Royal Stoke University Hospital

“The issue of why Mr [name redacted] did not have his gastroscopy on 7 April 2022 was discussed in the Gastroenterology Mortality and Morbidity Meeting on 18 May 2022; at that meeting, the Clinical Lead for Gastroenterology agreed to discuss further with the endoscopy manager to develop a system that facilitates an 'in-patient' bed space for those awaiting urgent or emergency gastroscopy.”

“All Clinical Leads to instruct Junior Doctors and Nurse [name redacted] that when summarising discharge letters, any significant event such as patient falls while in hospital is reflected on their discharge summary.”

“Ward staff to ensure that alongside the paper version of handover between UHNM and other hospitals, a verbal handover happens as part of a trusted assessment.”

“The Transfer of Care Form has now been revamped and a more comprehensive and holistic Patient Profile documentation is in place. This is a more detailed handover and requires other members of the multi-disciplinary team to contribute in its completion.”

“This incident was already shared widely across the General Medicine Department and Medical division. A Memo has been circulated divisionally to reiterate the importance of accurate and timely datix reporting.”