City of Sunderland

Coroner Area
Reports: 51 Earliest: Sep 2013 Latest: 1 Apr 2026

78% response rate (above 63% average).

Clear 40 results
James McLaren
All Responded
2018-0330 4 Oct 2018
Chartered Institution of Waste Manageme… Environmental Services Associations Health and Safety Executive +1 more
Other related deaths
Concerns summary (AI summary) Inadequate securing of commercial and communal bins, including unsecured lids and easily opened locks, increases the risk of people sheltering inside and potentially becoming trapped.
Noted (AI summary) The HSE clarifies the meaning of 'secure' in the WISH WASTE 25 guidance, stating that it requires a risk assessment to determine appropriate measures to prevent bin access, but does not mandate a specific type of lock. They emphasize liaison between waste producers and collectors. The ESA has been raising awareness of the dangers of people in waste containers since 2009 through various means, including the press, a cross-sector steering group, a safety week, a safety alert to members, and contribution to the WISH Waste 25 guidance. CIWM has produced imagery promoting the use of WASTE25 guidance and encourages waste producers and waste collectors to check the bins while filling and unloading, which has been shared on social media. CIWM will aim to write an article for the CIWM journal / website to promote the ‘People in Bins’ Steering Group and call for volunteer waste collection companies to get involved by providing data to mirror the 2014 report by February 2019. The LGA will include an item on the risk of death and injury in large bins in relevant LGA bulletins and updates to councils to raise awareness at a national level.
Susan Elliott
All Responded
2018-0275 6 Aug 2018
City Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned (AI summary) The trust has created an action plan to address shortfalls identified during an investigation and inquest, to prevent future deaths in similar circumstances; progress will be overseen by the Executive Director of Nursing, Midwifery and Allied Health Professionals.
Patricia Heslop
All Responded
2018-0102 12 Apr 2018
Department of Health and Social Care HC-One
Care Home Health related deaths
Concerns summary (AI 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.
Noted (AI summary) The Department of Health acknowledges the concerns and refers to existing statutory guidance, CQC investigations, and national resources like the 'Falls and Fracture Consensus Statement' and NICE guidelines. They also mention the 'Quality Matters' initiative and plans to reform the social care system. HC-One describes actions taken following the incident, including internal investigations, informing staff of clinical concerns identified during meetings and supervision, and additional internal scrutiny of Hebburn Court. They also refer to improvements noted in a recent CQC inspection report.
Andrew Finlay
All Responded
26 Jan 2018
North East Ambulance Service NHS Founda…
Community health care and emergency services related deaths
Concerns summary (AI 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.
1 response from Andrew finlay
Darren Powney
All Responded
2017-0346 10 Nov 2017
North East Ambulance Service NHS Trust
Community health care and emergency services related deaths
Concerns summary (AI 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.
Action Taken (AI summary) The Ambulance Service has disseminated a briefing and memorandum to staff specifying procedures for warning markers on properties, is rolling out THRIVE training to Emergency Operations Centre staff, has provided dynamic risk assessment training and conflict resolution training to operational staff, and has developed dashboard stickers for police assistance. They are also auditing staff's knowledge of the JOP and have disseminated the Regulation 28 report to other Ambulance Trusts.
James Vinson
All Responded
2017-0338 9 Aug 2017
City Hospitals Sunderland NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned (AI summary) The Trust is piloting an Enhanced Care Standard Operating Procedure (SOP) with an Enhanced Care Risk Assessment Tool and criteria for observation levels, with a target ratification date of January 2018. It is also reviewing its Prevention and Management of Hospital-Based Falls Policy, with completion targeted for November 2017, linking it to the Enhanced Care SOP.
Elsie Tindle
All Responded
2016-0098 8 Mar 2016
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) The Department of Health acknowledges CQC's administrative error and the SOAD shortage. CQC has undertaken a 100% comparison check and implemented process reminders and daily checks to mitigate errors, and is also reviewing the SOAD fee structure to potentially free up SOAD time. The Department of Health has strengthened the 2015 MHA Code of Practice concerning the use of section 62, and SOADs have been instructed to feedback any issues regarding the use of s62 directly to CQC.
Margaret Ferry
All Responded
2015-0450 23 Oct 2015
City Hospitals Sunderland NHS Foundatio…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The absence of a formal policy and poor communication between two NHS Trusts resulted in unclear responsibilities and misunderstandings during patient referrals.
Action Taken (AI summary) A new standing operational procedure has been developed to provide a comprehensive approach to inter-organisational referrals for plastic surgery opinions; it ensures that the referral is clearly documented, a suitable response is provided within clearly defined timescales, and it is clear to all parties that patients on wards at Sunderland Royal remain under the care of the admitting consultant at all times, and not the plastics team.
George Richardson
All Responded
2015-0189 15 May 2015
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be needed for safe catheterisation skills.
Noted (AI summary) The Department of Health acknowledges the concerns, highlights existing national guidance on catheterisation from NICE and RCN, and states that ensuring staff are aware of guidance and how to seek help is for hospital trusts to action locally.
Paige Bell
All Responded
2015-0075 3 Mar 2015
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Disputed (AI summary) The Trust believes there was confusion about contradictions in the observation policy. While acknowledging improvements are needed in recording information, they state that information was shared and available to decision-makers. The Department of Health acknowledges the concerns regarding electronic patient records, national policy on patient engagement and observation, and NICE guidelines for Borderline Personality Disorder. They describe existing systems and guidance, but state the choice of record systems is for individual NHS Trusts and that NICE recently reviewed and did not update the BPD guidelines.
Dolores Hubbert
All Responded
2014-0500 14 Nov 2014
Sunderland City Council
Road (Highways Safety) related deaths
Concerns summary (AI 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.
Action Planned (AI summary) The Council will undertake an assessment of possible measures for the A690/Durham Road, East Rainton junction in 2015. It intends to commence the statutory process to reduce the speed limit to 50mph on this section of road in January 2015, with the speed reduction potentially introduced in summer 2015.
Nathan Healer
All Responded
2014-0343 25 Jul 2014
Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Noted (AI summary) The Department of Health notes the concerns raised regarding the NICE guideline CG63 and its review. They state that draft guidance is due to go out for consultation in September 2014 and the finalized guidance is expected to be published in February 2015 and that there is no scope to expedite the process.
Sophie Allen
All Responded
2014-0256 5 Jun 2014
Department for Business Innovation and …
Product related deaths
Concerns summary (AI 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.
Noted (AI summary) BIS acknowledges the concerns and describes existing campaigns and partnerships promoting blind cord safety led by the British Blind and Shutters Association (BBSA) and the Royal Society for the Prevention of Accidents (ROSPA).
Jean James
All Responded
2014-0112 13 Mar 2014
City Hospitals Sunderland NHS Foundatio…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Planned (AI summary) The hospital information system is being updated to require completion of VTE prescriptions for at-risk patients, with alerts on medication administration records. A new format for clinical handover from the Acute Medical Unit to base ward has been introduced. The Trust will hold a clinical symposium in the autumn regarding VTE management.
Peter Pattinson
All Responded
2013-0250 6 Sep 2013
European Care group
Care Home Health related deaths
Concerns summary (AI 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.
Action Taken (AI summary) The care group has implemented new bed rail risk assessment and checking systems, along with staff training on safe bed rail usage. They also numbered daily statement documents to prevent misplacement.