City of Sunderland

Concerns summary An X-ray report was ignored and no CT scan performed before discharge, leading to decisions based on clinical impression without a definitive diagnosis and potentially delaying necessary surgery.

Concerns summary Failures in care home included unreported falls, poor record-keeping, un-updated care plans, and staff inadequately trained in recognising patient deterioration and dementia care.

Concerns summary The care home used an outdated falls risk assessment, had a limited buzzer system unable to provide timely assistance, and exhibited poor communication with the family.

Concerns summary Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact not directly with the patient compromised the initial clinical review.

Concerns summary Care home staff, without medical training, made assumptions about a resident's health after falls, disregarded an ambulance request, and communicated insufficiently with the GP.

Concerns summary Persistent paramedic vacancies continue to cause concerns regarding the timely despatch and arrival of ambulances, posing a risk of future deaths due to delayed emergency response.

Concerns summary Emergency ambulance staff showed confusion and lack of awareness regarding critical dynamic risk assessment protocols, including a 2016 policy. There was no bespoke policy for a frequent caller, and escalation procedures for confusion were insufficiently rapid.

Concerns summary The deceased was not under required close supervision despite a falls risk assessment, and plans for implementing an Enhanced Care/Observation Standard Operating Procedure remain unclear.

Concerns summary There was an hour-long delay in calling an ambulance for a patient with a head injury and known fall risk, despite clear need for immediate hospital transfer, indicating a failure in protocols for urgent escalation.

Concerns summary The nursing home failed to adequately assess and act upon a resident's vulnerability to falls. Concerns were raised regarding the admissions policy, falls risk assessments, and associated staff training.

Concerns summary The insufficient number of Second Opinion Appointed Doctors (SOADs) leads to delays, causing practitioners to default to urgent powers for ECT, risking the bypass of crucial safeguards and inappropriate treatment.

Concerns summary The absence of a formal policy and poor communication between two NHS Trusts resulted in unclear responsibilities and misunderstandings during patient referrals.

Concerns summary There is a lack of awareness among employers and employees regarding mental health issues in the workplace, particularly concerning disciplinary processes, suggesting ACAS guidance could be enhanced and better publicised.

Concerns summary Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be needed for safe catheterisation skills.

Concerns summary Fragmented patient records, a lack of electronic access to all notes, and inconsistent engagement policies across trusts compromise patient care. Outdated guidance on Borderline Personality Disorder also requires updating.

Concerns summary Concerns were raised about the overall safety of a junction, specifically regarding speed restrictions and the frequency of grass cutting which could obscure driver visibility.

Concerns summary Multiple failures in pressure ulcer prevention and management, including policy non-adherence, inadequate documentation, late referrals, inconsistent care, and poor record keeping.

Concerns summary A newborn's severe condition was not appreciated, leading to a missed opportunity for timely blood glucose testing despite existing hospital and NICE guidance. There is a delay in finalising and implementing updated national guidance for neonatal hypoglycaemia management.

Concerns summary Systemic failures included missed follow-up appointments, crucial missing documentation, and an absence of processes to identify and rectify these ongoing administrative issues affecting patient care.

Concerns summary Looped blind cords continue to pose a serious strangulation risk to young children, with existing installations in homes lacking the improved safety features of new standards.

Concerns summary Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently robust to prevent human factor failures.

Concerns summary Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments and identify domestic abuse, especially in elderly patients.

Concerns summary Mental health services had limited mechanisms to break the 'ping pong' referral cycle between agencies, and GPs faced limitations in directly admitting patients to a place of safety for detailed assessment.

Concerns summary Care home staff failed to act on family requests for bed rail use and repairs, did not conduct risk assessments, and maintained inadequate, unpaginated patient records.

Concerns summary The Mental Health Trust's ability to engage with a perpetrator was severely hampered by insufficient capacity and resources, especially during periods of staff absence.