Newcastle

Concerns summary Failure to promptly recognise heart failure and the absence of a HOCM patient referral SOP delayed specialist transfer. A lack of regular cardiac monitoring also meant deterioration was missed, losing intervention opportunities.

Concerns summary Mechanical thrombectomy services are unavailable outside 9 am-5 pm due to insufficient neuroradiologists, posing a risk of preventable deaths for patients requiring urgent treatment.

Concerns summary A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected early, delaying crucial treatment.

Concerns summary Hospital Trusts use multiple IT systems that don't integrate, leading to fragmented patient information, a risk of critical findings being missed, and slowed clinical decision-making. This systemic issue affects safe patient care and transfers.

Concerns summary A paramedic lacked crucial stroke symptom training, and chiropractors do not routinely obtain medical records before assessment, particularly after recent hospital visits, creating significant risks for patients.

Concerns summary A 40 mph speed limit on a residential road with bends, junctions, and a history of collisions is unsafe and requires permanent reduction.

Concerns summary Supply chain issues led to a sub-optimal cannula being used, which dislodged and contributed to the patient's death. Surgeons were restricted in their choice of appropriate medical equipment.

Concerns summary Inappropriate grading of vulnerable person incidents and severe lack of police resources led to significant delays in response and oversight, failing to provide timely assistance.

Concerns summary There were multiple missed opportunities to coordinate care through multi-disciplinary meetings and to make safeguarding referrals despite the deceased's known escalating risks.

Concerns summary A computer system's "locking facility" prevented clinicians from accessing and upgrading a patient's ambulance response, despite multiple calls highlighting their deteriorating condition.

Concerns summary Helium balloons are freely available without adequate warnings, and parents lack sufficient awareness of the significant risks they pose to young children.

Concerns summary A lack of mandatory induction training and online facilities for out-of-hours GPs, coupled with staff confusion over call centre systems and high GP turnover, compromises service quality.

Concerns summary Radiologists lack direct access to patient medical notes, relying on inadequate summary documents, and there is a pervasive issue of poor and misleading communication between clinicians and departments impacting patient care.

Concerns summary Inconsistent understanding between hospital and community teams, inadequate patient discharge advice, and poor communication/record-keeping for post-vascular surgery complications risked catastrophic deep patch infection.

Concerns summary Pedestrians commonly cross a busy road at non-designated points due to lack of fencing and warning signage. A comprehensive review of pedestrian crossing provision is needed to prevent future deaths.

Concerns summary GP IT systems lack automatic flags for patients who miss national smear test invitations, leading to inconsistent follow-up and reduced patient safety.

Concerns summary The report provides no specific details regarding the matters of concern, only a placeholder indicating that concerns (1), (2), and (3) exist.

Concerns summary A coach driver avoided emergency braking, despite seeing a pedestrian, due to training prioritising passenger welfare. Emergency braking procedures are not a required part of bus and coach driver training.

Concerns summary Patient falls risk assessment was inconsistently applied and documented between hospital transfers. There was a lack of clarity in observation levels, suboptimal note-keeping, and insufficient daily reassessment of falls risk.

Concerns summary A busy junction and pedestrian crossing is dangerously designed, allowing no margin for error for either pedestrians or drivers, and has led to multiple similar deaths.

Concerns summary There is a lack of appropriate national guidelines for implementing new interventional procedure programs and the necessary associated training, posing a risk to patient safety.

Concerns summary A national campaign is needed to highlight the inherent risks of rapid alcohol consumption and initiation events, focusing on identifying at-risk individuals and the importance of timely medical intervention.

Concerns summary The A593 lacked appropriate signage warning road users of severe gradients and visibility limitations. Concerns were also raised about the suitability of a 60 mph speed limit on this challenging single carriageway road.

Concerns summary Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound guidance. A critical lack of national guidelines exacerbates these risks.

Concerns summary The A1018 slip road lacks appropriate lighting to identify sudden hazards and crucial signage warning motorists of flooding risks.