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Patient deaths in Wales under scrutiny

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drakerfordA SENIOR doctor will lead work to make sure the way the NHS reviews the records of all patients who die in hospital is consistent throughout Wales, Health Minister Mark Drakeford announced on Tuesday (Sept 16) 

In July, the Welsh Government published an independent review into hospital mortality data. It concluded the current risk adjusted mortality index (RAMI) measure is not an effective “smoke alarm” to warn about potential failings in care at a hospital. The Palmer review said the twostage process of reviewing the medical notes of all patients who have died in hospital – a system pioneered in Wales – could provide a better, more robust way of assessing safety and quality of care.

The Health Minister has announced consultant pathologist Dr Jason Shannon will look at how variations in this process can be reduced so a consistent approach is taken across the country. Dr Shannon, assistant medical director at Cwm Taf University Health Board, will lead the further development of the Wales-wide approach to mortality reviews and extending them to deaths which occur in the community. He will also examine whether independent medical examiners, who will be introduced in Wales and England under changes brought in by the Coroners and Justice Act, could be responsible for the first stage of the case note mortality review process in Wales.

Professor Drakeford said: “The evidence from mortality case reviews demonstrates very clearly that deaths in Welsh hospitals are overwhelmingly not avoidable. Each one is a matter of intense sorrow and distress to those individuals most closely involved, including those who have provided care to the person who has died. “It is from these reviews that health boards learn how the overall quality of care can be improved. While mortality case note reviews already provide the most reliable and informative means of analysing deaths in hospitals there is more that can be done to improve the process further. “I am pleased to announce Dr Shannon will lead this work to develop the Wales-wide approach to mortality reviews and extending them to deaths which occur in the community.”

Consultant Pathologist and Assistant Medical Director at Cwm Taf University Health Board Dr Jason Shannon said: “In Cwm Taf, we do not rely solely on mortality indices to tell us about patient safety, we are pioneering the process of examining in detail the clinical record and circumstances in which a patient dies in hospital – the case note mortality review. “From April 2013, the hospital notes of every patient dying in either Prince Charles or Royal Glamorgan Hospital have been or are in the process of being reviewed by a team of senior clinical staff including GPs, hospital specialists and senior nursing staff.

As of April 2014 we extended this process to other hospital sites across Cwm Taf. “Our aim is not just to prevent avoidable death but to prevent any harm to patients, especially that which results in long-term suffering or disability. The process has already been valuable in highlighting areas where we think we could do better. For example, we have put in place more effective measures to reduce the risk of patients developing blood clots and significant infection during hospital admission. “I am delighted to be taking up the role on behalf of Welsh Government to work with other health boards to expand this work across the Welsh NHS.”

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Port boss: Pembroke Dock development full permission an ‘important step’

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THE CHIEF EXECUTIVE of the Port of Milford Haven has welcomed a decision of “non-intervention” by the Welsh Government over plans to re-vamp Pembroke Dock’s historic port facilities.

The redevelopment scheme, approved by Pembrokeshire County Council’s Planning Committee in May, will see some areas such as a dock covered with sand and “infilled”.

Plans also include the demolishing of some buildings, erection of buildings and ancillary works.
Despite planning being granted at council level, full authorisation to go ahead with the development was not to be issued until the Welsh Government made its decision regards the matter.

More about the planning application can be read here: https://www.herald.wales/west-wales/pembrokeshire/major-marine-project-causes-concern-about-visual-impact-and-heritage-loss/

Now that the Welsh Government has decided not to interfere with Pembrokeshire County Council’s grant of planning permission, the Port’s boss, Andy Jones, expressed his delight, saying: “This marks an important step forward in the development of Wales’ clean energy centre at Pembroke Dock.

“It will provide sustainable opportunities for the many people who rely on the activity along the Milford Haven Waterway for employment.

CEO: Port Authority’s Andy Jones (Pic MHPA)

“Pembroke Dock Marine will unlock new opportunities for young people to enter the maritime, renewable and engineering sectors, build resilience within Pembrokeshire’s business community, and make a positive contribution to our natural environment as we transition to a low carbon energy generation.”

Tim James, head of commercial and energy at the Port of Milford Haven called the project a “once in a generation opportunity to improve Pembrokeshire’s economy for years to come”.

Objectors had complained that the plans were too large and would damage the historic dockyard, as well as having a visual impact on the dock.

The was opposition from local heritage campaigners, with complaints over the size of two huge proposed hangars which the project’s critics said would impact adversely the landscape.

The economic benefits of the £60 million marine energy “far outweigh” any impact on the historic environment, a report earlier this year to council planners said.

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Medical evacuation from LPG tanker off St Ann’s Head

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ANGLE Lifeboat was launched on service at 12:59pm on Thursday afternoon (Jun 10) to assist in a medical evacuation from a LPG tanker 13 miles SSW off St Ann’s Head.

The coastguard helicopter from Newquay in Cornwall was also on route. With the poor visibility due to fog, Angle all-weather lifeboat was to stand by the vessel to provide an alternative route for evacuation if needed.

After a choppy route in the poor visibility the RNLI volunteers arrived on scene at 2:07pm.

At the time of their arrival, the paramedic from the coastguard helicopter was aboard the vessel preparing the casualty to be winched to the helicopter.

In less than ten minutes the casualty was winched up to the helicopter and flown to hospital, at which point the lifeboat and crews were stood down and headed back to the station.

After rehousing shortly after 3:30pm the lifeboat was washed fuelled and made ready for service shortly after.

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Milford Haven child sex offender Colin Sharpe jailed for 10 years

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A MILFORD HAVEN child abuser sat crying in court as details of his four-year long abuse of a schoolgirl were read out.

Colin Sharpe’s teenage victim says she is now “plagued by nightmares” that he will return and abuse her again, Swansea Crown Court heard.

Sharpe, 40, of Howarth Close was told by Judge Paul Thomas QC at Swansea Crown Court that “Your only concern was your own selfish sexual pleasure.”

The court heard that after the matter was reported to police and officers began a search for tSharpe. He was found in his vehicle in a car park at St Ann’s Head.

The court was told that police used their car to block Sharpe’s exist from the car park but he “sped off” across the grass towards the cliff edge before crashing into a fence.

The defendant abandoned his vehicle and made off on foot to the clifftop. A standoff then developed during which police brought in a specialist negotiator to talk him down.

After a lengthy negotiation Sharpe was arrested.

Passing sentence, the judge told Sharpe: “You had no concern for the psychological damage you did.”

He added: “But it is to your credit that you immediately admitted what you had done; this had saved his victim the further ordeal of giving evidence in a trial.

Judge Paul Thomas jailed Sharpe for 10 years and imposed an indefinite order requiring him to sign the sexual offences register on release.

Sharpe will now be subject to an indefinite sexual harm prevention order and an indefinite restraining order when he is released.

As The Herald previously reported, Sharpe, who has been on remand since March, admitted one charge of sexual assault and five of sexual activity with a child, all between July 2017 and March 2021.

Police were informed about the sexual abuse by a third party, who discovered what he had done, and he was arrested and questioned early last year.

Earlier, Ian Wright, counsel for the CPS said that Sharpe used “emotional blackmail to frighten the girl into staying silent”.

He added “Matters seem to have come to a head on March 12 this year after Sharpe had once again sexually abused his victim.”

Dean Pulling, defending, said that when the police interviewed Sharpe he gave ‘guilty pleas and admissions’ at the earliest opportunity.

Excerpts from a personal victim statement highlighting the ongoing ordeal of Sharpe’s teenage victim were also read out in court.

“I am having nightmares,” the statement reads.

“I have nightmares of him coming back from prison and starting to do worse. My life has been greatly affected.”

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