First report 18 Nov 2013•Latest report 15 Nov 2024
Recipient record
Reports, concerns and published responses
Health and care · NHS trust. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.
Reports
4
Naming this recipient
Published responses
100%
Found for named reports
Concerns addressed
17
Across all linked responses
Stated actions
35
Described in responses
Reports over time
Reports over time
Reports naming this recipient by issue year.
Evidence profile
Report topics
Share of this recipient’s reports compared with all other recipients.
100%published responses found
35stated actions described
Topic comparisons are not available in the current evidence snapshot.
Concerns and recipient responses
Statements from South Tees Hospitals NHS Foundation Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.
Teesside and Hartlepool
Concerns raised1
Fragmented and non-integrated record-keeping and prescribing systems
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.2
Action
Implement electronic medication-safety functions, including dashboards, laboratory-result integration, clinical decision support, warnings, hard stops and maximum-dose controls.
Stated completedThe respondent said that this action was complete when they made their response on 19 November 2024.
Action
Complete integration of the Better Medications electronic prescribing and medicines administration system in Cardiology.
Stated completedThe respondent said that this action was complete when they made their response on 19 November 2024.
Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1
Position
Existing integration measures for hospital prescribing systems have addressed the concerns about safe and effective medication prescribing.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Teesside
Concerns raised1
Failure to investigate discordant abdominal and vaginal examination findings to confirm fetal presentation
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.7
Action
Implement the presentation-scanning SOP for induction admissions and extend it to all women admitted in or suspected of being in labour after training completion.
Stated in progressThe respondent said that this action was in progress when they made their response on 23 March 2016.
Action
Update breech policies and guidance to require scanning where presentation is uncertain, senior clinical involvement, informed consent and specified delivery-management practices.
Stated completedThe respondent said that this action was complete when they made their response on 23 March 2016.
Action
Train midwives in presentation scanning, including equipment use, supervised cases and certification, with completion scheduled for June 2016.
Stated in progressThe respondent said that this action was in progress when they made their response on 23 March 2016.
Action
Maintain midwives’ scanning competency through annual evidence requirements and supervised retraining when skills are not maintained.
Stated completedThe respondent said that this action was complete when they made their response on 23 March 2016.
Action
Update labour and induction guidelines to reflect presentation-scanning requirements.
Stated completedThe respondent said that this action was complete when they made their response on 23 March 2016.
Action
Purchase and distribute eight handheld ultrasound scanners to maternity wards for presentation scanning.
Stated completedThe respondent said that this action was complete when they made their response on 23 March 2016.
Action
Implement Lincoln’s Rule, including red flags and a low threshold for presentation scanning when clinical findings are uncertain.
Stated completedThe respondent said that this action was complete when they made their response on 23 March 2016.
Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1
Position
Existing Trust scanning policies and safety measures are considered sufficient to alleviate the identified concerns and exceed national standards.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Teesside
Concerns raised1
Failure to communicate recent haemoglobin test results to clinicians assessing fitness for surgery
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
Teesside
Concerns raised5
Hand sanitiser gel stored within possible patient reach in A&E
Failure to keep A&E nursing notes complete and up to date
Failure to record nursing-observation frequency on the A&E whiteboard
Uncertainty over assessment on arrival at A&E
Failure to take hourly nursing observations in A&E
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.4
Action
Check hand-gel dispensers regularly, keep them correctly located and maintained, and replenish them when required.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 December 2013.
Action
Make staff aware of the importance of keeping the area clean and tidy and reporting environmental problems immediately.
Stated completedThe respondent said that this action was complete when they made their response on 27 December 2013.
Action
Return hand-gel dispensers to their correct locations throughout the department.
Stated completedThe respondent said that this action was complete when they made their response on 27 December 2013.
Action
Remind nursing staff to complete and accurately record patient observations.
Stated completedThe respondent said that this action was complete when they made their response on 27 December 2013.
Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.3
Position
The department’s layout and distributed hand-gel dispensers meant staff did not have a significant distance to travel between cubicles.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The Trust found no evidence that Mr Collins could access hand gel at the nurses’ station or that this contributed to his death.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Trust policy considered the Early Warning Score insufficient to require medical review, so observation levels and frequency were managed under existing arrangements.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations