Health inspectors have issued a report calling for immediate improvement to be made at the emergency department of Withybush General Hospital.

Healthcare Inspectorate Wales (HIW) made an unannounced inspection over three consecutive days in August 2023.

During the inspection a number of infection, prevention and control, governance and patient safety issues were identified, which required immediate action.

These issues were exacerbated by the demand on the emergency department, which was far exceeding the capacity and resourcing available.

Staff were not able to effectively protect the privacy and dignity of all patients due to the high numbers of people presenting to the department, and the limited space available as a result of poor patient flow within the wider hospital.

Structural issues within the hospital were also significantly impacting patient flow, with multiple wards closed for safety.

Inspectors found patients were being accommodated in several surge areas within the Emergency Department.

A surge area is used when a hospital’s usual areas for accommodating patients has reached the point of over-capacity.

These included patients being seated or bedded in open areas of the department, and more than one patient within a cubicle at a time i.e., on a bed and recliner respectively.

Patients were observed waiting for lengthy periods in chairs, and some of the patient beds were located to the side of the open plan staff station area. There is a need for the service and health board to carefully monitor the way in which patients, particularly in surge and newly established areas, are accommodated within the department.

The health board declared an internal major incident in August 2023, relating to the identification of Reinforced Autoclaved Aerated Concrete (RAAC), which could cause significant structural and safety issues at the hospital.

HIW said: "We acknowledge the significant challenges this presented to the emergency department due to the closure of over 100 beds for safety reasons.

"This also meant the department was not able to transfer patients to these wards, causing significant overcrowding challenges in addition to the pre-existing demand.

"Inspectors observed staff engaging with patients in a kind and respectful manner and overall, patients told us that they were happy with aspects of their care and experience.

"Relatives also provided positive feedback in relation to the care being provided to their loved ones who were near end of life."

Inspectors went on to say: "The process of triaging patients was being completed in a timely manner in most cases, and we identified positive practices in relation to certain pathways, including Same Day Emergency Care (SDEC) and notably the frailty service.

"Staff were working hard to ensure patients were provided with dignified and respectful care despite significant challenges.

"Examples included talking to patients in a quiet manner to avoid being overheard, and ensuring there was consistent use of screens or curtains for privacy and dignity within the surge areas of the department. When asked, patients expressed an understanding of the pressures facing the department, but there was frustration in relation to the lack of privacy, dignity, and the availability of information regarding the next steps of their care.

"Some staff reported not being able to provide timely care to patients due to the numbers of patients present in the department and insufficient staffing levels. Examples observed by inspectors included delays to changing dressings, providing timely assistance with eating, and delays in patients being taken for scans."

The report says immediate improvements were needed in relation to infection, prevention, and control processes to minimise risks to patients, staff, and visitors.

Inspectors identified several immediate assurance issues, which required the health board to take urgent action. Examples included staff not always wearing the appropriate protective equipment or adhering to infection prevention policies, and ineffective cleaning due to overcrowding.

Risk assessments were found to be outdated and checks regarding the availability of lifesaving equipment during an emergency were not consistent. It was noted that whilst the department was warm there were no blankets or pillows provided for those patients sleeping in chairs overnight. There was a short supply of toilet and shower facilities and amenities available for patients.

Inspectors were informed that the General Surgical Clinical team has been unable to sustain a 24/7 consultant on-call cover at the hospital due to vacancies and staff absences.

Inspectors noted examples of patients who required a transfer from the department to Bronglais Hospital for surgery due to these circumstances.

Whilst this was captured on relevant risk registers and there were contingency plans in place, this remains an issue for the department and wider hospital.

There was an appropriate management structure in place and leaders demonstrated imminent plans with the intention of strengthening aspects of the department in response to the pressures faced by the service.

Workforce plans were under review to increase staffing, skill mix and overall resilience within the service.

However, there is a need to move at pace regarding certain vacant positions to ensure there is robust management and leadership at all levels within the department.

Chief Executive of Healthcare Inspectorate Wales, Alun Jones said: "There are mounting pressures on NHS services and Withybush General Hospital, like all hospitals across Wales, continues to face extraordinary challenges due to increased demand.

"Patient flow is a nationally recognised problem, caused by system-wide pressures and HIW acknowledges the health board is working to manage these challenges. It is positive to hear the commitment of staff to ensure the fundamental care needs for patients are being met at such a challenging time. Some immediate improvements were identified during our inspection, and I hope this report will accelerate Hywel Dda University Health Board to take improvement action. We will continue to engage with the health board to ensure progress against our findings."

Russell George
Shadow Health Minister, MS Russell George (Phil Blagg)

Reacting to the report, Welsh Conservative Shadow Health Minister, Russell George MS said:

“Outdated risk assessments, ineffective cleaning, infection control issues and inconsistent lifesaving equipment checks are just some of the issues highlighted by this damning report of yet another unreliable Labour-run Welsh NHS hospital.

“Labour’s handling of RAAC at Withybush Hospital has resulted in capacity issues impacting on the delivery of safe care and a large number of vacancies has precipitated in the unavailability of 24/7 consultant on-call cover, a common theme across our Labour-run Welsh NHS.

“It’s clear that the Labour Welsh Government need to step up and step in to provide additional support. "The Welsh Conservatives want to see Rishi Sunak’s long-term workforce recruitment plan replicated, with a tuition fee refund for healthcare workers that stay in Wales at its heart.”