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The Wales Ergonomics and Safer Patients Alliance (WESPA) was formed in response to supporting the NHS during the COVID-19 pandemic. WESPA comprises early career and senior researchers from across Cardiff University (Business, Engineering, Mathematics, Medicine) with expertise in operations management, human factors and resilience engineering. We work closely with NHS professionals (clinicians, managers and executives) to model how the design of health services impact on staff and patient outcomes. WESPA's primary aim is to carry out applied research driven by clinical need by drawing upon research expertise from across Cardiff University to enable innovation and implementation of practices to improve patient safety in the NHS, by: Partnering with NHS organisations, and working directly with NHS staff, to identify improvement priorities, it will: - embed researchers-in-residence to analyse patient safety data and observe in clinical settings; - build capability to develop data infrastructures that promote timely organisational learning to inform service design, planning and management; - evaluate models of service delivery to identify where and how the service can be designed / redesigned to improve staff and patient outcomes. Leading engagement activities with key stakeholders – healthcare professionals, managers, executives, patients, services users and the public – to gain timely feedback on our research findings. Facilitating co-production activities in the NHS to maximise understanding of human factors influencing staff and patient outcomes. Engaging with the third sector and other organisations with the purpose of influencing policy and achieving impact in the NHS. Research Development and testing of methodological approaches to apply human factors theory, principles and tools in the NHS to understand and learn from complex socio-technical systems; Identification of opportunities for health systems improvement from analysis of routine patient safety data; and, Understanding complex systems by modelling and quantifying variability using the Functional Resonance Analysis Method (FRAM).

Internationally there is recognition that a holistic quality management system (QMS) approach will enable healthcare organisations to meet the needs of their populations and continuously improve the care and experience provided. In NHS Wales, the Duty of Quality was introduced in 2023 through the Health and Social Care (Quality and Engagement) (Wales) Act 20201 and requires Welsh NHS bodies to establish an effective QMS where appropriate focus is placed upon Quality Control, Quality Planning, Quality Improvement and Quality Assurance The 90-day cycle methodology was used to explore how high performing organisations manage for quality – identifying universal findings across all the organisations, a summary of what a QMS can achieve and the importance of the role of the Board. The findings informed the development of a QMS Framework for healthcare which has supported the development of the Duty of Quality and includes: A definition of quality: Continuously, reliably and sustainably meeting the needs of the population that we serve (aligned to the Duty of Quality). A definition of QMS for NHS Wales: An operating framework to continuously, reliably and sustainably meet the needs of the population we serve. Descriptions of the four aspects within a QMS: Quality Planning, Quality Improvement, Quality Control and Quality Assurance and examples of tools and resources that can be used to support their implementation. Descriptions of the organisation enablers for a QMS: leadership, workforce and culture; learning, improvement and research; whole system approach; and, information (aligned to the Duty of Quality Standards). A methodology to implement and embed a QMS: an adaptation of Quality as an Organisational Strategy (QOS) informed by the experience of piloting the approach at directorate and organisation level.

PROMPT (Practical Obstetric Multi-Professional Training) is an evidence-based training package for local maternity staff, previously associated with improvements in maternal and neonatal outcomes, reduction in litigation related to preventable harm and improved safety culture. PROMPT has previously been disseminated internationally using a train-the-trainer model. However, this has been associated with variations in uptake, fidelity and impact. In Wales, the project was supported by Welsh Government, and a structured scaling plan was developed, encompassing ongoing implementation support from a multi-professional team. This study describes the approach and process measures for national scaling of PROMPT across 12 obstetric-led maternity units in Wales.

The Public Services Ombudsman for Wales has powers under the Public Services Ombudsman (Wales) Act 2019 to undertake ‘Own Initiative’ investigations, where evidence suggests that there may be systemic service failure or maladministration. Four local authorities were included in the investigation: Caerphilly County Borough Council, Ceredigion County Council, Flintshire County Council and Neath Port Talbot Council. The investigation considered: Whether the local authorities being investigated were meeting their statutory duties under the Social Services and Well-being (Wales) Act 2014 and its Code of Practice and The Care and Support (Assessment) (Wales) Regulations 2015. Whether those entitled to a carer’s needs assessment were being made aware and understand their right to request a carer’s needs assessment. Where carers’ needs assessments are commissioned, whether those assessment services are being delivered appropriately and whether local authorities appropriately monitor the contracting arrangements. Whether carers’ needs assessments, including those completed by commissioned service providers, are undertaken in accordance with the Social Services and Well being (Wales) Act 2014. The investigation considered evidence provided by each of the Investigated Authorities, in the form of documentary evidence and evidence from staff, evidence from commissioned service providers and their staff, evidence from those with lived experience of having their needs as carers assessed and evidence from other organisations. Advice was also sought from one of the Ombudsman’s professional advisers The investigation found: Between 10% and 12% of the population (over 5 years old) in the Investigated Authorities identified as a carer in the 2021 Census. Only 2.8% of the carer population in the Investigated Authorities had their needs assessed. Only 1.5% of the carer population in the Investigated Authorities had an assessment that led to a support plan. Many carers are not aware of their rights and are unaware of the support that may be available to them. There was evidence of carers not being fully informed of their rights by the Investigated Authorities. In some instances, carers were signposted to commissioned service providers without being informed of their rights. Carers’ needs assessments are referred to by different names, which caused confusion amongst carers and carers were sometimes unaware that their needs had been assessed. There needs to be consistency in the language used. There is lack of clear information about the process of assessment, the role of commissioned service providers (where applicable), what carers may expect from the assessment and how carers may be supported following an assessment. This would enable carers to make an informed decision about whether to have their needs assessed. Where they are undertaken, carers’ needs assessments at the Investigated Authorities are generally being completed appropriately, with the exception of young carers’ needs assessments in Ceredigion and Neath Port Talbot. Some improvements could be made to the recording of carers’ needs assessments, including the involvement of the cared for person (where feasible), the extent the carer is able and willing to provide care and the carer’s wishes in terms of work, education, training and leisure. There is a need to implement quality assurance audit processes for completed carers’ needs assessments in Caerphilly, Ceredigion and Neath Port Talbot council areas. There are discrepancies between the Investigated Authorities in the way that support provided to carers is recorded. Improved, consistent and comparable data collection could enable better analysis to drive improvement, monitor progress and identify areas in which further improvements are necessary. Carers must be offered advocacy – the decision on whether an advocate is needed is not one for the staff completing assessments to make, nor is it appropriate for the staff member to consider themself to be the advocate. The appropriateness of Direct Payments for carers is variable and 3 of the Investigated Authorities need to ensure that Direct Payments are something the carer is able to manage, with this being reviewed if circumstances change. The SSWB Act places a duty on both local authorities and health services in respect of carers. Collaboration and joint working between health services and local authorities in relation to carers and their rights is essential and should be strengthened. The recording of equality data relating to carers is limited and inconsistent at the Investigated Authorities.

David Colin Strachan was aged 76 years when he died on 16 March 2022 at his home address in Uangollen, Denbighshire. At 23.20 hours on 15 March 2022, he experienced a sudden onset of chest pain, vomiting and became clammy with shortness of breath. A number of 999 calls were made to the Welsh Ambulance Service but it was not until 9.10am, some 9 hours and 52 hours from the initial call that an ambulance and paramedics arrived. An ECG by paramedics indicated that Mr Strachan had suffered an ST elevation myocardial infarction. He was conveyed directly to the North Wales Cardiac Centre at Ysbyty Gian Clwyd and following investigations he was transferred to the Coronary Care Unit. On arrival his breathing weakened and he died at 12.27pm on 16 March 2022 in hospital. The cause of death was recorded as: 1a. Acute myocardial infarction 1b. Coronary artery atheroma. Coroner's Matters of Concern: The causes of the ambulance delay were that all available resources were managing incidents of a higher acuity or the same category but registered prior and there were significant handover delays across all BCUHB sites. The matters of concern are longstanding and multifactorial and despite proposed future action significant concerns remain. The Welsh Ambulance Service NHS Trust and Health Board maintain that they are continuing to work closely in border to address handover delays and yet any improvements appear extremely limiting. Deaths are occurring and will continue to occur as a result of delayed ambulance attendances caused by these multifactorial issues.

At Patient Safety Learning we often get asked by patients and families who have received poor healthcare what they need to do to make a complaint. Although we cannot get directly involved in individual cases, we have put together a simple guides on the steps you can take if you need to make a complaint about NHS care in Wales. We also have the following guides: How do I make a complaint about my NHS care in England: a simple guide for patients and families How do I make a complaint about my NHS care Northern Ireland: a simple guide for patients and families How do I make a complaint about my NHS care in Scotland: a simple guide for patients and families How do I make a complaint about my private care: a simple guide for patients and families How do I make a complaint: Sources of help and advice If you are a healthcare professional looking at these pages, the NHS Complaint Standards, model complaint handling procedure and good complaint handling guides set out how organisations providing NHS services should approach complaint handling. They apply to all NHS organisations in England and independent healthcare providers who deliver NHS-funded care. Since April 2011, the NHS Complaints Procedure in Wales has been replaced by a new system called Putting Things Right. A complaint under this new system is defined as a ‘concern’. This is when you feel unhappy about any service provided and funded by the NHS, which includes treatment funded by the NHS in Wales, even if this is provided in England. This may result in you having your concerns investigated, the offer of an apology or improvement of services. Step 1: Raising a concern If you feel able to do so, in the first instance you should try and speak to the staff who were involved in providing your care. This may enable your concerns to be resolved immediately. If this does not resolve your concerns or you do not feel able to speak to the staff, then you can contact a member of the concerns team at the NHS trust or your local health board. If your concern relates to primary care (a GP, dentist, pharmacist or optician), you can either raise your concern with the primary healthcare provider directly or contact your local health board to investigate your concerns. You should raise your concern within 12 months of the incident happening, but ideally as soon after the event as possible, so that the details are still fresh in your mind. Even if more than 12 months have passed, if there are valid reasons for the delay, such as coping with a bereavement or illness, the organisation may still agree to investigate your concerns. If you need assistance with raising your concern, you can contact Llais. Llais is an independent body which provides free and confidential complaints advocacy and support. Step 2: Public Services Ombudsman for Wales If you are not satisfied with the outcome of the investigation, you have the right to take your complaint to the Public Services Ombudsman. The Public Services Ombudsman for Wales has legal powers to look into complaints about public services in Wales, which include health boards, NHS trusts and GP services. The Ombudsman can investigate concerns where you feel you have been treated unfairly or have received an unsatisfactory service due to a failure on the part of a public service provider. You will normally be expected to make a complaint within 12 months of becoming aware of the problem. However, the Ombudsman will consider how much time the healthcare provider in question has spent dealing with your initial concern. If you feel that you have experienced medical harm, further investigations may need to be undertaken as part of NHS Redress arrangements. Step 3: Redress and compensation Redress relates to situations where you may have experienced harm as a result of your treatment. Redress is made up of either one or a combination of all of the following: An explanation. A written apology. A report on the action which has or will be taken to prevent similar incidents happening in future. An offer of financial compensation and/or remedial treatment (remedial treatment refers to medical treatment which is offered to you to try and restore you— as near as possible—to the position you would have been in had the medical harm not occurred.). Financial redress can only be considered if it is proven that the NHS organisation has failed in its duty of care and that that failure has caused the harm. This is also the case for pursuing a civil claim for negligence. Payment of financial redress will only be considered when both these tests are satisfied. Financial compensation is offered on the condition that you will not seek to pursue the same redress through further civil proceedings. In accordance with the redress regulations, you will be able to access free legal advice, but this can only be sought from solicitors with known expertise in clinical negligence who are accredited by the Law Society or AvMA.

Eirian Edwards and Chris Subbe explain how they have implemented Martha's Rule in Wales. In April 2023 Yybyty Gwynedd Hospital officially launched the Call 4Concern service for all adult patients admitted to the hospital in Bangor, as the first site in Wales to offer such a service. Call 4Concern is the option for patients, relatives, or friends to contact a member of the Critical Care Outreach team. Locally this means that callers ring the hospital switchboard, ask for Call4Concern and get a call back to discuss their concern. The Call 4Concern service is one service model that is in line with the recommendations made by the Patient Safety Commissioner for Martha’s Rule. Since then the hospital has seen over 70 patients (1-2 per week), admitted one patient to the Intensive Care Unit, treated one patient with diabetic ketoacidosis on the ward, and adjusted treatments in a number of other patients. Most calls were from relatives, many were concerns about communication, and very few calls were made at night. Patient feedback has shown that patients really appreciate that the critical care outreach team is taking their calls seriously and that they are listening to their concerns.

This report by the National Audit of Dementia (NAD) presents the results of the fifth round of audit data. For the first time, the audit has been undertaken prospectively, which will enable hospitals to take earlier action to improve patient care and experience. However, this has demonstrated that many hospitals still have no ready mechanism to identify people with dementia once admitted. One notable improvement is delirium screening (dementia is the biggest risk factor for developing delirium). Screening for delirium has improved from 58% in round 4 to 87% in the current audit. In addition, a high number of pain assessments are also being undertaken within 24 hours of admission (85%). Although encouraging, the report highlights that 61% of these assessments were based only on a question about pain—an approach that can be unreliable in patients with dementia. While this report acknowledges that our health services have experienced an extraordinarily difficult and challenging time, it does shine a light on a need for more training. It states that is encouraging that many staff have received Tier 1 dementia training (median 86%), but suggests that a much higher proportion of ward-based patient facing staff should have received Tier 2 dementia training (median 45%). It found that only 58% of hospitals are able to report the proportion of staff who have received training. As such, the report recommends that any member of staff involved in the direct care of people with dementia should have Tier 2 training, and this training should be recorded to provide assurance to the public and regulators.

The Duty of Candour for Wales statutory guidance. From April 2023 the Duty of Candour is a legal requirement for all NHS organisations in Wales. This duty builds on the Putting Things Right process which has been in place since 2011.

Wales' national policy on patient safety incident reporting and management. The National Policy on Patient Safety Incident Reporting and Management published by the Welsh Government Delivery unit can be downloaded from the attachment below. It covers the following: Section 1 – Never Events list Section 2 – Reporting processes Section 3 – Guidance on specific incident types Section 4 – Joint investigation process Section 5 – Safety II guidance Section 6 – Commissioned services flowchart – NRI reporting.

The Digital Medicines Transformation Portfolio aims to use digital technologies to make prescribing, dispensing and administering medicines everywhere in Wales, easier, safer and more efficient for patients and professionals. It brings together the programmes and projects that will deliver a fully digital prescribing approach in all care settings in Wales. This video outlines the different elements of the portfolio that will be introduced across primary and secondary care, including the Shared Medicines Record, which will store information about a patient's medications all in one place.

This report by Healthcare Inspectorate Wales (HIW) relates to vascular services provided by Betsi Cadwaladr University Health Board following the de-escalation of these services as a Service Requiring Significant Improvement (SRSI). The review outlines that while progress has been made against all nine recommendations made by the Royal College of Surgeons, the health board still has improvements to make. Review recommendations The health board must consider its responsibilities in line with the NHS Wales Putting Things Right process. This is to establish whether timelier responses could have been given following the two formal complaints it received, and whether it is assured that updates were given appropriately throughout the course of the complaint investigation. The health board should set out what action will be taken to ensure that in future, people are communicated with in a timely manner when raising concerns. The health board must maintain the record keeping audit process, to assure itself that the standards expected for record keeping, are consistent and are being maintained in the immediate and long term. Particularly within its vascular services, but also across the health board. This includes record keeping for all members of the MDT. The health board must explore the reasons for reported inconsistencies in the implementation of the Diabetic Foot Pathway across its three acute sites. The health board must consider and address the issues reported to us regarding the lack of clinical areas at YG, to review patients pre and post operatively. The health board must consider the comments and findings in this report regarding staff culture and the perceptions of different teams. This is to establish whether there is learning, or development required to improve the working relationships across all teams, to support a positive working culture. The health board must consider the comments made by staff regarding the ongoing issues following the implementation of new pathways. This is to establish whether the pathways need to be revised, or further action is required for compliance with the pathways as appropriately. The health board must ensure that all staff are completing all aspects of the consent process as applicable and are documenting this within the relevant clinical records. In addition, further consent process audits must be undertaken and continue on a regular basis, with feedback provided to all staff and actions implemented as applicable. The health board must ensure that: a) All clinical record entries are filed in chronological order; b) Surgical operation records are filled promptly after the surgical procedure. The health board must address the issue where we found examples of misfiling an incorrect patient clinical record, in a different person’s record. The health board must ensure that clinical documentation entries are signed with the clinician’s name legibly printed for identification of the author. The health board must ensure a process is in place to evaluate the sustainability of its vascular service support from UHNM to determine what arrangements will be in place once current agreements end in 2024.

This report published by the National Vascular Registry (NVR) contains information on emergency (non-elective) and elective procedures for the following patient groups: patients with peripheral arterial disease (PAD) who undergo either (a) lower limb angioplasty/stent, (b) lower limb bypass surgery, or (c) lower limb amputation patients who have a repair procedure for abdominal aortic aneurysm (AAA) patients who undergo carotid endarterectomy or carotid stenting.

A report has been published by Healthcare Inspectorate Wales (HIW) setting out the findings of a review of patient flow in Wales. Patient flow is the movement of patients through a healthcare system from the point of admission to the point of discharge. HIW specifically examined the journey of patients through the stroke pathway. This was to understand what is being done to mitigate any harm to those awaiting care, as well as to understand how the quality and safety of care is being maintained throughout the stroke pathway. The review findings reveal consistent challenges caused by poor patient flow throughout Wales, hindering the timely and appropriate delivery of care. These challenges are wide ranging, but primarily stem from the high demand for beds combined with the complexities involved in discharging medically fit patients from hospitals. Unnecessarily long stays in hospital due to delayed discharge can place patients at risk of hospital acquired infections or deterioration whilst awaiting discharge. The bottleneck at the point of discharge has a knock-on impact on emergency departments, ambulance response times, inpatient care, planned admissions and overall staff wellbeing. These challenges are wide ranging; the high demand for inpatient hospital beds combined with the complexities with discharging medically fit patients from hospital, leads to the inpatient healthcare system across Wales operating under extreme pressure.