A Welsh accident and emergency department presents a "clear and significant risk to patient safety", inspectors have warned. Healthcare Inspectorate Wales (HIW) completed an unannounced inspection of A&E at Ysbyty Glan Clwyd, Denbighshire, across three days in May following a previous check last March.
While they praised staff for "working above and beyond in challenging conditions" during a period of "unrelenting demand", they found the department was not compliant with many health and care standards - some of which were deemed an immediate risk to the safety of patients.
HIW identified that Betsi Cadwaladr University Health Board, which runs the hospital, did not have adequate arrangements in place within A&E to support the delivery of safe healthcare. As a result, the emergency department was designated a 'service requiring significant improvement' (SRSI) on May, 9.
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Chief executive of Betsi Cadwaladr University Health Board Jo Whitehead apologised to patients "who didn't receive the care they deserve", while the Welsh Government said it was "extremely concerned and disappointed" in the contents of the report.
During the inspection HIW inspectors found:
- Doctors were left to "come across" high-risk patients instead of being alerted to them;
- Patients were not monitored enough - including a suspected stroke patient and one considered a suicide risk;
- Used underwear was discovered among dirty equipment found in cupboards;
- Cupboards containing prescription only medicines, scalpels and needles were left unlocked;
- Children were at serious risk of harm as the public could enter the paediatric area unchallenged;
- An adult patient was in the paediatric area when a child was receiving care there;
- Inspectors found evidence of children leaving unseen or being discharged against medical advice.
In addition, inspectors said many staff told them they were unhappy, struggling to cope and did not feel supported by senior managers. North Wales Community Health Council's Geoff Ryall-Harvey told BBC Wales that some people would rather travel to England than go to Ysbyty Glan Clwyd should they suffer a stroke.
The HIW report states: "On the evening of our arrival, we reviewed the care records of 12 patients who had been triaged and were awaiting further assessment, treatment or intervention. We found significant issues relating to the timely provision of medical and nursing care for these patients and the ongoing assessment, monitoring, observation and escalation of those who were either unwell or at risk of becoming unwell.
"For example, we noted a patient with chest pain and ECG abnormalities was placed in waiting area for five hours with no further escalation and another patient who, despite having been recorded by a doctor as possibly having had a stroke, was placed in the waiting room for over 17 hours with infrequent observations and no documented checks until 12 hours after arrival. This presents a risk of harm to patients."
Ysbyty Glan Clwyd frequently has among the worst A&E waiting times of any Welsh hospital. In June more than half (51.6%) of patients spent more than four hours in the department before being admitted, transferred or discharged, while 1,296 out of 5,110 patients spent in excess of 12 hours there.
Earlier this year vascular services at Betsi Cadwaladr UHB were also designated as requiring "significant improvement". The health board as a whole was controversially taken out of special measures, the highest level of Welsh Government control, in November 2020.
Commenting on the report, chief executive of HIW, Alun Jones, said: "The findings within this report are extremely concerning, and we have urged the health board to take immediate action to protect patients from the risks identified. The designation has been made to strengthen and accelerate the measures taken to drive timely improvements within the service. We will be working with the health board to ensure robust improvements are made in a timely manner, and will consider the timing of any follow up activity, which will need to be evidenced."
Plaid Cymru's Health and Social Care spokesman, Rhun ap Iorwerth MS, said: "Another week, another damning report, and more concerns for patients safety. When will this end? This report again speaks of patients being put at risk and staff 'working above and beyond in challenging conditions'. I have little faith in Welsh Government’s ‘targeted interventions’, and once again I call on the health minister to look at how starting again with new health structures in the north could provide the fresh start patients and staff need. It's not because I particularly want a health reorganisation but that I think we have little choice."
Shadow Minister for North Wales, Darren Millar MS, said: "Once again, the Labour Government in Cardiff Bay is failing the people of north Wales. It will be deeply alarming to people across the region that the situation at Ysbyty Glan Clwyd still isn't getting things right despite being put into targeted intervention – Labour ministers need to step up and take responsibility for their failings.
"It is becoming ever more evident that Betsi Cadwaladr Health Board was only taken out of special measures ahead of the Senedd Elections for purely political reasons. It is unbelievable that Labour are focusing their efforts on expanding the Senedd rather than address the issues facing the NHS, especially in north Wales."
Helen Whyley, director of the Royal College of Nursing Wales, said the findings of HIW’s report were "unacceptable". "I am deeply concerned with the statement that ‘not all aspects of care were being delivered in a safe and effective manner’," she said.
"Patients deserve to receive safe and effective care. I am concerned that without significant investment into nursing the experience of patients in Ysbyty Glan Clwyd will be replicated elsewhere. The Welsh Government do not publish the number of nursing vacancies in the NHS, but RCN Wales knows that there are over 600 nursing and midwifery vacancies in Betsi Cadwaladr alone. To protect patient care the Welsh Government must pay nurses a fair wage, introduce a national nursing retention strategy and prioritise safe and effective care for patients.
"Section 25B of the Nurse Staffing Levels (Wales) Act 2016 places a statutory duty on health boards to take all reasonable steps to calculate and maintain nurse staffing levels on certain wards. RCN Wales knows that on wards covered Section 25B health boards have increased the level of nursing staff available. The RCN collected 10,572 signatures from across Wales calling for the Welsh Government to extent this legislation to protect patient care. The Welsh Government must prioritise safe and effective care – this means extending Section 25B."
In response, a Welsh Government spokesperson said: "We are extremely concerned and disappointed in the contents of this report. This standard of care falls considerably short of what we expect for patients in Wales.
"We took immediate action in June by escalating this service to targeted intervention status and commenced an improvement intervention to make immediate changes to ensure that the service is safe.
"We are assured by the health board that many of these actions have now been implemented and that it is safe for people to continue attending the emergency department at Ysbyty Glan Clwyd. It must be remembered that the majority of patients who attend this emergency department receive good, safe care."
Jo Whitehead, chief executive of Betsi Cadwaladr University Health Board said: "This latest report shows some patients have received a standard of care well below what they, and we, expect. I apologise unreservedly to those patients who didn’t receive the care they deserve.
"I have made several visits to speak with our hard working staff in the department to discuss how we can better support them to do their jobs more effectively, as we all have a shared responsibility to get this right.
"Clinical staff have been under immense pressure and often understaffed. Our improvement approach seeks to enable staff to be open about the pressures they are under and the things preventing them from giving the care we all want to provide and for us all to provide the support required to put things right.
"Managers and leaders, alongside all those on the front line, have a responsibility to escalate issues quickly and effectively in the interests of patients. We have been working hard since the initial remote quality check to put systems in place which help our Emergency Department function in a smarter, more proactive way.
"A new computerised patient tracking system, support for the emergency department from acute clinicians of all specialties, the opening of the refurbished Ward 10 and a planned ambulance reception centre will help us to drive the change which is needed, and we continue to make more improvements.
"Staffing continues to be an issue but we are committed to recruiting the permanent staff we need to ensure patients get the best possible emergency care, which is what happens in the vast majority of cases and of course, I sincerely thank staff for their continued hard work."
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