Wales prevention of future deaths reports

Concerns summary Failures in consent processes, misleading risk information, premature discharge, and significant delays in triage, escalation, fluid/antibiotic administration, and critical care admission collectively led to sepsis complications.

Concerns summary A&E consultants and agency nurses lacked adequate training in paediatric sepsis identification and management, including using risk stratification tools and appropriate terminology. Failures were noted in considering alternative antibiotic administration methods.

Concerns summary There is no national NICE guidance on Acute Behavioural Disturbance, which is vital for emergency services and police, contributing to a rising number of related deaths.

Concerns summary The Scout Association failed to implement or ensure understanding of critical safety policies, including risk assessments and leadership oversight, for an organised trip, directly endangering young people.

Concerns summary Police misinterpreted Section 136 of the Mental Health Act, believing they lacked power to detain a suicidal individual in a hotel room. This highlights a need for clearer guidance on how such temporary accommodations are classified under the Act.

Concerns summary Paramedics failed to pre-alert the hospital about suspected sepsis due to discretionary policy. They also could not administer vital antibiotics, and did not escalate concerns about patient condition or admission delays.

Concerns summary Motorcyclists using Trelai Park as an unfettered racing area pose a significant safety risk to the general public, particularly children and the elderly.

Concerns summary Concerns exist regarding the continuing accessibility and use of novel psychoactive substances (NPS) within HMP Berwyn, posing significant health risks and a high probability of future deaths.

Concerns summary Repeated cancellation of consultant psychiatrist appointments without clinical input on patient urgency meant individuals at serious need could "fall through the net," as a preventative system was not yet operational.

Concerns summary Patients on finite oxygen supplies risk being unmonitored; oxygen administration training is incomplete, and there are no formal procedures for tracking oxygen expiry times. The root cause analysis was also deficient.

Concerns summary Missed opportunities for a CT scan and lack of a system for overnight consultants to authorise scans contributed to delayed diagnosis and potentially preventable death.

Concerns summary Persistent, unacceptable delays in patient handover at emergency departments and prolonged ambulance waits continue to put patients' lives at risk by delaying timely medical intervention, despite previous assurances.

Concerns summary Ambulance call scripting for seizures is inadequate, failing to ascertain fit duration for correct callback advice and lacking clear protocols for urgent upgrades when airways are compromised. There's also no pathway for updating prison staff or facilitating dialogue with hospital EDs on call categorisation.

Concerns summary Gateway assessors had incomplete access to patient notes, potentially resulting in inadequate assessments and treatment plans due to missing critical information.

Concerns summary Gateway assessors lacked full access to patient notes, risking incomplete assessments and treatment plans based on insufficient information.

Concerns summary The care home had incomplete staff falls training, incorrectly categorised a high-risk patient as medium, and lacked a policy for reassessment following multiple falls.

Concerns summary Inconsistent and inadequate nursing documentation for FACE records and NEWS charts, missed observations, ad hoc ECG request systems, and poor detail in patient observation charts indicate significant training and procedural failures.

Concerns summary The improvement plan failed to address specific issues, and there's no dedicated pathway for urgent clinical discussions between external healthcare professionals and ambulance staff to ensure proper assessment of response urgency.

Concerns summary Complex polypharmacy involving Clozapine led to severe side effects and potential misinterpretation of overdose symptoms, while a possible contraindicating familial lipid disorder was not confirmed.

Concerns summary Inadequate bed rail safety was due to incorrect mattress use, poor staff training, absent risk assessments and policies, and delays in care plan completion. There was also a failure to inform families of medically relevant events.

Concerns summary Lack of appropriate support channels for high-profile individuals removed from government positions, especially concerning media interest and potential mental vulnerabilities.

Concerns summary Inefficient and outdated neurosurgical referral systems, relying on switchboards and bleeps, cause delays and miscommunications, with no backup for busy on-call doctors. Modern digital solutions are available but not utilized.

Concerns summary There was no overarching risk management plan for patient care, coupled with deficiencies in record-keeping, including outdated strategies and poor preservation of handover information.

Concerns summary A dysfunctional team exhibited unclear clinical leadership, poor CTG interpretation and communication, inadequate record-keeping, and insufficient staffing, with junior staff unable to challenge decisions.

Concerns summary Paramedics lacked awareness and training regarding the dangers of administering anticoagulants like Rivaroxaban to elderly fall patients with head injuries, requiring enhanced caution.