as follows: –

(1) Signing and administration of opiate analgesia to a patient without any evidence of ascertaining why such analgesia was required, and if it was appropriate;

(2) Failure by the on-call Registrar to review a patient in the early hours of the morning when called for advice by the FY1 doctor;

(3) Failure by a Consultant Physician to follow an established Vascular Pathway despite clearly recognising the correct diagnosis of acute lower limb ischaemia;

(4) Poor communication between medical and radiology doctors resulting in: a) delays in CTA being performed; b) inadequate imaging being performed; and c) a complete lack of urgency in reporting the findings of the CTA to the requesting doctors.

(5) Very poor standard of care in respect of continuity of care; leaving the vascular referral to Sunderland to a very junior doctor on-call who did not even know the patient;

(6) An insufficiently robust review by The Trust of the circumstance leading to the death of Mr Alan Hodgson and of the lessons to be learnt from it, i.e. an insufficient review of the vascular pathway, including its dissemination, awareness and continuous training to improve the importance of the rapid escalation of care against the background of effective communications and handovers between staff to promote holistic patient care.