County Durham and Darlington

Concerns summary Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory processing, posing a risk of future harm.

Concerns summary Procedural differences in observing detained persons during toilet visits between police and GeoAmey custody created an opportunity for prohibited items to be hidden. The subsequent search was also potentially inadequate.

Concerns summary Care rounds were erroneously reduced from hourly to four-hourly, and the staff member responsible couldn't explain how the error occurred, raising concerns about potential recurrence.

Concerns summary Inadequate physical barriers and non-deterrent design allowed track access, compounded by train crews failing to report a person on the tracks despite multiple trains passing, hindering intervention.

Concerns summary Poor communication with family and power of attorney led to incorrect baseline information for discharge planning, misunderstandings among medical staff, and the failure to arrange a crucial follow-up appointment.

Concerns summary Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health teams' inability to enter locked premises, and leading to dangerous delays in supervisor reviews.

Concerns summary There is a lack of specific national guidance for assessing mental capacity in adults with Hoarding Disorder and Executive Dysfunction, hindering effective intervention and requiring revised protocols.

Concerns summary The care home exhibited inadequate fall reporting, ineffective patient monitoring, reliance on family for medical intervention post-fall, and poor, unsecured record-keeping, hindering proper resident care and risk assessment.

Concerns summary Outdated national guidance led to a nurse not cleaning skin before an injection, potentially increasing infection risk due to lack of disinfection and reliance on 20-year-old evidence.

Concerns summary A pharmacist unilaterally provided multiple advanced doses of a controlled drug, contrary to supervised prescription instructions and without informing the treatment provider, significantly increasing overdose risk.

Concerns summary Carers were not informed of Section 17 leave conditions or provided forms, and compliance audit data is inconsistent. Removing the requirement for carer signatures in a new policy increases future risks.

Concerns summary Ambulance crews lacked crucial patient information from multi-agency plans due to electronic device data limits, necessitating manual contact with control. This compromises accessibility in emergencies for vulnerable individuals.

Concerns summary A fatal accident investigation identified critical safety issues with road markings, signage, and lighting that required urgent attention from the council's technical services.

Concerns summary A significantly delayed and incomplete patient safety investigation failed to adequately address systemic failures in anticoagulant administration and capacity assessments across hospital transfers, hindering timely learning and comprehensive training.

Concerns summary Prison staff failed to escalate or monitor a prisoner's reported refusal of food and fluids, highlighting a national absence of formal policy for monitoring prisoner meal collection.

Concerns summary A specific road with a steep gradient and bend poses a significant hazard and risk of death to road users, especially in slippery conditions without effective mitigation.

Concerns summary Critical drug interaction information recorded in patient notes was not seen or actioned by clinicians due to poor accessibility within the medical records system, impacting patient safety.

Concerns summary There was no protocol to warn patients about critical medication risks with alcohol, and a lack of joined-up communication between acute, mental health, and drug treatment teams hindered safe discharge planning.

Concerns summary Lessons from past failures in pressure wound care, including offloading advice and escalation, have not been adequately learned, with crucial training and protocols remaining uncompleted.

Concerns summary There is a critical lack of specific medical and official guidance regarding the fatal risks associated with combining clozapine with alcohol.

Concerns summary A new Emergency Department computer system lacks a clear RAG rating for patient acuity, making it difficult for clinicians to quickly identify critically ill patients, especially during peak demand.

Concerns summary Identified systemic failures in mental health services were not effectively addressed. Significant delays in Serious Incident Investigations (9 months) compromise evidence quality, hindering prompt learning and improvement in patient safety.

Concerns summary The care home exhibited inadequate falls risk management with inconsistent documentation, no plan reviews for changing risks, and a majority of staff lacking essential falls training.

Concerns summary The electronic risk assessment system (BadgerNet) at Royal Victoria Infirmary does not fully align with national guidance, hindering effective assessment. A critical updated risk chart (NEWTT2) remains unimplemented despite being overdue.

Concerns summary The Trust routinely experienced substantial and prolonged delays in completing serious incident investigations, far exceeding national guidelines, potentially allowing lethal hazards to persist longer than necessary.