City of Sunderland

Concerns summary Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks of over/under medication and patient harm.

Concerns summary Absence of clear policy for medication administration when hospital discharge letters are missing caused staff confusion, resulting in an opioid overdose and continued use of harmful medication.

Concerns summary Radiologists receive inconsistent and limited patient information, often focused to specific areas, risking confirmation bias and delayed diagnoses by restricting comprehensive scan interpretation.

Concerns summary Organised open water swimming events lack clear safety responsibilities, specific briefings, participant oversight, and regulatory guidance, creating significant unmanaged risks.

Concerns summary Level 2 EICO observation guidelines requiring a nurse to be within sight or sound were not met, as the patient's side room was too far. This lack of escalation and compliance likely contributed to an unwitnessed fall.

Concerns summary An ambulance crew failed to recognise a patient's critical deterioration into cardiogenic shock and incorrectly prioritised their backup request, resulting in a prolonged delay to definitive medical care.

Concerns summary Electronic custody records contained inadequate detail regarding mental health concerns and suicide risk from police and family, coupled with a lack of comprehensive analysis from the CJLD assessment.

Concerns summary Dispensing full packs of medication with special container status, rather than weekly doses, poses a severe risk to suicidal patients with a history of overdose attempts.

Concerns summary Despite previous safety improvements, cyclists remain at significant risk at a specific road location, necessitating further measures to prevent future collisions.

Concerns summary Poor information recording, inadequate home leave and discharge planning, and insufficient situational awareness from conflicting accounts compromised mental health care.

Concerns summary Concerns exist regarding the safety of standalone midwife-led birthing centres, the lack of midwife recruitment for continuity of care, and insufficient detection of small gestational age babies.

Concerns summary There is no national guidance for managing large babies in pregnancy without diabetes, and counselling for shoulder dystocia lacks clarity on rare risks of foetal or maternal death.

Concerns summary The Trust lacked contingency for multiple urgent responses, leaving callers at risk, and had a 12-hour delay in following up a high-risk call with no tracking mechanism for unprogressed cases.

Concerns summary Dementia care was undermined by insufficient multidisciplinary skills, a lack of proactive prevention, inadequate comprehensive assessments, poor family engagement, and a failure to implement person-centred policies effectively.

Concerns summary Revision of sepsis recognition guidance, mandatory, up-to-date sepsis training, and a review of overly cautious antibiotic prescribing are needed to prevent future deaths.

Concerns summary The care home lacked clear policy for handling hazardous personal property and a functioning sensor mat for falls detection. Observation protocols were unclear, and no rapid learning exercise followed the incident.

Concerns summary A specific section of the A690 has a high incidence of collisions, including two fatal incidents at the same location, necessitating a review of safety restrictions and drainage.

Concerns summary A perpetrator of domestic abuse was not subject to any police bail conditions or restrictions for over a month, leaving the victim unprotected and at severe risk.

Concerns summary A dysfunctional public protection system for offenders on life licence relied excessively on self-reporting and suffered from poor information sharing between police and probation, with inadequate monitoring and challenges to deceit.

Concerns summary Further learning and explicit timescales are needed for implementing and refreshing training on the crucial maintenance of lead attachments for medical monitors.

Concerns 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.

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 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.