2016

Concerns summary Unregulated private holiday swimming pools, non-standard pool design, and inadequate adult supervision ratios created significant safety hazards for children.

Concerns summary The ambulance service is critically under-resourced, operating frequently under severe capacity constraints due to high demand and recruitment issues, exacerbated by hospital handover delays.

Concerns summary Nursing staff performing catheter changes were unaware of the risk of air embolization from uncapped/unclamped catheters, and there was a lack of accessible guidance on this critical safety point.

Concerns summary Bus drivers transporting students are not required to have Basic Life Support training or emergency protocols, and BLS is not routinely taught in secondary education.

Concerns summary The road layout, safety notices, and barriers on a specific section of the A3075 are inadequate, posing a persistent risk of vehicles leaving the road.

Concerns summary Prison healthcare failed to adequately assess mental health, record vital information, or continue prescribed antidepressants. Delays in emergency response included slow 999 information, a nurse failing to acknowledge radio calls, and not immediately bringing a defibrillator.

Concerns summary Police left a vulnerable, injured person in an unsafe situation without awaiting an ambulance, leading to further assault. Ambulance dispatch algorithms are inaccurate, causing critical delays in response times for seriously injured patients.

Concerns summary An acutely unwell patient was admitted to a private hospital lacking HDU/ITU facilities and emergency protocols. Chest drain insertion was performed against guidelines, without appropriate imaging or confirmation of its position, delaying critical haemothorax management.

Concerns summary There was a failure to issue a Code Blue appropriately, a lack of understanding about its emergency consequences, and a failure to use an available defibrillator.

Concerns summary A junction has a history of multiple fatalities, but proposed remedial safety works lack funding and commencement dates. There are also concerns about the national speed limit on the approach and insufficient warning signs.

Concerns summary Illegible clinical records and incomplete documentation create a serious risk of communication breakdown and misinformation within patient care pathways.

Concerns summary The Orwell Bridge has easily accessible walkways with a low concrete wall offering inadequate fall prevention. There are no physical deterrents or handholds, posing a significant risk of falls that has led to multiple deaths.

Concerns summary Rib fractures and a subsequent haemothorax were not identified on admission, leading to undetected blood accumulation and death during a chest drain insertion procedure.

Concerns summary A lack of acute mental health facilities in Powys forces patients to be moved far from home, causing discontinuity of care and negatively impacting patient engagement, thus increasing self-harm and suicide risk.

Concerns summary Incomplete documentation and a care assistant's failure to adhere to observation policy for a vulnerable patient led to an unwitnessed fall. There was also a complete lack of documentation for specialling observations, contravening Trust and national policies.

Concerns summary The road surface had a crumbling edge, pothole, and debris, which may have contributed to a loss of control. Review and remedial action on these road conditions are needed.

Concerns summary Healthcare complex case planning was inadequate and not updated, multi-disciplinary meetings lacked formalisation and information access, and a prior overdose was not investigated as a safeguarding opportunity.

Concerns summary The A66's varied road standard, including single carriageway sections, is inadequate for high traffic volumes, particularly HGVs, leading to head-on collisions; it should be dual carriageway throughout.

Concerns summary Windows in Morlais Ward service user areas are not ligature-free, posing a safety risk, and planned remedial work has not yet been completed.

Concerns summary Pentobarbital, a Schedule 3 drug, is frequently used in suicides due to less strict controls; stricter regulation could reduce suicide rates.

Concerns summary A high-risk service user lacked a smoke detector in his bedroom; social workers failed to assess or address this significant fire safety risk.

Concerns summary Dangerous plant growth on a central reservation severely restricted driver visibility at a junction, requiring regular maintenance and review of similar junctions.

Concerns summary A patient was discharged without a discharge letter or prescribed antibiotics being provided to his GP or care staff, leaving them unaware of his medication needs.

Concerns summary A nationwide shortage of neurologists leads to significant delays in accessing specialist care, including long outpatient waiting times and lack of out-of-hours neurological expertise in some hospitals.