11 unexpected deaths among incidents reported by board
UNEXPECTED deaths of 11 patients known to mental health services are among the serious incidents Cardiff and Vale NHS has reported to Welsh Government.
Cardiff and Vale University Health Board says it is thought the coroner is likely to conclude suicide in three of the patients’ deaths, while the circumstances for the deaths of the remaining eight patients are not yet confirmed.
Their deaths were among 76 serious incidents the health board has reported to Welsh Government in September and October. A total of 47 of those serious incidents related to pressure ulcers across several services and departments of the hospital board.
Work has been done with district nurses to improve the reporting of pressure damage in community care settings, which is contributing to the number of related serious incidents being reported, a health board report says. The health board reported eight falls where patients suffered significant injuries.
A patient had an incorrect lens inserted during a ophthalmology procedure on their eye. The procedure was being managed by an external provider commissioned by the health board.
This incident is now being treated as a “never event” – classed as a serious, largely preventable and should not have happened.
In another incident reported to Welsh Government, a patient was discharged from a ward and unexpectedly readmitted five days later – and died following his readmission.
An incident of “significant” selfharm to a patient who required admission to acute services to tend to her physical wellbeing, prior to transfer to Hafan Y Coed mental health unit, was also reported to Welsh Government.
Cardiff and Vale University Health Board report all serious incidents to the Welsh Government, the public and to its board members. Welsh Government guidance also requires the health board to report unexpected deaths of patients who are known to mental health services and die unexpectedly or experience serious harm in a community setting.
A health board spokeswoman said: “Patients and their families are made aware of incidents and are kept informed during investigations and discussions with our clinical teams.
“The increased reporting of pressure damage reflects a period of education and training of staff to improve the quality of data being recorded. All incidents are fully investigated and appropriate actions are taken to reduce the risk of recurrence in the future.
“This enables clinical boards and the corporate teams to identify areas of good practice but also to identify emerging trends and issues that require action in order to improve safety and quality of services.”
■ ‘Patient’s human rights compromised’: Page 16