Tameside General Hospital

“The joint approach to Mr [name redacted] care from both the microbiologist and the consultant physician, specifically around the decision to withhold antibiotics.”

“The documentation from the ICU consultant setting out/not setting out their rationale, specifically no discussions' between the medical consultant and the ICU consultant within the medical notes”

“The Trusts' policy around NEWS2 escalation had not been followed”

“the Matron for theatres has met with and provided feedback to the individual staff members involved in the post-operative recovery period with respect to completing the appropriate documentation.”

“the Matron for theatres has taken measures to improve communication with ward staff, by introducing a formal telephone handover for patients identified as 'high risk' detailing the current NEWS score and management plan in place.”

“The Matron for Theatres has also provided assurances that an audit of recovery documentation has been commissioned to provide evidence of compliance and continuous monitoring.”

“The Matron for the Orthopaedic Unit has provided assurances that formal discussions have taken place with the nursing staff identified through our investigation as failing to comply with Trust Policy in respect to the regularity, recording and appropriate escalation of NEWS observations, and consideration given to identified support or training needs.”

“The Matron for the Orthopaedic Unit has advised that the learning from our investigation into the care provided to Mr. [name redacted] was shared and discussed at the Divisional Senior Nurses meeting and subsequently, has been raised again on receipt of your Se areng the Consultant [name redacted] who ied the Trust investigation, has provided his assurances that the case has also been raised and discussed at the Orthopaedic Speciality meeting, which is attended by all grades of Orthopaedic medical”

“the Trust Patient Safety Team have drafted and distributed a 'Time out for Learning' bulletin focusing on the importance of completing, recording and escalating NEWS observations appropriately.”

“We would hope that once you have had a chance to consider this further information with respect to documentation within the ED Department you will be reassured that there is clear evidence that there is nota cultural acceptance of poor documentation with the ED Department and that the department, particularly the Senior Consultants, work hard to ensure that all clinicians fully understand their obligations with respect to documentation and where these expectations are not met, that action is taken”

“The Trust is planning to introduce new bespoke software to enable the production of an electronic casualty card, to replace the current handwritten casualty cards produced by the doctors and nurses in the Emergency Department. The key data from the electronic casualty card will be used to create a discharge summary which will be electronically sent to the patient's GP practice. It is anticipated that this will ensure that a discharge summary is completed for every patient seen within the Emer”

“measures have been put in place which have led to a significant reduction of delay in the allocation of cases”