City of Sunderland

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 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 Outdated guidance on Borderline Personality Disorder also requires updating.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 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 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 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.