Philip Robinson

“The discharge stamp was trialled and found to be unsuccessful within ATC with its high turnover of patients. Since this incident ATC has undergone an”

“The i-Hospital white board system is due for implementation later this year. This will highlight which patients have a high EWS and the next due time of observations. On discharging a patient from the system, the system will provide the nurse with an additional opportunity to assess EWS on discharge”

“The safety brief at the end of the ward round involves the whole of the ward team including HCA's to improve communication of EWS between all the Multi-disciplinary team. The observations project has been completed and education undertaken with respect to the importance of clear communication between all members of the team. A safety brief is embedded in practice between shift change overs to improve whole team awareness of issues on the whole unit”

“Audits on ATC of documentation of EWS by HCA in the notes have consistently improved, reducing the chance of verbal communication failure. Recent audits show 100% compliance with the escalation policy on ATC”

“The medical staff involved in this Inquest do not agree with the SUI author, that an ECG was indicated during Mr [name redacted] admission. There are no clear guidelines to assist medical staff with this clinical decision making when a patient presents with acute breathlessness. An audit to monitor the threshold for performing an ECG has shown this is still not reliably performed when clinically indicated”

“There are no clear national guidelines to assist medical staff when ordering ECGs in patients who present with breathlessness. Acute medicine at Bassetlaw relies on early senior review by consultants. However variation in clinical judgement will occur. This incident has been communicated widely within the emergency care group by way of awareness”