2024

Concerns summary There is open, unwarned access to a dangerous wooded area with a significant drop, posing an ongoing risk of serious injury due to lack of barriers or warning signs.

Concerns summary A significantly delayed and incomplete patient safety investigation failed to adequately address systemic failures in anticoagulant administration and capacity assessments across hospital transfers, hindering timely learning and comprehensive training.

Concerns summary Failures in communication between police forces led to a significant delay in conducting a welfare check, raising concerns about avoidable fatalities in future cases.

Concerns summary There is a critical and long-standing national and local shortage of suitable placements for high-risk children with complex mental health needs.

Concerns summary The Health Board's investigations are consistently of poor quality, ineffective, and untimely, failing to identify and address care omissions or implement learning promptly, leading to recurring patient safety risks.

Concerns summary Poor communication between care agencies, an under-resourced district nursing team lacking clinical curiosity, and carers failing to challenge poor patient decisions led to severe health deterioration and inadequate living conditions.

Concerns summary Clinicians lack a central resource to identify medications increasing suicidal behaviour, call recordings for remote interactions are limited, and there were significant delays in accessing mental health services and medication reviews despite escalating patient distress.

Concerns summary A culture within midwifery led to delayed action and an assumption of benign causes for antepartum haemorrhage (APH), with established guidance not followed, representing a regional and potentially national concern.

Concerns summary Prison staff failed to escalate or monitor a prisoner's reported refusal of food and fluids, highlighting a national absence of formal policy for monitoring prisoner meal collection.

Concerns summary Hospital policy regarding bed rail erection before falls assessment is routinely ignored, and procedures for ensuring call bells are functional are inadequate.

Concerns summary Despite capnography being the gold standard for tracheal tube placement, its universal endorsement and dissemination are lacking, with previous PFD reports on unrecognised oesophageal intubation failing to prompt necessary changes.

Concerns summary Lack of night-time healthcare in prison means untrained officers manage intoxicated prisoners without clear guidance, compounded by inconsistent information sharing policies between healthcare and prison staff regarding medication and risk.

Concerns summary The Health Board's investigations into care failings lack accountability for staff and suffer from incomprehensible delays in implementing identified actions, perpetuating ongoing risks to patient safety.

Concerns summary Further research is needed to confirm or refute whether Clozapine materially increases the risk of patients developing certain blood cancers, given international study suggestions.

Concerns summary HSE guidance and support materials lack clear images and instructions for drivers on safely loading and unloading overhanging bales on slopes, particularly concerning widthways loading and centre of gravity risks.

Concerns summary The unit experienced widespread poor record-keeping, inadequate observation chart entries, and a rising trend of missed and falsified observations, indicating a failure to adhere to critical safety protocols despite training and previous PFD reports.

Concerns summary A book detailing suicide methods is freely available on Amazon UK, and existing legislative frameworks, including the Suicide Act and Online Safety Act, appear ineffective in preventing its marketing and supply.

Concerns summary Excessively long national waiting lists for heart treatment, particularly for patients with weakened heart muscles due to long-term steroid use, pose a fatal risk despite local improvements.

Concerns summary Significant national backlogs for cardiology appointments cause patients to wait over 40 weeks, delaying specialist input and increasing the risk of complications and death.

Concerns summary Inadequate and poorly placed warning signs for a flood-prone ford, coupled with insufficient and delayed road closure measures, failed to prevent incidents and posed a significant risk to road users.

Concerns summary Hospital doctors lacked access to crucial GP records for out-of-area patients due to IT system differences, and a practitioner failed to arrange appropriate follow-up despite the patient's history.

Concerns summary Frequent patient transfers between overcrowded wards and the routine use of "escalation beds" in corridors led to breaks in care continuity and increased risk, highlighting systemic hospital capacity issues.

Concerns summary The railway station, a known location for suicides, met the 'hotspot' criteria with three incidents in 12 months, despite previous categorisation suggesting otherwise.

Concerns summary Clinicians relied on potentially misleading guidance to prescribe aripiprazole as a monotherapy for bipolar disorder, which was ineffective in protecting the patient from depressive relapse.

Concerns summary Police lacked adequate understanding, training, and procedures for responding to automated car crash alerts from electronic devices, leading to delayed response and potential risk to life.