Pennine Acute Hospitals NHS Trust

“the RCPCH is unable to comment on the specifics of the case and the Pennine Acute Hospitals NHS Trust has been asked to respond directly on local communication, record keeping and policies and procedures.”

“The Division of Women and Children's is undertaking a programme of rolling audits on communication and documentation. The purpose is to ensure compliance with policy standards and to identify areas where there are challenges in order to implement remediating measures.”

“The division has commissioned an improvement programme of work focusing on these three areas in order to fully embed effective and reliable processes into clinical practice.”

“There has been guidance issued to all practitioners to reiterate the need to obtain a thorough, probing history from the patients to ensure questioning covers the potential rupture of membranes in line with policy and carry out an appropriate speculum examination.”

“Undertaking correct acute monitoring of patients condition, through using early warning scores is currently a Trust wide project to improve practice.”

“The neonatal services has developed a module of training entitled Care of the Compromised Infant, which now forms part of each midwife's mandatory training; the .....”

“The Division have developed a programme of training to emphasise recognition of signs and symptoms or deviations from normal physiological observations.”

“We are undertaking a review of current documentation to ensure it meets all Trust standards and therefore supports improvements in care delivery. On a monthly basis the ward is audited using the nursing metrics which includes the quality of record keeping.”

“¢ Since January 2015 Ward T7 has recruited into a number of vacant registered nurse posts; as part of the induction for these new staff we have developed an induction booklet which includes the requirement for a senior member of the nursing team to observe the staff member undertaking various tasks to confirm that these are being performed competently - this includes completion of documentation such as District Nurse referrals, SKIN bundles (for tissue viability) and Rounding Tools”

“There are also weekly audits of documentation undertaken by the Clinical Matron/Unit Manager and the Band 6 Sisters and feedback is given to the relevant member of staff at the time of the audit. These include accurate and timely completion of risk assessments, use of appropriate care plans and timely reassessments.”

“SKIN bundle training has also been provided by the Equipment Co-ordinator who is a member of the Tissue Viability team.”

“For early detection and management of pressure ulcers the use of scenario training on the completion of the PurposeT tool is now in place.”

“Since February 2015, the Unit has achieved 90% and above in the Nursing Care Indicators Audit except for May when the results reduced to 84% and this reduction was responded to immediately recognising that this was related to a trial of incorporating nursing documentation within the medical records. This was addressed and results improved to 92% in June, 95% in July and 93% in August.”

“advice, the Trust has taken action to prevent future deaths as documented below. This work has been led by Vascular Surgeon and Clinical Lead for Anaesthetics. New Thrombolysis Policy drafted November 2014 prior to inquest (please see attached in appendix 1). The new Thrombolysis policy was circulated and is now available on the Trust Intranet. All Critical Care staff have had a series of Training sessions in the care of the thrombolysed patient which was provided by the Vascular and Radiology 27”