Falls where seven patients suffered a serious injury – and two died – are among the 88 serious incidents that been reported by Cardiff and Vale of Glamorgan hospitals in November and December.

Cardiff and Vale University Health Board also reported five unexpected deaths of patients known to mental health services, while 60 of the incidents related to patients suffering bed sores, or pressure damage.

The health board has also received a report from a coroner about a patient who took a deliberate overdose in an in-patient ward.

‘Serious incidents’- events such as unexpected or avoidable deaths, permanent harm to patients, visitors or members of the public, or incidents which threaten an organisation’s ability to deliver ongoing healthcare – are regularly published by the health board and reported to Welsh Government.

Most serious incidents occur at University Hospital of Wales, the country’s biggest, followed by University Llandough, a report to the health board says.

In November and December, seven patients suffered serious injury after falling – two of whom died. The deaths has been reported to the coroner.

It comes as almost 5,000 patient accidents or falls were reported between November 2017 and December 2018.

Of the five unexpected deaths to patients known to mental health services, one was found hanging at home but the cause of deaths of the other patients are not yet confirmed.

One dental patient was diagnosed with squamous cell carcinoma – a form of skin cancer – having previously been downgraded from urgent to routine.

Another patient suffered a stroke after “follow-up processes were not followed” and had not started blood thinning treatment, while another patient died whilst on the cardiac surgery waiting list.

In another serious incident, an eye disorder patient’s sight “deteriorated significantly” after not being offered a follow-up appointment.

A regulation 28 report – which is sent to organisations when a coroner   believes that action should be taken to prevent further deaths – has also been sent to the health board since the end of November.

The report relates to an inquest in which the coroner concluded that a patient died after taking a deliberate overdose of his prescribed medication on an in-patient ward at University Hospital of Wales.

The medication was not locked away in his bedside cupboard, which contravened the medicines code patient property policies, a health board report says.

The health board report says: “The management of patient’s own medication is one which presents a particular challenge in the healthcare environment. Following the incident the UHB has carried out a benchmarking exercise across the UK and it does not appear that there is anyone centre that has managed to put an effective solution in place.

“While patients are always encouraged to hand over all medication or to send it home with family, there are many practical issues that make this difficult to implement and monitor robustly. Medication is the patient’s own property and they can refuse to hand it over should they wish. Staff would of course always have a discussion with the patient and the family with regards to the risk.

“It is not possible for staff to monitor patients’ property on a continuous basis and there are occasions when family members bring in additional property for patients while they are in hospital and this may include medication.

“The UHB has submitted a response to the coroner and will continue to benchmark in order to find an effective solution.”

No new ‘Never Events’ took place between November and December.

Of the 4,960 falls reported between November 2017 and December 2018, 95% resulted in no harm, or minor harm.

In December 2018, more than 300 falls were reported – but this was the lowest monthly figure for that period.

The health board is developing a strategy to reduce falls and reviewing prevention and management of bed sores.

New guidance from the Welsh Government will mean fewer pressure damage incidents will be reported as ‘Serious Incidents’, a health board report says.

Patient approval remains high with the area’s two main hospitals as surveys suggest 97% are satisfied with their experience at University Hospital of Llandough, and 98% of patients are satisfied at University Hospital of Wales.

A spokeswoman for Cardiff and Vale University Health Board said: “In line with our duty of candour we report all serious incidents to Welsh Government, the public and to our board in line with best practice.

“Welsh Government guidance requires us to report unexpected deaths of patients who are known to mental health services and die unexpectedly or experience serious harm  in a community setting.  Patients and their families are made aware of incidents and are kept informed during investigations and discussions with our clinical teams.

“The increased reporting of pressure damage reflects a period of education and training of staff to improve the quality of data being recorded.

“All incidents are fully investigated and appropriate actions are taken to reduce the risk of recurrence in the future. This enables clinical boards and the corporate teams to identify areas of good practice but also to identify emerging trends and issues that require action in order to improve safety and quality of services.”