Teesside and Hartlepool

Concerns summary Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 and over.

Concerns summary Current resources for safeguarding intoxicated individuals with mental health illnesses are insufficient, as assessments cannot occur until sobriety, leaving vulnerable people at risk.

Concerns summary Insufficient ambulance availability leads to delayed patient attendance, exacerbated by excessive handover delays at hospitals, hindering ambulance crew release and further impacting response times.

Concerns summary The workplace exhibited a severe lack of risk assessment, inadequate training, unsafe equipment, and inappropriate working conditions, compounded by a culture that disregarded employee safety concerns and supervision.

Concerns summary Fragmented and non-integrated record-keeping and prescribing systems across hospital wards pose risks by hindering cohesive patient information management.

Concerns summary Ambulance staff lack understanding of steroid medication importance and Addison's Crisis, with no NHS Pathways guidance for triaging. Awareness and GP use of Steroid Emergency Cards and system alerts are inadequate.

Concerns summary The use of unlicensed door supervisors and misrepresentation of SIA-registered staff roles led to inaccurate safety registers, indicating a systemic failure in security and licensing compliance.

Concerns summary Ineffective internal communication meant nursing home staff were unaware of critical concerns regarding a nil-by-mouth patient drinking water, despite the manager being informed.

Concerns summary The ambulance service's call handling system failed to detect deteriorating patient condition and escalate the emergency, resulting in a significant delay in response time.

Concerns summary Multiple failures in surgical planning, medical knowledge regarding prophylactic antibiotics, post-operative vigilance, and communication with family led to critical care oversights and unsafe discharge.

Concerns summary Paramedics failed to adequately check an unlocked door, leading to a 30-minute delay awaiting police entry, an issue not addressed in the internal investigation. Alternative transport options were also not considered.

Concerns summary The Emergency Department lacked a clinical pathway for suspected aortic dissection and a system to flag patients with genetic predispositions, leading to missed critical diagnostic steps.

Concerns summary A Health Care Assistant failed to perform first aid during a choking incident, and confusion over a DNA CPR order caused delays. The care home also failed to investigate or identify these critical issues internally.

Concerns summary Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.

Concerns summary Ambulance arrival was significantly delayed due to severe demand, staff shortages, and challenges presented by road closures and diversions.

Concerns summary Both a patient's hand-held buzzer and specialist bed alarm failed to alert staff when she got out of bed, resulting in a fall that was only discovered by hearing a 'thud'.

Concerns summary This junction is a recurring danger zone with a history of several serious and fatal incidents, specifically for vehicles making right turns to or from the northbound A19.

Concerns summary An electricity supply interruption to the main oxygen apparatus stopped oxygen provision, as there was no backup system in place to continue oxygen delivery.

Concerns summary A significant mismatch exists between police and A&E staff perceptions regarding the treatment of aggressive patients, including those with Excited Delirium, compounded by a lack of dialogue and clear guidelines.

Concerns summary Unclear and insufficient signage for a 'no entry' slip road, with temporary warnings frequently being ineffective, leading to repeated instances of drivers entering incorrectly.

Concerns summary An open front door created a wind tunnel, causing the back door of a public house to move forcibly and suddenly, leading to an accident.

Concerns summary A critical failure occurred in communicating recent haemoglobin test results to the surgical team. This information was vital for assessing surgical fitness and could have altered treatment or delayed surgery.

Concerns summary Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training gaps for staff in risk assessment and ACCT procedures also contributed to concerns.

Concerns summary Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a hazardous item was left accessible to the patient.

Concerns summary Persistent national issues with out-of-hours access to s.12 doctors and timely ambulance transport delay Mental Health Act assessments and patient transfers, increasing risk.