Major patient safety concerns have been identified at one of Wales' busiest A&E departments. Healthcare Inspectorate Wales (HIW) paid an unannounced visit to Ysbyty Glan Clwyd in Bodelwyddan, Rhyl, between May 3 and 5 and found that many areas of concern identified during a previous inspection in March had not been rectified.
During their March visit, inspectors found "excessive" delays in the time it took patients to be reviewed by doctors "in most cases". In one instance they discovered that a patient should have been seen within 10 minutes of triage but waited more than six hours to see a doctor and subsequently became unwell. In 14 out of 20 cases inspectors reviewed, patients were not seen within the recommended time for their triage category.
Similarly, HIW said it was not assured that sufficient risk assessment processes were in place to protect patients from avoidable harm. "In one case it was deemed that a patient who had presented with a potentially lethal overdose was not managed effectively in the department. The patient discharged themselves against medical advice and the form to facilitate this discharge was not completed fully," the report stated.
Read more: Toddler sent home to die given escort from hospital by nearly 100 bikers
Inspectors also found that important checks of patient conditions were either not undertaken or not documented "in most cases". The report added: "This included a patient presenting with a very high heart rate and staff not undertaking an important investigation to check their heart (ECG). In another case a patient presented with abnormal blood test results and these were not noted or actioned by the department."
Meanwhile they identified that some patients showing significant signs of infection and possible sepsis were not screened or treated in line with the national guidelines. "This posed a risk that patients may not receive time critical interventions when required," inspectors said.
There was also major failings when it came to monitoring patients' mental health conditions. The report added: "Patients presenting with mental health issues and self harm were not routinely assessed for their risk of further harm. This had resulted in several patients leaving the department without being seen and in some cases returning after further self harming."
Documentation was also seen as a major failing. HIW added: "In all cases reviewed, the standard of nursing documentation fell far below the expected standard and did not include significant information required. This included the complete absence of documentation in some instances. This was despite some patients being present in the department for in excess of eight hours and requiring nursing care."
Finally, inspectors were told by staff that senior operational and nursing leadership was "inconsistent" and did not always support the staff within the department to deliver safe and effective care. The report added: "We found that the culture within the department lacked accountability and did not encourage nursing staff to deliver evidence based, safe care.
"The department was routinely operating at a high level of escalation. We found that due to this, staff were not always escalating their concerns, or reporting patient safety issues and incidents. This meant key lessons were not always learned and posed a risk of reoccurrence."
On Monday, May 9, in accordance with its escalation process, HIW held a meeting to determine that the department was a "service requiring significant improvement". Inspectors said this designation was based on an accumulation of evidence, originating in January 2022 which led to the completion of a quality check on March 8 and the unannounced onsite inspection in May.
A HIW statement read: "Consequently, having considered the findings and evidence gathered since January 2022, HIW has determined that the health board has not been able to demonstrate sufficient progress against several key areas of concern relating to patient safety and quality of care. HIW is working with the health board to ensure improvements are made in a timely manner."
In March Ysbyty Glan Clwyd recorded the worst A&E figures with 55.9% spending more than four hours there before being admitted, transferred or discharged, followed by Wrexham Maelor with 53.8% and Prince Charles Hospital with 48.9%. Dr Suresh Pillai, vice president of the RCEM in Wales, said the "health system is broken" and more patients would come to harm if the situation continued.
In November 2020 Betsi Cadwaladr University Health Board, which covers the six counties in north Wales and is responsible for Ysbyty Glan Clwyd, was taken out of special measures - the highest level of government control - and downgraded to the "targeted intervention" category. However several concerning safety incidents have been reported in its vascular services over recent months by the Royal College of Surgeons of England (RCS). In February this year, Health Minister Eluned Morgan said "further escalation measures" could be imposed if improvements aren't apparent in the next three months.
Commenting on the HIW report, Welsh Conservative and Shadow Minister for North Wales, Darren Millar MS said: "Today's news is deeply concerning, but sadly not shocking given the correspondence in my inbox in recent months. It is alarming that in spite of being given the opportunity to develop an action plan and implement change, the Betsi Cadwaladr University Health Board has been incapable of being able to demonstrate sufficient progress against several key areas of concern relating to patient safety and quality of care.
"I find it appalling that a health board that was previously in special measures – under direct Welsh Government control – does not appear to have the capacity or ability to address serious concerns about patient safety quickly. Patients in north Wales deserve better and with ongoing concerns over mental health services, vascular services and other aspects of care Cardiff-based Ministers urgently need to get a grip of this situation and deliver the improvements we so desperately need."
Jo Whitehead, chief executive of Betsi Cadwaladr University Health Board said: "It is clear from this report, and HIW’s subsequent visit, patients received a standard of care well below what they, and we, expect. We have fallen short of those expectations and we must, and we will, do better. On behalf of the health board I apologise to those patients who did not receive the care they deserve.
"I can assure the public, senior leaders already have more robust oversight of the emergency department at Glan Clwyd Hospital, including different models of care which are designed to ensure earlier assessment of patients.
"Emergency departments are for people who are seriously ill or injured with life-threatening injuries and illnesses, which need immediate action and we encourage you to attend if you need this support. We treat hundreds of thousands of patients every year, safely. We take our duty of care to patients very seriously and we are working with HIW to put things right.
"We continue to be extremely stretched in our emergency departments across North Wales, which together with staff shortages puts a greater stress on those who are working, often having to cover extra shifts so our departments can function. This situation is compounded because we are seeing more people who are very unwell on arrival at our emergency departments. This is not to deflect from the findings of this report, which we accept in its entirety. It was extremely disappointing to read."
A Welsh Government spokesperson said: "This is a very disappointing report and the failings of care highlighted are not acceptable. Healthcare Inspectorate Wales (HIW) have now identified the emergency department at Ysbyty Glan Clwyd as a service requiring significant improvement. We expect the health board to work with HIW to make the necessary improvements, and we will continue to provide support to achieve that.
"The health board has reassured us that more robust oversight arrangements are now in place and that it is safe for people to continue attending the emergency department at Ysbyty Glan Clwyd." To get stories on the biggest issues affecting Wales straight to your inbox, subscribe to our Wales Matters newsletter here.
