coupled with significant hospital patient transfer delays, prevented ambulances from being released for other emergencies.

Concerns summary Welsh prisons lack an integrated treatment system, failing to automatically offer opiate substitution therapy to new arrivals addicted to opiates, creating an inequality in healthcare provision compared to England.

Concerns summary Failures in checking medical records upon prison admission led to missed antidepressant medication, exacerbated by staff shortages, heavy workloads, and the absence of a "red flag" warning system for suicide risk.

Concerns summary A lack of protocol for assessing locum staff's practical skills and managerial reluctance to thoroughly check references created risks that locums might perform tasks beyond their capabilities.