Peter Anzani

Mr Adam Hodson 
HM Assistant Coroner  
The Birmingham & Solihull Coroner’s Court 
Steelhouse Lane 
Birmingham 
B4 6BJ 

Co-National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

25 June 2025  

Dear Mr Hodson, 

Re: Regulation 28 Report to Prevent Future Deaths – Peter Michael Anzani who 
died on 23 November 2024  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  1 
May 2025 concerning the death of Peter Michael Anzani on 23 November 2024. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express  my  deep  condolences  to  Peter’s  family  and  loved  ones.  NHS  England  are 
keen  to  assure  the  family  and  yourself  that  the  concerns  raised  about  Peter’s  care 
have been listened to and reflected upon.   

Your Report raised the concern that The Robert Jones and Agnes Hunt Orthopaedic 
Hospital  NHS  Foundation  Trust  (RJAH)  had  repeatedly  requested  additional  funds 
for  workforce  development  and  expansion  but  was  not  being  adequately  supported 
financially  by NHS England, and that two Workplace Funding Reviews were turned 
down by NHS England.  

Peter  was  a  patient  of  the  Midlands  Centre  for  Spinal  Injuries  (MCSI).  The  Spinal 
Cord  Injury  (SCI)  Service  at  RJAH  is  a  specialised  commissioned  service  that 
provides  care  in  line  with  the  national  service  specification  170119S  (Spinal  Cord 
Injury  Services  (Adult  &  Children)). Specialised  commissioned  services  support 
people  with  a  range  of  rare  and  complex  medical  conditions  and  often  include 
treatments  for  such  conditions.  Specialised  commissioned  services  are  not  directly 
commissioned  or  funded  by  NHS  Trusts.  Historically,  NHS  England  has  directly 
commissioned  all  specialised  services,  but  Integrated  Care  Boards  (ICBs)  are  now 
increasingly taking a larger role in commissioning some specialised services, as part 
of an agreed delegation of responsibilities to ICBs. You can find out more information 
about specialised services here: NHS commissioning » Specialised services 

the  requirements 

The  SCI  service  specification  outlines 
inpatient 
management of traumatic and non-traumatic SCI patients and the ongoing ‘lifelong’ 
management  of  patients  with  SCI. Following  inpatient  discharge  from  a  SCI  unit, 
patients are reviewed by outreach practitioners and in outpatient clinics. Care for the 
consequences of SCI is life-long with regular clinic or telephone review appointments 
(6 weeks, 6 months, and 1, 2 and 3 years then at least every 3 years or more often 
depending on the clinical indications). 

initial 

for 

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 To aid my response, my Regulation 28 Leads for the Midlands region have reviewed 
Peter’s care. As part of his lifelong care, Peter was overseen by an outpatient model 
of  care  as  per  the  national  SCI  service  specification.  To  support  and  provide 
mitigation to outpatient waiting lists for follow-up clinics, a nurse-led triage process is 
undertaken which involves contacting patients to clinically risk assess and prioritise 
patients  that  need  to  be  seen.  In  line  with  the  RJAH  Harms  Policy,  Peter  was 
contacted by a senior nurse as part of the prospective harms process on 14 August 
2024 and, following this, some concerns were raised triggering an urgent review. An 
appointment was then expedited and he was seen in clinic on 20 August 2024. The 
agreed action plan put in place included:  

•  pressure ulcer management advice 
•  GP request to monitor and manage chest issues 
•  a  review  in  18  months’  time  by  an  MCSI  practitioner,  or  earlier  if  there  was 

any need.  

This was three months prior to his admission to Heartlands Hospital on 22 November 
2024. 

NHS  England’s  Specialised  Commissioning  funds  RJAH’s  SCI  service  as  part  of  a 
block  funded  commissioning  system  to  cover  the  complete  costs  for  the  service, 
including inpatient and outpatient activity with inflationary finance being applied to all 
NHS  England  contracts  annually  since  2020.  As  a  Foundation  Trust,  RJAH  take 
organisational decisions on individual service spends, including workforce, to deliver 
services  as  identified  in  the  national  service  specification.  In  June  2024,  a  Trust 
internal  workforce  review  was  shared  for  information  with  NHS  England  and  we 
understand this is being updated at this current time. No formal requests for funding 
have been received through the contract review meeting process between RJAH and 
NHS England, to support the findings of the RJAH internal review.  

NHS England was not given Interested Party status or asked to provide any witness 
evidence during the inquest into Peter’s death. The Coroner’s findings have resulted 
in  an  internal  NHS  England  review  and  we  have  not  identified  any  specific  formal 
workforce  funding  requests  that  have  been  rejected  by  NHS  England  for  the  SCI 
service at RJAH with regard to outpatient services.   

During  2023/24,  workforce  development  funds  of  £171,077.73  were  allocated  to 
Shropshire  Telford  and  Wrekin  (STW)  ICB,  which  includes  RJAH  as  one  of  four 
Trusts  operating  in  this  system.  The  funding  was  used  for  system  wide  initiatives. 
While  there  was  no  specific  workforce  development  funding  allocation  in  2024/25, 
RJAH  have  not  been  refused  any  of  the  Clinical  Expansion  /  Multi-professional 
Education  and  Training  Plan  Considerations  posts  that  they  requested.  In  2024/25, 
some Advanced Practitioner MSC training places were allocated to them, which they 
did not utilise.   

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  death  of 

 Peter, are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank  you  for  bringing  these  important  patient  safety  issues  to  my  attention  and 
please do not hesitate to contact me should you need any further information.  

Yours sincerely,  

Co-National Medical Director  
(Secondary Care)

Oswestry 

Shropshire 

SY10 7AG  

Chairman & Chief Executive’s Office 

Tel: 01691 404394 

Mr Adam Hodson  
Assistant Coroner for Birmingham and Solihull  
50 Newton Street  
Birmingham  
B4 6NE  

24 June 2025  

Dear Mr Hodson  

Re: Regulation 28 Report to Prevent Future Death - Peter Anzani Inquest  

Thank you for your Report to Prevent Future Deaths (hereafter “PFD report”) dated 1 May 2025 
concerning the death of Peter Anzani on 24 November 2024. 

In advance of responding to the specific concerns raised in your PFD report, I would like to express 
my  deep  condolences  to  Peter’s  family  and  loved  ones.  The  Robert  Jones  and  Agnes  Hunt 
Orthopaedic Hospital NHS Foundation Trust (hereafter “the Trust”) is keen to assure the family, 
and the Coroner, that the concerns raised about Peter’s care have been listened to and reflected 
upon. 

I am advised that the Trust was not initially recognised as an Interested Person (IP) to this inquest 
nor provided with a copy of the statements and documentation from other IPs ahead of the inquest.  
I understand that the Trust was recognised as an IP following a verbal application made by the 
Trust’s legal representative during the inquest hearing.  

As  a  Trust,  we  fully  recognise  the  importance  of  addressing  the  concerns  raised  by  your  PFD 
report to prevent similar instances in future. I have set out the concerns outlined in your PFD report 
below and the relevant work the Trust has undertaken. 

1.  I  considered  evidence  from  a 

  who  indicated  at  paragraphs  20-21  of  his 
statement, “I did not see any record of his pulse, blood pressure or oxygen. The normal 
practice is to complete these observations, and I would expect this to be done, especially 
with him presenting with chest issues. However, I am unable to comment why this was not 
recorded  of  confirm  that  these  were  carried  out.  (21)  This  is  a  learning  point  for  the 
department, and I have taken steps to ensure this learning is taken forward by the Trust. I 

1006127061.1 

1 

 
 
 
 
 
 
 
 
 
 have  alerted  the  Sister  in  charge  of  the  Spinal  Injuries  Outpatients’  Department  and 
requested  that  adequate  measures  are  taken  to  ensure  that  all  observations  made  are 
recorded in the outpatient forms…”  

2.  It was unclear whether this was a single one-off event involving human error or indicative 
of a wider and systemic issue involving a lack of learning. There was no evidence before 
the court that this “learning point” had been actioned or that any adequate steps had been 
taken to ensure proper and accurate recording of records by staff.  

3.  There is a real risk of future deaths occurring where staff do not have adequate training 

and that patient records are not being properly completed.  

Immediate actions  

Following  receipt  of  the  PFD  report,  the  Trust  took  immediate  action  to  address  the  issues 
identified, specifically relating to timely and accurate recording of patient observations.  

Clear  and  visual  notices  have  been  placed  in  relevant  clinical  areas  to  remind  staff  of  the 
importance of recording patient observations promptly and accurately. Also, additional observation 
machines have been made available to ensure staff have immediate access to appropriate tools 
for carrying out vital sign monitoring. In addition, the importance of accurate observation recording 
has been communicated directly to staff both via verbal briefings and written email communication.  

Also, a re-audit was completed on 21 June 2025 in relation to 20 patient who attended the clinic 
between 16 – 19 June 2025. The results show that a full set of clinical observations was recorded 
for  100%  of  patients,  including  those  undergoing  procedures.  A  copy  of  the  audit  has  been 
provided in the Trust’s PFD response bundle.  

Digital record keeping system  

The Trust has undertaken a review of how our current systems and processes to support accurate 
and timely clinical documentation.  

One of the key tools supporting this work is implementation of our new electronic patient record 
system  called  Apollo,  which  is  used  Trust  wide  to  facilitate  consistent,  legible  and  auditable 
documentation  of  patients’  clinical  notes.  The  Outpatient  Observation  Form  now  includes  all 
baseline observations, and this essentially follows the process used in the Trust’s Main Outpatient 
Department. A paper format will be utilised during any period of digital downtime, when access to 
the digital system is limited, or not available.  

In addition to the above, the Trust recognises that it needs to be able to record patient observations 
taken in the outpatient setting on Vitals (this is a digital platform for recording clinical observations). 
This is currently in development with the digital team and implementation date is anticipated to be 
March 2026, although the timeframe is restricted by the external digital company called System 
C.  In  the  meantime,  the  Outpatient  Observation  Form  will  be  the  primary  source  for  recording 
clinical observations for patients attending outpatient appointments.  

Standard Operating Procedure 

A new Standard Operating Procedure (SOP) has been developed and is in the process of being 
implemented to provide a clear, visual guide for clinical staff working in outpatient settings. The 
SOP  includes  a flowchart to  ensure  ease  of  understanding  and  practical  application  across  all 
relevant clinics. It outlines mandatory baseline observations for all outpatient appointments. The 
SOP is scheduled to be approved at the next Patient Safety Meeting on 08 July 2025.  

1006127061.1 

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 The  SOP  further  specifically  requires  completion  of pre-  and  post-procedure  observations in 
higher-risk  outpatient  procedures,  including  Baclofen,  Fertility,  Botox  and  Suprapubic  Catheter 
(SPC) clinics.  

We consider these actions are essential to ensure patient stability before and after interventions 
that may involve medication administration, sedation, or procedural risk. 

Quality Accreditation Programme 

The Trust has adopted a local Quality Accreditation Programme (QAP), and we are using this as 
a structured and sustainable mechanism to drive improvements across all clinical areas.  

As part of the QAP, all wards, units and departments at the Trust will aim to achieve the highest 
level of quality accreditation to improve efficiency, productivity, patient outcomes and to enhance 
patient  and  staff  experience. This  underpins  the  goals  of  the Trust’s  Nursing  and Allied  Health 
Professional Strategy, the Trust’s Quality Strategy and wraps a framework around demonstrating 
regulatory compliance and best practice. 

The objective and focus of this work are to align the QAP to CQC’s key principles of Safe, Effective, 
Caring, Responsive and Well Led. I have provided within our PFD response bundle the QAP audit 
in relation to documentation and record keeping. Where compliance was found to be less than 
100%, the Trust has recommended steps to ensure increased compliance. 

Moreover, the quality accreditation process has helped guide Trust’s quality improvement priorities 
for  the  year.  Some  of  the  core  objectives  of  the  Trust’s  quality  improvement  priorities  include 
improvement  of  documentation  and  record  keeping  related  to  falls  risk  assessments  and 
management plans. The Trust has also prioritised measures to improve the use of fluid balance 
charts across the Trust.  

The  measures  agreed  to  achieve  these  objectives  are  focused  on  improved  compliance  with 
completion of risk assessments, management plans and fluid balance charts (via tenable audits).  

A copy of the Trust’s Quality Priorities has been provided in the PFD bundle. 

NEWS2 compliance audit 

the National  Early  Warning  Score 
To  evaluate  adherence 
(NEWS2) system,  a compliance  audit was  carried  out  by  the  Trust’s  Patient  Deterioration  & 
Resuscitation Committee in January 2025.  

to  national  standards 

for 

The  objective  of  this  audit  was  to  review  whether  the  Careflow  Vitals  (formerly  VitalPAC)  e-
observation NEWS2 track, and trigger system supports prompt and appropriate escalation for a 
physical review by an appropriate competent clinician. The review involved a retrospective audit 
of  NEWS2  clinical  observations  and  escalation,  which  included  a  review  of  565  observation 
datasets from 112 patients.  

The audit report highlighted the National Institute of Clinical Excellence’s (NICE) clinical guideline 
entitled  ‘Acutely  ill  patients  in hospital: recognition  of  and response  to  acute  illness  in adults  in 
hospital’  (NICE  clinical  guideline  50).  As  outlined  in  the  Trust’s  audit  report,  one  of  the  key 
recommendations in the NICE guideline is that as a minimum physiological observation such as 
heart rate, respiratory rate, systolic blood pressure, level of consciousness, oxygen saturation and 
temperature should be recorded at the initial assessment.  

1006127061.1 

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 The audit report has made appropriate recommendations and actions for better outcomes, which 
has been provided in our PFD response bundle.  

I confirm that a repeat audit has been scheduled for April 2026.  

Deteriorating patient compliance audit 

The Trust also undertook a compliance audit in January 2025 pertaining to deteriorating patients, 
which  involved  a  review  of  monitoring  and  escalation  of  patient  care. This  was  a  retrospective 
audit of 113 2222 medical emergency calls and cardiac arrests.  

This audit similarly refers to the NICE guideline referred to above and recommendation relating to 
recording of physiological observations. The audit makes mention of a report from the National 
Patient  Safety  Agency  (NPSA  2007),  which  evidenced  failure  to  recognise  and  act  upon 
deterioration in 15% of serious incidents resulting in death reported on the national reporting and 
learning system (NRLS). The sub-themes identified were a failure to measure basic observations 
of  vital  signs,  a  lack  of  recognition  of  the  importance  of  worsening  vital  signs  and  delay  in 
responding 
the  Trust’s  audit  (amongst  other 
recommendations) has emphasised learning around the global assessment of patients “including 
review of the patient’s baseline physiological trends and not solely upon the NEWS2 score”.  

to  deteriorating  vital  signs.  Accordingly, 

I confirm that a repeat audit has been scheduled for February 2026.  

I  hope  the  above  offers  you  reassurance  of  the  Trust’s  ongoing  commitment  and  work  being 
undertaken, specifically relating to the issues raised in your PFD report. 

The following documents are included in the PFD disclosure bundle. 

•  The NEWS2 compliance audit (appendix 1) 

•  Deteriorating patient compliance audit (appendix 2) 

•  The latest MCSI observational audit of 21 June 2025 (appendix 3) 

•  Quality Priorities 2025-26 (appendix 4) 

•  Quality Accreditation Programme – Documentation and Record Keeping (appendix 5) 

Thank you for bringing these important issues to my attention and please do not hesitate to 
contact me should you need any further information. 

Yours sincerely, 

CHIEF EXECUTIVE OFFICER  

1006127061.1 

4 

 
 
 
 
 
 
 Appendix 1 - Clinical Audit Report Template 

NEWS 2 compliance audit 

Craig Lammas 
Jan 2025 

- 1 - 

 
 
                             
 
 
 
 
 
 
 
 
 
 
 
 
 
 Contents 

INTRODUCTION 

AIMS & OBJECTIVES 

METHODOLOGY 

RESULTS 

DISCUSSION & CONCLUSION 

RECOMMENDATION 

ACTION PLAN 

APPENDIX  

REFERENCES 

PG 4 

PG 5 

PG 6 

PGS 7 

PGS 8-9 

PG 9 

PG10 

PG 11-12 

PG13 

- 2 - 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Date of final 

report 

Priority Level 

January 2024 

Division & Department 

Trust wide/Corporate 

Driver 

CQC  Fundamental Standards  Regulation 12:  

Safe Care & Treatment 

Background 

The Royal College of Physicians made recommendations for the national early warning score to be updated in December 2017. 
NHS England mandated for the newly revised NEWS2 to be adopted by ALL NHS Trusts by 2019.    

Aim and 
Objectives 

To review whether the Careflow Vitals (formerly VitalPAC) e-observation NEWS2 track and trigger system supports prompt 
escalation for physical review by an appropriate competent clinician 

Methodology 

Retrospective audit of NEWS2 clinical observations and escalation    

Criteria and Standard:  Acutely ill adults in hospital: recognising and responding to deterioration 
NICE Clinical guideline [CG50] Published date: July 2007 

1.10 A graded response strategy for patients identified as being at risk of clinical deterioration should be agreed and delivered 
locally. It should consist of the following three levels. 

Low-score group: 
Increased frequency of observations and the nurse in charge alerted. 

Medium-score group: 
Urgent call to team with primary medical responsibility for the patient. 

Simultaneous call to personnel with core competencies for acute illness. These competencies can be delivered by a variety of 
models at a local level, such as a critical care outreach team, a hospital-at-night team or a specialist trainee in an acute medical 
or surgical specialty. 

Standards 

High-score group: 
Emergency call to team with critical care competencies and diagnostic skills. The team should include a medical practitioner 
skilled in the assessment of the critically ill patient, who possesses advanced airway management and resuscitation skills. There 
should be an immediate response. 

1.11 Patients identified as 'clinical emergency' should bypass the graded response system. With the exception of those with a 
cardiac arrest, they should be treated in the same way as the high-score group. 

1.12 For patients in the high- and medium-score groups, healthcare professionals should: 

initiate appropriate interventions 

assess response 

Formulate a management plan, including location and level of care. 

1.13 If the team caring for the patient considers that admission to a critical care area is clinically indicated, then the decision to 
admit should involve both the consultant caring for the patient on the ward and the consultant in critical care. 

Key Results 

Feedback 

Actions 

Improvement
/ Outcomes 

Contact 

565 observation datasets from 112 patients reviewed 
94% were low risk tier (News2 scores = 0-2) 
5.5% were medium tier (News2 scores = 3-6) 
0.18% were HIGH risk (news2 score >7) 
0.35% met NEWS2 escalation response criteria  
Only 1 patient actually needed an escalated trigger response 

97.9% had observations that were within or met the minimum 12hourly  
66.2% were ON time and compliant to the prior identified observation frequency  
20.3% were completed but overdue the prior identified frequency  
13.4% were considered to ‘breach’ prior identified timeframe 

Deteriorating Patient / Resuscitation Committee 

Explore options to better and readily promote identified frequencies to increase compliance rate 
Consider Divisional daily/weekly/monthly audit reviews 

The required escalated response time vs actual response time remains difficult to determine and audit due documentation 
(written and digital) being retrospective to the action(s) taken place.  A deterioration sticker (rolled out 2024) was not noted within 
the records of the 1 escalated patient.  Please consider within the digital priorities timeline the integration of careflow connect as 
means to escalate calls from/via careflow vitals e-observation software.  

Craig Lammas 

- 3 - 

 
 
   
 
 
 
 
 
 Introduction 

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD 
2005) identified the prime causes of the substandard care of the acutely 
unwell in hospital as being delayed recognition, and institution of inappropriate 
therapy that subsequently culminated in a late referral. The report found that 
on several occasions these factors were aggravated by poor 
communication between the acute and critical care medical teams.  

It is well recognised that abnormal physiology is associated with adverse 
clinical outcomes. A multicentre, prospective, observational study (Kause et 
al. 2004) found that the majority (60%) of primary events (deaths, cardiac 
arrests and unplanned ICU admissions) were preceded by documented 
abnormal physiology, the most common being hypotension and a fall in 
Glasgow coma scale. In the NCEPOD report (2005), the majority (66%) of 
inpatients who had been in hospital for more than 24 hours before ICU 
admission exhibited physiological instability for more than 12 hours. Another 
study (Goldhill and McNarry 2004) found that mortality increased with the 
number of physiological abnormalities (p < 0.001), being 0.7% with no 
abnormalities, 4.4% with one, 9.2% with two and 21.3% with three or more. 

In aim to address and improve the care of Adult patients in acute hospital care 
settings the National Institute of Clinical Excellence (NICE) published the short 
clinical guideline ‘Acutely ill patients in hospital: recognition of and response to 
acute illness in adults in hospital’ (NICE clinical guideline 50) and outlined evidence 
based recommendations  upon the measurement of a set (see table 1) of 
physiological observations linked to a ‘track and trigger’ system to support 
both appropriate observation frequency and the timely physiological review of 
a deteriorating patient by the most appropriate clinician.    

Key recommendations  

- 4 - 

 
 
 
 
                                                                                   
 
 
 
 
 
 
 By weighting the abnormal physiological observations within the track and 

trigger the appropriate clinician can be identified and determined.  A 

recommendation (1.2.2.10) for a 3tier graded response was outlined.  

• 

• 

Low-score group   

Increased frequency of observations and the nurse in charge alerted. 

Medium-score group:   

Urgent call to team with primary medical responsibility for the patient. 

Simultaneous call to personnel with core competencies for acute 

illness. These competencies can be delivered by a variety of models at 

a local level, such as a critical care outreach team, a hospital-at-night 

team or a specialist trainee in an acute medical or surgical specialty. 

• 

High-score group:  

Emergency call to team with critical care competencies and diagnostic 

skills. The team should include a medical practitioner skilled in the 

assessment of the critically ill patient, who possesses advanced airway 

- 5 - 

 
 
 
 
 
 management and resuscitation skills. There should be an immediate 

response. 

Onward from the NICE clinical guideline much debate has arose upon the 

specificity and sensitivity of such track and trigger systems and therefore a 

task group established (NEWSDIG) by the Royal College of Physicians (RCP) 

reviewed various MEWS (modified early warning score) in operation and 

made recommendation for the national adoption of what they deemed the 
‘best’ multi-parameter track and trigger system, which became known as the 
National Early Warning Score (NEWS)  

Royal College of Physicians NEWS2 score tier response 

The RCP additionally suggest that where NEWS scores >7 are observed 

a transfer to a higher dependency area is usually necessary. 

Using the e-Observation application careflow vitals (formerly known as 

vitalPAC) the Trust operates a graded response and escalation pathway 

triggered by the NEWS2 score (see appendix)   

Aims & Objectives 

To determine compliance to NEWS2 observation frequency and escalation 
standards 

To identify baseline patient acuity and activity against the NEWS2 tier  

Methodology 

A randomised retrospective audit of 4 patients per month per ward across the 
months of September, October, November and December was undertaken 
where feasible.  The inputted observation data and data listings being 
correlated from vitalPAC clinical, VitalPAC administrator and vitals reporting 
(VOR) 

- 6 - 

 
 
 
 
 
 
 
 In keeping with compliance reporting methodology adopted by the careflow 
vitals software, observations were categorized as compliant, overdue or 
breached with each carrying the following time allowances 

Compliance - time allowances 
Frequency compliance  
On time 
Overdue 

Breached 

Criteria 
Less than 10% over the due time 
10% to less than 33% over the due 
time 
33% or more over the due time 

Scores were grouped into NEWS2 tiers (LOW, MEDIUM, HIGH). Clinical 
records of those with triggered score values were reviewed to determine if a 
clinical review was needed and what actions were taken (see appendix for 
graded response) 

Results 

565 physiological datasets from 113 patients were captured. 

Observation Status 
Completed on time 
Overdue / delayed 
Breached required frequency 

Percentage 
66.2% 
20.3% 
13.4% 

                Table 1 - NEWS2 score - Tier Distribution  

Tier group 
Low 
Medium 
High 

Total triggers 
533 
31 
1 

Total % 
94 
5.5% 
0.18% 

26 of the medium risk (News score 3 to 6) triggers correlated to an 
accumulated non-triggering NEWS2 score of 3, and NOT a single (3) 
parameter trigger that may have necessitated an escalated response and 
increased observation frequency. 

There were only 4 (0.7%) instances of NEWS2 triggers meeting the 
escalated response criteria (see appendix) 

The instances related to only 2 patients: - 

Patient 1, consecutive news scores of 7,6 and 4 (with single parameter 3 
trigger) recorded.  Within this period correct adherence to observation 
frequency was observed, escalations to both the on-call medic and outreach 
had been made and physical reviews had been timely completed.                   
(No deteriorating patient sticker compiled) 

Patient 2, single isolated NEWS score 5 (with single parameter 3score trigger 
for systolic blood pressure).  In this instance, observation frequency was 
correctly increased to 1hourly, with further repeat observations being 

- 7 - 

 
 
 
 
 
 
 
                    
  
 
 
 
 
 
 undertaken 1hr 11mins later where a non-triggering NEWS score of 3 was 
recorded.  No escalation was undertaken; it was determined that the single 
trigger score of 3 for blood pressure was within the patient's normal range, 
and no new clinical signs suggested a need for escalation. The patient 
remained stable, and subsequent NEWS scores did not indicate triggering.       

Recommendation 1.2.2.3 12hourly minimum standard 

80 datasets had modified observation frequency (frequency reduced to 8 or 
12hrly) 

Observation Frequency 

8hourly 
12hourly 

Total 
datasets 
21 
59 

Total datasets  
Exceeding frequency 
5 
16 

The 16 datasets observed to exceed the 12hourly minimum standard, 
correlated to 12patients, 11 of which were none acute spinal rehabilitation 
patients. 

Discussion 

The audit revealed notable adherence to observation protocols, with a 
significant majority of the observations being timely. Specifically, 66.2% of the 
observations were recorded 'on time' within the prior identified observation 
frequency. Conversely, 20.3% of the observations were categorized as 
delayed, and 13.4% breached the required frequency for observations. 

Modified observations 

The dataset analysis showed most modified observation frequency 
adjustments matched patient stability and clinical needs. The pragmatic 
modifications sensibly optimized resource allocation and patient monitoring, 
ensuring that higher scoring patients received timely and frequent 
observations, while stable patients were monitored at a sustainable frequency. 
This approach not only aligns with best practice guidelines but also enhances 
overall patient care and safety.  This also highlights the importance of 
including clinical judgment in determining the appropriate observation 
frequency, particularly in cases where the NEWS2 score may not fully capture 
the patient's condition. For example, in instances where low blood pressure or 
other parameters could trigger false alarms, the responsible nurse's clinical 
judgment should also play a crucial role in deciding the care pathway. 

Spinal Rehabilitation  

The NICE guidance relates to acutely unwell adults and therefore 
consideration to the use of other identified and documented monitoring plans 
should be considered for use within spinal rehabilitation, where the Trust’s 
largest grouping of delays exceeding the 12hourly acute care minimum 

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 standard is observed.  Arguably the specialist spinal nursing staff have used 
their own judgement and discretion (exceeding the 12hourly minimum) to 
ensure their patients onward physical rehabilitation program/regimes (i.e. gym 
or other OT/Physio/psychological therapies) are not being impacted by un-
necessary NEWS protocols demands, which the Royal College of Physician’s 
actively acknowledge do not necessarily appropriately work or recognise the 
altered physiology of the spinally injured patient.     

Digital platforms 

The recording of the NEWS2 data via careflow vitals and other digital program 
provided by System C allowed for many datasets to be reviewed within a 
relatively short period of time.  The digital EPR also provided quick access to 
readily legible timed and dated notes in contrast to the paper records which 
were often difficult to collate. 

Whether digital or written what was difficult to determine was the time to 
clinical response as most notes upon actions taken were retrospective entries 
and the deteriorated patient sticker rolled out in 2024 could not be found 
compiled in the nursing records. 

CONCLUSION  

The audit underscores the need for a balanced approach that incorporates 
both systematic observations and clinical judgment to ensure optimal patient 
outcomes. 

The audit demonstrated a compliance rate of 66% this figure is comparable to 
compliance rate (70%) observed within a separate deteriorating patient 
antecedence audit. 

Recommendations 

Explore options to readily promote increased daily/weekly/monthly 
surveillance of compliance to identified frequencies 

Divisional oversight to promote and encourage improvement 

Continue to encourage and educate around the global assessment of the 
patient including review of the patient’s baseline physiological trends and not 
solely upon the NEWS2 score. 

Encourage staff to use their own clinical judgment alongside the use of NEWS 
2 and careflow vitals to trigger early and appropriate escalation of care where 
they have ‘worry and concern’. 

- 9 - 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Continue to encourage additional and early use of other clinical decisions 
tools like the Sepsis screening tools and integrate into careflow vitals. 

Continue with expansion of the careflow suite of digital products to include 
careflow connect and the use of smartphone technology for escalation 
messaging to be via digital applications and easily auditable time-stamped 
push notification as opposed to existing telephone and bleep messaging 
which get referenced in retrospect.   

- 10 - 

 
 
 
 
 
 
 
 Action Plan  

This improvement plan should be drawn up when all the recommendations have been agreed.  It is intended to show what will be done and when, and 
who will be responsible for ensuring that the actions are carried out.  It should also include a review date by which time all actions should have been 
completed and a re-audit date agreed. 

Area Requiring Improvement 

Actions Required 

By Whom 

By When 

Comments 

Graded response  

Review escalation & 
clinical response  

Q4 2026 

Patient 
deterioration & 
resuscitation 
committee 

Response times difficult to determine 

Time stamps for primary 
concern, referral and 
actual clinician response   

I. Escalation 
sticker – HDU 
admissions 

i. Q4 2025 

ii. Q4 2026 

ii. digital 
escalation  

The vitalPAC software would need to be updated by 
System C to support display of the clinical response.  
A testing phase would need to be undertaken to 
sanity check the revised new software for faults and 
stability before full installation – this would likely fall 
to Q4 2026 given present delayed delivery and 
limited functionality of the anticipated Digital EPR 
and Careflow Connect integration anticipated Q3 
2024 

i.Deteriorating Patient sticker & SOP 
sieve/audit on ward transfers to HDU. 
  Though sticker was approved and introduced 
in JAN 2024 no sticker was located in the 1 
patient requiring escalated response in this 
audit.    

Digital integration of Careflow Connect 
originally proposed for Q2/3 2024 

Re-audit Date 

01/04/2026 

Project Lead 

Craig Lammas 

Group 

Comments 

Patient deterioration & resuscitation 
committee 

- 11 - 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix  

RJAH News2 Escalation and graded response  

- 12 - 

 
 
 
 
 
 Deteriorating Patient Sticker 

- 13 - 

 
 
 
 
 
 
 
 References 

National Confidential Enquiry into Patient Outcome and Death. London: 
NCEPOD, 2005. https://www.ncepod.org.uk/2005report/NCEPOD_Report_2005.pdf 
[Accessed January 2024] 

Kause J, Smith G, Prytherch D, Parr M, Flabouris A, Hillman K; Intensive Care 
Society (UK);Australian and New Zealand Intensive Care Society Clinical 
Trials Group. A comparison of antecedents to cardiac arrests, deaths and 
emergency intensive care admissions in Australia andNew Zealand , and the 
United Kingdom - the ACADEMIA study. Resuscitation 2004; 62(3)275-282.  

Goldhill DR, McNarry AF. Physiological abnormalities in early warning scores 
are related to mortality in adult inpatients. Br J Anaesth 2004; 92(6):882-884 

National Institute for Health and Clinical Excellence. Acutely ill adults in 
hospital: recognising and responding to deterioration. Clinical guideline 50. 
London: NICE, 2007. https://www.nice.org.uk/guidance/cg50  [Accessed January 2024] 

Royal College of Physicians. National Early Warning Score (NEWS) 2: 
standardising the assessment of acute-illness severity in the NHS. Updated 
report of a working party. London: RCP, December 2017  
https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 [accessed January 
2024] 

Asafu-Adjaye K, Gall A. Letter to the Royal College of Physicians regarding 
the suitability of the National Early Warning Score in the assessment of the 
unwell spinal cord injury patient. Clin Med (Lond) 2015;15:406–7 

Bibliography 

O’Driscoll BR, Grant K, Green D et al. The national early warning score gives 
misleading scores for oxygen saturation in patients at risk of hypercapnia. Clin 
Med (Lond) 2014;14:695–6. https://doi.org/10.7861/clinmedicine.14-6-695 [Accessed January 
2024] 

O’Driscoll BR, Howard LS, Earis J et al. British Thoracic Society Emergency Oxygen 
Guideline Group. BTS guideline for oxygen use in adults in healthcare and 
emergency settings. Thorax 2017;72(Suppl 1):ii1–ii90. 
http://bmjopenrespres.bmj.com/content/4/1/e000170 [Accessed January 2024] 

- 14 - 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 2 - Clinical Audit Report Template 

Deteriorating patient compliance audit 

Craig Lammas 
Jan 2025 

- 1 - 

 
 
                             
 
 
 
 
 
 
 
 
 
 
 
 
 
 Contents 

INTRODUCTION 

AIMS & OBJECTIVES 

METHODOLOGY 

RESULTS 

DISCUSSION & CONCLUSION 

RECOMMENDATION 

ACTION PLAN 

APPENDIX  

REFERENCES 

PG 4 

PG 5 

PG 6 

PGS 7 

PGS 8-9 

PG 9 

PG10 

PG 11-12 

PG13 

- 2 - 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Date of final 

report 

Priority Level 

February 2025 

Division & Department 

Trust wide/Corporate 

Driver 

CQC  Fundamental Standards  Regulation 12:  

Safe Care & Treatment 

Background 

.    

Aim and 
Objectives 

Methodology 

To review monitoring and escalation of care surrounding patient deterioration   

Retrospective audit of all in-patients 2222 medical emergency/cardiac arrest calls 

Criteria and Standard:  Acutely ill adults in hospital: recognising and responding to deterioration 
NICE Clinical guideline [CG50] Published date: July 2007 

1.10 A graded response strategy for patients identified as being at risk of clinical deterioration should be agreed and delivered 
locally. It should consist of the following three levels. 

Low-score group: 
Increased frequency of observations and the nurse in charge alerted. 

Medium-score group: 
Urgent call to team with primary medical responsibility for the patient. 

Simultaneous call to personnel with core competencies for acute illness. These competencies can be delivered by a variety of 
models at a local level, such as a critical care outreach team, a hospital-at-night team or a specialist trainee in an acute medical 
or surgical specialty. 

Standards 

High-score group: 
Emergency call to team with critical care competencies and diagnostic skills. The team should include a medical practitioner 
skilled in the assessment of the critically ill patient, who possesses advanced airway management and resuscitation skills. There 
should be an immediate response. 

1.11 Patients identified as 'clinical emergency' should bypass the graded response system. With the exception of those with a 
cardiac arrest, they should be treated in the same way as the high-score group. 

1.12 For patients in the high- and medium-score groups, healthcare professionals should: 

initiate appropriate interventions 

assess response 

Formulate a management plan, including location and level of care. 

1.13 If the team caring for the patient considers that admission to a critical care area is clinically indicated, then the decision to 
admit should involve both the consultant caring for the patient on the ward and the consultant in critical care. 

Key Results 

Feedback 

1 cardiac arrest call (Jan – Dec 2024) 
113 2222calls received 
49 emergency calls correlated to adult in-patients 
1 case had persistent NEWS2 >5 and met RCP criteria considered for HDU transfer 
70% of observations were compliant to NEWS2 frequency standards  

Deteriorating Patient / Resuscitation Committee 

Actions 

Additional ward manager/divisional matron NEWS2 audits need to be conducted to promote increased NEWS2 frequency 
compliance.  

Improvement
/ Outcomes 

Contact 

    NEWS2 observation frequency compliance needs to be promoted and improved 

Craig Lammas 

- 3 - 

 
 
 
 
   
 
 
 
 Introduction 

In some instances, patients who are, or become, acutely unwell in Hospital 
receive sub-optimal care as their deterioration is not recognised, appreciated 
or acted promptly upon.  Within the NCEPOD Report ‘An Acute Problem’ 
(2005) suboptimal ward care and subsequent delays in transfer to critical care 
were evidently shown to contribute to increased hospital mortality.   

The National Patient Safety Agency (NPSA 2007) also evidenced failure to 
recognise and act upon deterioration in 15% of serious incidents resulting in 
death reported on the national reporting and learning system (NRLS).   Upon 
categorising the incidents 3 sub themes became apparent 

1. Failure to measure basic observations of vital signs; 
2. Lack of recognition of the importance of worsening vital signs; 
3. Delay in responding to deteriorating vital signs 

To address and improve the care of Adult patients in acute hospital care 
settings the National Institute of Clinical Excellence (NICE) published the short 
clinical guideline ‘Acutely ill patients in hospital: recognition of and response to 
acute illness in adults in hospital’ (NICE clinical guideline 50) and outlined evidence 
based recommendations  upon the measurement of a set (see table 1) of 
physiological observations linked to a ‘track and trigger’ system to support 
both appropriate observation frequency and the timely physiological review of 
a deteriorating patient by the most appropriate clinician.    

Key recommendations  

- 4 - 

 
 
                                                                                   
 
 
 
 
 
 
 
 
 By weighting the abnormal physiological observations within the track and 

trigger the appropriate clinician can be identified and determined.  A 

recommendation (1.2.2.10) for a 3tier graded response was outlined.  

• 

• 

Low-score group   

Increased frequency of observations and the nurse in charge alerted. 

Medium-score group:   

Urgent call to team with primary medical responsibility for the patient. 

Simultaneous call to personnel with core competencies for acute 

illness. These competencies can be delivered by a variety of models at 

a local level, such as a critical care outreach team, a hospital-at-night 

team or a specialist trainee in an acute medical or surgical specialty. 

• 

High-score group:  

Emergency call to team with critical care competencies and diagnostic 
skills. The team should include a medical practitioner skilled in the 

assessment of the critically ill patient, who possesses advanced airway 

- 5 - 

 
 
 
 
 management and resuscitation skills. There should be an immediate 

response. 

Onward from the NICE clinical guideline much debate has arose upon the 

specificity and sensitivity of such track and trigger systems and therefore a 

task group established (NEWSDIG) by the Royal College of Physicians (RCP) 

reviewed various MEWS (modified early warning score) in operation and 

made recommendation for the national adoption of what they deemed the 
‘best’ multi-parameter track and trigger system, which became known as the 
National Early Warning Score (NEWS)  

Royal College of Physicians NEWS2 score tier response 

The RCP additionally suggest that where NEWS scores >7 are observed 

a transfer to a higher dependency area is usually necessary. 

Using the e-Observation application careflow vitals (formerly known as 

vitalPAC) the Trust operates a graded response and escalation pathway 

triggered by the NEWS2 score (see appendix)   

Aims & Objectives 

Determine/identify whether there was any antecedence within NEWS2 clinical 
observations or other physiological decline prior to identified 2222 medical 
emergency.  

Methodology 

Utilising the clinical e-observation system (care-flow vitals -formerly VitalPAC) 
and the electronic patient records (EPR) clinical notes and observation data 
from the preceding 24hour period prior to an in-patient 2222 emergency call 
was retrospectively reviewed. 

- 6 - 

 
 
 
 
 
 
 
 Results 
Across 2024 (Jan to Dec) there were 113 2222 call activations across the 
Trust.   

*2 cardiac arrests occurred, only 1 of these related to an in-hospital patient.   
* 1 member of the public driven to the hospital, already in cardiac arrest upon arrival and despite staff 
and ambulance service attempts sadly was pronounced deceased. 

49 of the 113 emergency calls correlated to adult in-patients of these  
6 were excluded from the review. (5 HDU as not on NEWS2 and 1 spinal patient with 
anaphylactic response to CT contrast with no known prior allergies) 

Only 1 of the 43cases reviewed had NEWS2 score triggers preceding. 
The first being a NEWS score of 7 approximately 8hrs 40minutes before the 
time of the 2222call.   This trigger was correctly and promptly escalated as per 
escalation response (see appendix) and physical reviews undertaken by the 
Medic on-call and the outreach service.  However, despite interventions the 
NEWS scores continued to remain between 5-7, no decisions upon escalating 
care, ceiling of treatment or resuscitation status were considered during this 
timeframe.   Days prior to this incident the patient had already been identified 
as very frail and unfit for surgery.   

The 1 cardiac arrest incident had NO prior NEWS2 triggers, signs or 
reported symptoms prior.  The last observations (News=0) had been 
conducted 8hrs 22mins prior, with frequency modified to minimum 12hourly 
post.  At time of the cardiac arrest the patient had been discharged and 
imminently about to leave the hospital, the due repeat of the physical 
observations would not have been required for further 3hrs 22mins later 

3 cases had been escalated through nurse concern NOT NEWS2.  2 of 
which were specifically due to pyrexia (38°c & 38.2 °c) and onward escalation 
correctly undertook sepsis screening. 

1 case did not meet the minimum 12hourly standard, the frequency had 
been modified to 24hourly, there was no noted senior level decision or 
rationale for this.   On scrutiny of the e-observation software, the frequency 
had been modified by ward ‘agency’ login (0208hrs) and all onward 
observation data inputted by RJAH staff had not rectified or amended this 
modification. 

3 cases had the observation frequency modified to the minimum 12hourly 
standard. 

Observation frequency compliance - Time delays 

8 cases had NEWS2 observation frequency delays of <30mins  
13 cases had NEWS2 observation frequency delays >1hr 
(The figures above include 4cases which had time delays of both <30mins and >1hr noted) 

- 7 - 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 9 cases related to immediate post-operative observations and not NEWS2.  
Of these 2 cases post-operative frequency had not been correctly maintained. 

Discussion 

Only a temperature of 35°c or less will trigger a single parameter 3 
activation of NEWS2.    Pyrexia is permissively allowed within NEWS2 with 
even temperatures >39.1 only being awarded 2pts.  

NEWS2 scores were not an evident predictor  

The observation frequency delays within 13 of the 43 cases 
reviewed would indicate a NEWS2 frequency compliance of 70% 

Recommendations 

Continue to encourage and educate around the global assessment of the 
patient including review of the patient’s baseline physiological trends and not 
solely upon the NEWS2 score. 

Encourage staff to use their own clinical judgment alongside the use of NEWS 
2 and careflow vitals to trigger early and appropriate escalation of care where 
they have ‘worry and concern’. 

Continue to encourage additional and early use of other clinical decisions 
tools like the Sepsis screening tools and integrate into careflow vitals. 

Ward managers and Matrons to conduct monthly NEWS audits to monitor and 
encourage compliance to NEWS2 frequency standards.  

- 8 - 

 
 
   
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Action Plan  

This improvement plan should be drawn up when all the recommendations have been agreed.  It is intended to show what will be done and when, and 
who will be responsible for ensuring that the actions are carried out.  It should also include a review date by which time all actions should have been 
completed and a re-audit date agreed. 

Area Requiring Improvement 

Actions Required 

By Whom 

By When 

Comments 

Compliance to NEWS2 frequency 

Monthly auditing needs to 
be conducted to both 
police and encourage 
compliance to NEWS2 
frequency 

Ward Managers & 
Matrons 

monthly 

Trust to consider utilizing and 
interrogating data capture from e-
observation software to lessen onerous on 
clinical staff to conduct additional audits 
when data already captured. 

Re-audit Date 

01/02/2026 

Project Lead 

Craig Lammas 

Group 

Comments 

Patient deterioration & resuscitation 
committee 

- 9 - 

 
 
 
 
 
 
 
 
 Appendix  

RJAH News2 Escalation and graded response  

- 10 - 

 
 
 
 
 
 Deteriorating Patient Sticker 

- 11 - 

 
 
 
 
 
 
 
 References 

National Confidential Enquiry into Patient Outcome and Death. London: 
NCEPOD, 2005. https://www.ncepod.org.uk/2005report/NCEPOD_Report_2005.pdf 
[Accessed January 2025] 

National Institute for Health and Clinical Excellence. Acutely ill adults in 
hospital: recognising and responding to deterioration. Clinical guideline 50. 
London: NICE, 2007. https://www.nice.org.uk/guidance/cg50  [Accessed January 2025] 

Royal College of Physicians. National Early Warning Score (NEWS) 2: 
standardising the assessment of acute-illness severity in the NHS. Updated 
report of a working party. London: RCP, December 2017  
https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 [accessed January 
2025] 

Bibliography 

O’Driscoll BR, Grant K, Green D et al. The national early warning score gives 
misleading scores for oxygen saturation in patients at risk of hypercapnia. Clin 
Med (Lond) 2014;14:695–6. https://doi.org/10.7861/clinmedicine.14-6-695 [Accessed January 
2024] 

O’Driscoll BR, Howard LS, Earis J et al. British Thoracic Society Emergency Oxygen 
Guideline Group. BTS guideline for oxygen use in adults in healthcare and 
emergency settings. Thorax 2017;72(Suppl 1):ii1–ii90. 
http://bmjopenrespres.bmj.com/content/4/1/e000170 [Accessed January 2024] 

- 12 - 

 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 3 - MCSI Outpatient Department Clinical Observations Re 
Audit Report 

Report Date: 23rd June 2025 
Prepared by: Hannah Cheesman (Matron) 

Background 

Following a retrospective and prospective audit of clinical observations within the MCSI 
Outpatient Department, a new Observation Form was developed and implemented in the 
Apollo system. A corresponding Standard Operating Procedure (SOP) was introduced, requiring 
that a full set of observations be recorded for all patients attending the clinic. 

In particular, the SOP specifies that patients undergoing invasive procedures- such as 
suprapubic catheter (SPC) changes or baclofen refills- must have observations completed both 
pre- and post-procedure. 

Re-Audit Summary 

A re-audit was conducted on 20 patients who attended clinic between 16th June and 19th June 
2025. The results show that a full set of clinical observations was recorded for 100% of patients, 
including those undergoing procedures. 

Conclusion 

The re-audit demonstrates full compliance (100%) with the updated SOP and use of the Apollo 
observation form. 

Next Steps 

To ensure continued adherence to the SOP, a further audit will be carried out in three month’s 
time (scheduled for 23rd September 2025). 

Recording of Clinical Observations in MCSI 
OPD

s
e
u
l
a
V

120%

100%

80%

60%

40%

20%

0%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

Was the patient's
heart rate
recorded?

Was the patient's
heart rate
recorded?

Was the patient's
blood pressure
recorded?

Was the patient's
oxygen
saturation
recorded?

Was the patient's
temperature
recorded?

Clinical Standard

1 

 
 
 
 Appendix 4 - Quality Priorities 2025/26 

Committee / Group / Meeting, Date 

Council of Govenors, 14 May 2025 

Author: 
Name: Kirsty Foskett 
Role/Title: Assistant Chief Nurse and Patient 
Safety Officer 

Contributors: 

Report sign-off: 
Name: Sam Young 
Role/Title: Interim Chief Nurse and Patient Safety Officer 

Is the report suitable for publication? 

Yes 
Key issues and considerations: 
Each year the Trust sets out several quality priorities that focus on improvements relating to 
patient safety and patient experience.  

Last year the priorities aligned to that of the Trusts Patient Safety Incident Response Plan, 
recognising that the introduction of the new Patient Safety Incident Response Framework 
(PSIRF) was change in how we respond to patient safety events and was a key focus for 
the organisation.  

During 2024/25 the Trust launched the Quality Accreditation Programme for all wards and 
departments. The outputs of theses quality assessments along with learning insights 
through PSIRF, we have used this information to inform what the quality priorities will be for 
2025/26.  

The quality priorities for 2025/26 will be 

Inpatient Falls 

• 
•  Managing the Deteriorating Patient 
• 
Improving Information Sharing 
• 
Introducing a complex care pathway 

Strategic objectives and associated risks: 

The following strategic objectives are relevant to the content of this report:  

Trust Objectives 
1  Deliver high quality clinical services 

2 

Develop  our  veterans  service  as  a  nationally  recognised  centre  of 
excellence 
Integrate the MSK pathways across Shropshire, Telford and Wrekin 

3 
4  Grow our services and workforce sustainably 
5 

Innovation, education and research at the heart of what we do 

 

 

This  report  relates  to  the  following  Board  Assurance  Framework  (BAF)  themes  and 
associated strategic risks:  

Board Assurance Framework Themes 
1  Continued focus on excellence in quality and safety 
2  Creating a sustainable workforce 

Report Template V2.1 

 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 Appendix 4 - Quality Priorities 2025/26 

3  Delivering the financial plan 
4  Delivering the required levels of productivity, performance and activity  
5  Delivering innovation, growth and achieving systemic improvements 
6  Responding to opportunities and challenges in the wider health and care 

system 

7  Responding to a significant disruptive event 

System partners in Shropshire, Telford and Wrekin have identified four strategic objectives 
for  the  integrated  care  system.  The following  objectives  are  relevant  to  the  content  of  this 
report:  

System Objectives 
1 
Improve outcomes in population health and healthcare 
2  Tackle inequalities in outcomes, experience and access 
3  Support broader social and economic development 
4  Enhance productivity and value for money 

Recommendations: 
The group is asked to note the quality priorities for 2025/26. 

 

Report Template V2.1 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 4 - Quality Priorities 2025/26 

Quality Priorities 2025/26 

Patient Falls 

Key Objectives 

•  To improve documentation and 

record keeping in relation to Falls risk 
assessments and management plans. 
•  To Improve the use of visual aids that 
highlight if a patient is at risk of falls. 
•  To introduce the new post-fall toolkit 

Measures for Improvement 

Leads  

• 

• 

Improved compliance with completion 
of risk assessments and management 
plans. 

Improved compliance with the use of 
visual aids. 

Linda Head, Falls Lead and Rachael Flood, 
MSK Matron.  

Supported by the Quality Improvement Team 

Managing the Deteriorating Patient 

Key Objectives 

Measures for Improvement 

Leads  

•  To introduce a deteriorating patient 
simulation study day, to improve the 
early recognition and management of 
the unwell patient 

•  To improve the use of fluid balance 

charts across the Trust 

•  Reduction in the number of patient 
safety reviews requested due 
deterioration 

•  Uptake of simulation training amongst 

clinical staff  

• 

Improved compliance (through 
Tendable audit)  in the completion of 
fluid balance charts 

Nicki Bellinger (Critical Care Nurse 
Consultant), Craig Lammas, Resuscitation 
Officer Lowri Mansell, Critical Care Manager 
& Donna St John, Simulation Education 
Lead. 

Supported by the Quality Improvement Team 

Report Template V2.1 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 4 - Quality Priorities 2025/26 

Improving Information Sharing 

Key Objectives 

Measures for Improvement 

Leads  

•  To introduce bedside nursing 

• 

handovers 

Improved communication with staff in 
understanding ward (quality) 
performance 

Unit ACNs and Matrons and Hayley Gingell, 
Quality Assurance Lead  

Supported by the Quality Improvement Team 

•  To introduce visual Quality 

Dashboards in ward/departmental 
areas 

•  To review the effectiveness of safety 
huddles in the ward environment 
•  To review the effectiveness of “Link 

Nurse” meetings 

•  To introduce new patient bed boards 

across the trust 

•  Reduction in incidents relating to 
communication in ward area 

• 

Improved scores through Well-led of 
the quality accreditation assessment 

Introduction of a complex care pathway for patients with mental health, Learning Disability and/or Autism 

Key Objectives 

Measures for Improvement 

Leads  

• 

Improving the experience of those 
patients with LD&/or A or mental 
health needs  

•  Reduction in communication incidents 
•  Reduction in complaints 

Geraint Davies, AHP Consultant, Rachael 
Flood, MSK Matron and Kirsty Foskett, ACN  

Supported by the Quality Improvement Team 

Report Template V2.1 

4 

 
 
 
 
 
 
 Appendix 4 - Quality Priorities 2025/26 

Report Template V2.1 

5 

 
 
 
 Appendix 5 -Quality Accreditation Audit Elements Related to Documentation & Record Keeping 

Domain 

Section 

Question 

SAFE 

Patient Observations / 
Clinical Records 

•  NEWS charts are completed on time  
• 

Falls risk assessment and management plan 
completed  

Medication Safety and 
Documentation 

Catheter Care 
Documentation 

EFFECTIVE 

Patient Pathways 
(Documents Completed) 

Documentation Standards 
(NMC & HCPC Code of 
Conduct Compliance) 

•  VTE assessment has been documented and 

reviewed within 24 hours  
Is the patient’s mobility status recorded above 
the bed? 
Patients' prescription charts are legible and 
medication given on time as prescribed  
Food allergies and intolerances recorded  

• 
•  Drug allergy status is recorded 
• 

Is catheter in use and documented in patient 
notes? Is the size of catheter documented in 
the pathway document?  
Is the mls of water documented in the 
pathway documentation? 

• 

• 

• 

Are the following documents completed in 3 patient 
pathways? 
Purpose T / Waterlow 
• 
•  Bed rails assessment 
•  Medication records 
•  Nutrition documentation 
•  Moving & handling plan 
•  Confirmation of personal details 

Check 3 patient records to ensure documentation: 

o 
Is dated 
o 
Is timed 
o 
Is signed 
o 
Is legible 
o  Avoids jargon 
o  Non-registered staff entries are counter-

signed by registrants 

Current 
compliance 
across all 
completed 
assessments 
(21) 
88% 

86% 

90% 

95% 

Gaps in Assurance  

Steps being undertaken to 
enhance compliance. 

Incomplete NEWS charts on 
Ludlow ward in assessments 
1&2. 
Falls documentation and visual 
cues incomplete. 
VTE documents completed but 
unsigned and misfiled. 
Allergy status recorded but 
patients not wearing allergy 
bands 

Falls risk management has started in 
SSU, with clear coordination and 
handover updates. Daily 
communication reinforces 
expectations for ongoing 
compliance. 

Catheter bags not labelled or 
dated 

Training is embedded into SSU 
rolling programmes, with huddles 
and emails reinforcing key 
messages.  
Shift checks support consistent 
practice and compliance. 
Incomplete bed rail assessments   Bed Rail Policy Review  

Collaborative work with Linda Head 
to revise policy for paediatrics. 
Links made to related compliance 
areas like VTE, falls, mobility status, 
etc. 

100% 

No Gaps 

Daily Wellness & Fluid 
Records 

•  Have daily wellness checks been undertaken?  
•  Are fluid balance charts completed 

accurately?  

71% 

Fluid Balance charts not 
completed  

 
 
 
 CARING 

Safety & Communication 
Records 

Discharge Documentation 
Staff Induction & Access 
Records 
ADRT & ReSPECT 
Documentation 

Communication and 
Patient Identification 
Discharge Information 

Referral & Signposting 

Consent & Care 
Involvement 

•  Are safety huddles undertaken and 

• 

documented?  
Is the handover documentation adequate for 
holistic patient care?  
Is the discharge checklist completed? 

•  Have staff received local induction?  
•  Have staff received Apollo & Careflow login? 
•  Has the patient been asked if they have an 

Advance Care Directive?  

•  ReSPECT form has been completed fully and 

dated (where appropriate) 
Are patients called by their preferred name? 
(#CALLME – check bed board and wristband) 
Do discharged patients feel they have enough 
information, equipment, and know who to contact if 
they have concerns? 
Are patients and relatives referred or signposted to 
appropriate services, such as: 

o  Patient Advice & Liaison (PALS) 
o  Spiritual advice / chaplaincy 
o  Safeguarding 
o 
'Call for Concern' facility 
Is consent for clinical intervention requested?  
• 
•  Are patients consulted and involved with their 

care? 

95% 

100% 
100% 

95% 

Handovers conducted, but staff 
report inconsistent safety 
huddles. 

No Gaps 
No Gaps 

ADRT & Respect pathways not 
completed. 

Communications have been shared 
with relevant clinical teams to 
support timely completion of key 
documentation. 

100% 

No Gaps 

100% 

No Gaps 

100% 

No Gaps 

100% 

No Gaps 

RESPONSIVE  Freedom to Speak Up 
(FTSU) 

Are Freedom to Speak Up posters displayed on the 
ward?  

72% 

No Freedom to Speak Up 
posters displayed in some areas 
during Assessment 1, and staff 
were unaware of the champions. 

Feedback & Complaints 
Records 

Notice Boards 

Internal Communication 
(These assess the 
availability and awareness 
of documented internal 
communications.) 

•  Are staff aware of any compliments?  
•  Are staff aware of any complaints?  
•  Do staff know what their Friends and Family 

• 

Test / IVQA results are?  
Is patient feedback shared and used for 
improvement?  

•  Are notice boards up to date?  
•  Are all notices compliant with IPC (Infection 

Prevention & Control)? 

•  Do staff have access to Percy (internal 

platform)? 

•  Are staff aware of the latest communication 

bulletins?  

95% 

Staff unaware of IVQA results  

100% 

No Gaps 

100% 

No Gaps 

Compliance with poster display has 
increased for ongoing assessments. 
Posters featuring FTSU champion 
information have been developed 
for display in designated areas. 
Work is underway to implement a 
digital ward metric screen for 
display in ward areas, which will 
include IVQA results. Works tracked 
through the Quality Priorities action 
plans  

 
 
 
 
 
 
 
 
 
 
 
 
 WELL-LED 

Staffing, Schedules, and 
Records 

•  Are rosters published 6 weeks in advance, 

• 

and are staff aware?  
Is staff sickness/absence managed according 
to policy? (Ward Manager only)  

100% 

No Gaps 

•  Are appraisals in date?  
•  Are 6-monthly reviews undertaken for new 

• 

starters?  
Is CPD (Continuing Professional 
Development) identified during PDR?  
•  Has CPD been completed within the time 

frame identified?  

Performance, Risk & 
Accreditation 
(These items involve 
awareness of key 
documented metrics and 
risk records, which must 
be maintained and 
communicated regularly.) 

Equipment & Safety 
Checks 
(Implies a formal daily log 
of safety-critical equipment 
– a vital documentation 
process.) 
Business Continuity & 
Emergency Preparedness 
(These are formal 
documented plans and 
protocols essential for 
emergency response.) 

•  Are staff aware of the ward’s performance 

quality metrics?  

81% 

•  Are staff aware of the staff survey results and 

any improvements taken?  
•  Are staff aware of the last Quality 
Accreditation Assessment award  

•  Do staff know the Top 3 risks in their area?  
•  Are staff aware of the risk register?  

Staff unaware of ward 
performance quality metrics and 
top three risks in their area. 

Work is underway to implement a 
digital ward metric screen for 
display in ward areas, which will 
include IVQA results. Works tracked 
through the Quality Priorities action 
plans 

QI Training for Band 6 Staff (Alice) 
e-learning completed by all band 6s. 
Band 6 staff booked onto QI course. 

Is the resuscitation equipment checked daily and 
equipment in date? 

100% 

No Gaps 

Shift lead or manager should be able to provide/identify 

72% 

o  The business continuity plan 
o  The response required during a major incident 
o  Relevant action cards 
o  Major incident management response 

principles (Silver/Gold/Bronze framework) 

There was a lack of 
understanding of Business 
Continuity Plans in areas during 
their initial assessment; however, 
compliance improved 
significantly in follow-up 
assessments. 

The Quality Accreditation and 
Business Continuity systems are 
integrated, enabling the Trust 
Business Continuity Lead to monitor 
low compliance and target training 
and awareness needs. 

Business Continuity Awareness 
Plans are being developed to 
familiarise shift leaders with 
business continuity procedures. 
This area has been identified as a 
compliance gap with progress 
anticipated