Dorset County Hospital

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. However, since the last inspection report in 2018, the service had made significant improvements for quality of record keeping and risk management for patients with mental health concerns.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service recorded 34 serious incidents between January and December 2025. Of these, 31 were identified as low harm incidents and 3 were moderate harm incidents. All low harm incidents were reviewed on a weekly basis by the emergency department (ED) team at a patient safety huddle. All incident reports were verified to confirm the actual risk and harm level. Staff reported themes and specific incidents to the trust patient safety huddle. This provided leaders with the assurance that incidents were appropriately investigated.

Staff and leaders demonstrated an open and transparent reporting culture. Staff understood when and how to report incidents and were confident leaders would investigate these. Moderate harm incident records showed staff had undertaken swift action to report incidents and escalate concerns when they realised an incident had occurred. Patient safety incident investigation (PSII) reports reflected NHS England’s ‘just and learning culture’ charter. Learning actions and outcomes recognised both organisational and individual accountability.

During the assessment of this service, there was 1 PSII in progress relating to a Never event incident that occurred between January and December 2025. A Never Event is a serious, preventable patient safety incident in healthcare that should not occur if national preventative measures are properly implemented. Leaders had undertaken statutory duty of candour and given both a verbal and written apology to the patient. The statutory duty of candour is a legal requirement for health and social care providers to be open and honest with patients when an unexpected or unintended incident leads to serious harm or death. In the interim, leaders started to make improvements to medication safety controls, environmental design and workload pressures.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. However, there was routine use of corridor care which risked patients’ safety, privacy and dignity and staff’s ability to provide safe care.

The ED was operating significantly beyond it’s intended capacity. The number of patients waiting over 24 hours in ED had doubled from 236 in October to December 2024, to 570 in the same period in 2025. The ED was originally designed to accommodate 22,000 attendances per year, but the forecast for 2025/2026 meant the service was accommodating 60,000 attendances per year. On the first day of inspection, all resuscitation and high care beds were fully occupied, with 8 patients waiting for an inpatient bed. The longest recorded time since arrival was 40 hours in resus/high care and 36 hours in majors. In addition, three patients were waiting for medical care beds in the ED Admissions Unit (EDAU). As a result of sustained demand exceeding capacity, patient flow through the ED was compromised, and pathways into and out of the department were complex, contributing to extended waits for inpatient beds and definitive care.

Staff and leaders reported that the use of corridor spaces, including the ‘queue in’ and ‘queue out’ areas, had become an established response to capacity pressures. Staff and leaders took steps to mitigate risks and protect patients from harm within the limitations of the environment. Policies and guidelines were followed to ensure corridor care was used only when necessary, and higher risk or vulnerable patients were not routinely managed in the ‘queue out’ corridor in line with NHSE guidance. Clinical oversight was maintained, with all patients discussed at morning and evening handovers and allocated a named lead clinician, even when already under a medical or surgical specialty.

To support the 2025 national 45-minute ambulance offload protocol, the ED introduced a ‘queue in’ strategy to mitigate frontline crowding risks. When ambulance handovers exceeded 30 minutes, the nurse in charge triggered an immediate escalation to senior leadership, mandating a strategy meeting within 15 minutes.

The protocol aimed to achieve 15 minute handovers and 30 minute initial assessments in the Fast Assessment Bay (FAB). Key recovery actions included deploying additional staff to manage corridor overflow, identifying immediate inpatient bed capacity, and requiring medical, surgical, and transport teams to prioritise patient "pull" and discharges to restore ED flow.

Ongoing system wide pressures meant both ‘queue in’ and ‘queue out’ corridors were frequently in daily use, showing sustained risk to patient flow and care delivery. Staff and leaders followed risk assessments to ensure the most vulnerable patients were not looked after in these spaces in line with local and national guidelines. On the day of inspection, there were no patients who were high acuity, with mental health needs, children or patients with confirmed or suspected infection cared for in this area. Staff performed rounding every 2 hours, for patients in the main ED waiting room and the fit to sit areas. Rounding is a structured process where nursing staff perform regular routine checks such as basic observations and pain scores to manage patient safety and wellbeing. On the day of inspection, we reviewed a sample of care records of patients who were triaged from walk in ED to the waiting room or fit to sit areas, and these had been completed well.

While patients waited for a ward bed in the ‘queue out’ corridor, the ED team remained responsible for the care and treatment of the patient, with input from the relevant onward team. There was effective cross departmental team working to prevent gaps in planned care. Although, this placed additional strain on the ED team as the ‘queue out’ corridor required additional staffing, not included in workforce numbers, there was a process to ensure there were safe staffing levels.

However, patients were not always streamed to the most appropriate service for their needs at the front door of the ED. Nurse led streaming and redirection options were limited by the patient attendance route. Patients who attended ED through the ambulance service, required nurse coordinator review and ED clinician assessment before moving to FAB or referred away from ED. The only option for redirection out of the main ED was to Same Day Emergency Care (SDEC) on completion of initial assessment. This required a referral to SDEC, before an SDEC clinician could review and accept transfer. Some staff said this contributed to the crowding problem in ED.

However, patients attending the walk in ED area usually received nurse led triage in less than 15 minutes. They were either treated in the connected ‘see and treat’ service, streamed to main ED or SDEC or discharged and redirected to another more appropriate service off site. Also, patients who were referred by their GP or NHS 111 to SDEC, were able to attend these services directly and this pathway worked effectively. The SDEC and Frailty SDEC were run by the Acute Medicine and Elderly Care services in line with national guidance. There were long term plans to improve patient flow by establishing additional speciality SDEC pathways, rapid assessment clinics and expanded pathways into the existing Acute Hospital at Home service.

Staff and leaders were supported by an electronic patient record system (EPRS) used to visualise the flow of patients through the department and record care and treatment. However, staff who had used this system elsewhere noted several functionalities not available at this ED, which could improve quality of care. This included a required task list for each patient which flagged outstanding tasks, lists of patients waiting to be reviewed by other specialties and digital flags for pre-existing conditions and priority health concerns. Leaders confirmed existing functionality to review open referrals and digital flags on the system. While information was available to staff, staff navigated multiple digital interfaces to retrieve this. The trust had a structured digital transformation strategy which addressed this vulnerability. This included a new integrated electronic patient health record system scheduled for implementation in 2028.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff completed safeguarding training, knew how to raise safeguarding concerns, and did this when required. Leaders were well informed of the safeguarding risks associated with their ED attendees. Between July and December 2025, the service submitted 35 adults referrals and 204 children's referrals to various internal hospital teams and external stakeholders. This included cause for concern referrals, domestic abuse advocates, local multi-agency front door children’s services, local and non local children's services. Of these, most were serious concerns relating to the safety and welfare of children, which resulted in statutory referral to partner agencies such as the local authority safeguarding teams.

Systems and processes were designed to support staff and the service to raise safeguarding concerns effectively. Safeguarding policies and guidelines were available to staff through the intranet. These were up to date and included current terminology. Most of these included quick reference guides and information on how to complete a good quality referral. Staff said these were easy to complete and could demonstrate how to generate and submit these on the Electronic patient record system (EPRS).

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies to share information in a timely manner. The EPRS included features such as an internal flagging system which meant information about high-risk children, such as children with a child protection plan, was shared with staff caring for the patient.

The trust rolled out a new mental capacity act training package in December 2025 to improve the quality of training. This included a new competency assessment tool which meant staff were required to demonstrate safe and effective application of mental capacity act principles.

The trust ensured staff received safeguarding training in line with national guidelines and requirements, but completion rates were lower than expected. The ED department’s safeguarding training completion rate was reviewed at the safeguarding committee and reported up to quality surveillance committee. The trust had set the expectation for safeguarding training compliance at 85-90%. In December 2025, the ED service reported 78% overall completion rate across all staff grades for safeguarding children level 3 training. There were no reported compliance rates for safeguarding adults' level 3 training. Level 3 safeguarding for adults training was not made available to staff until mid 2025. The trust planned to begin monitoring compliance from 6 months after the new training delivery. There was cross divisional working to remove outdated training reporting information for staff who no longer required safeguarding children level 3 training. This was expected to bring the training rate up to the expected level by April 2026 and was reviewed quarterly by the trust as an ongoing risk.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe and supportive.

The walk in area of ED did not always manage the risk of deteriorating patients well. Walk in ED reception staff did not have a list of red flag symptoms to alert the nursing team of potentially seriously unwell patients. Red flag symptoms are warning signs indicating potentially serious, underlying, or life-threatening conditions that require immediate assistance. Royal College of Emergency Medicine (RCEM) recommends that well defined red flag presentations such as crushing chest pain or profuse bleeding should be recognised and escalated by ED reception staff. However, there were no incident records shared with us showing this had occurred. Walk in ED reception staff said they ‘used common sense’ to raise concerns with the triage nurse if patients reported becoming more unwell. Additionally, there was no direct line of sight from the reception area to the waiting room. Although there was a security camera with a feed in the adjacent triage room, the triage nurse would primarily be focused on assessing the needs of the patient being triaged. While the service endeavoured to keep triage time under 15 minutes, this sometimes increased to 30-40 minutes during busy periods. The service could not be assured that staff would respond with timely care and treatment if patients in the walk in ED waiting room became seriously unwell. The service had ongoing plans to resolve this risk, with completion of the open plan waiting area due in August 2026. Following the onsite inspection, leaders confirmed mitigations such as daytime volunteer support and observation mirrors for reception staff were already in place. Following feedback, leaders identified that staff had access to a standardised list in line with national guidance, although this was not visible in the walk in ED at the time of inspection. Leaders reviewed the document, ensured it was visible and improved staff training and awareness.

The service was improving compliance with the trust target for Sepsis 6 management within the Emergency Department. The ‘Sepsis 6’ was designed to improve the early recognition and management of sepsis, a time-critical condition caused by the body’s extreme response to infection. Audit data from October to December 2025 showed compliance ranging between 67% and 92% across the 6 components of Sepsis 6, with 5 out of the 6 areas achieving over 83% compliance. Oxygen administration and documentation showed 67% compliance against the trust target of 100% for each area. There was a comprehensive ongoing action plan to continue driving improvement in sepsis management across the Emergency Department.

ED staff used the Paediatric Early Warning System (PEWS) consistently well. PEWS is a nationally recognised tool used to recognise and respond to the deterioration of children or young people. Paediatric sepsis audits showed no children or young people required treatment for sepsis despite high PEWS scores.

When staff used restraint, it was lawful, for a legitimate purpose, safe and necessary. Restraint is an intervention that prevents a person from behaving in ways that threaten to cause harm to themselves, to others, or to property. The security team were based in the main ED and supported clinical staff with restraint avoidance where possible and safe holding techniques when situations escalated. In 2025, there were 45 incidents reported for use of physical and/or chemical restraint in the ED. Incident records showed security staff undertook proportionate and approved safe hold techniques for the minimum amount of time required. Most of these were no harm incidents, and 5 resulted in low harm.

Staff had access to policies and quick reference guidelines which supported them to respond appropriately when patients required chemical restraint. These documents reflected national laws and guidelines such as the Mental Capacity Act 2025 and Royal College of Emergency Medicine guidelines. Incident records showed staff had followed guidance to use the least restrictive option when caring for vulnerable patients with acute behavioural disturbances. Staff treated patients with dignity and respect when they were at their most vulnerable. However, there were occasions when restraint needs suddenly escalated and some staff said improved communication between clinical and security staff could have reduced risk of staff injury

There was enough equipment for staff to manage emergency situations specific to the ED environment. Most ED areas had dedicated resuscitation trolleys nearby and audits between April 2025 and December 2025 showed these had been checked daily in line with local policy. Paediatric emergency equipment containing age and size appropriate medical devices were kept in a labelled trolley located in resus. Quick grab boxes for time critical interventions, paediatric documentation and guidelines were kept in centralised locations to allow prompt and easy access.

We scored the service as 2. The evidence showed some shortfalls. The service had significant challenges due to the aged estate and poorly suited infrastructure which exacerbated Emergency Department crowding. The design of the environment did not always promote the safety of the people who used it.

The ED department had outgrown its’ designated footprint. The building was no longer suitable for the needs of a modern hospital which presented a challenge to direct clinical and operational oversight. There were challenges to keep the ED operational while long term improvements, such as essential improvement works and new facilities were being built.

The ‘queue out’ corridor was regularly used and did not have all the facilities to support the same high standards of care for patients as those in inpatient bed spaces. There were no immediately co-located showers or medicines preparation spaces. At times nursing staff had to leave the area to prepare medicines, such as pain relief, in the main ED. During the inspection, we observed the area unattended by nursing staff for 8 minutes.

There were privacy and security risks as the ‘queue out’ corridor space would normally be used for access to areas such as the mortuary and radiology. Although there were fixed privacy screens between patient bedspaces and other necessary equipment such as call bells and hand-washing sinks, there were no secure access doors or other barriers to prevent unauthorised entry, meaning members of the public could gain access to patients in the ‘queue out’ corridor. Also, on the day of inspection, in the ‘queue out’ area, we observed medicines administrations printouts which had not been disposed of in confidential waste. However, staff and leaders followed risk assessments to ensure the most vulnerable patients were not looked after in these spaces. Other patient records were stored securely. Improvements were being made to improve the conditions in the ‘queue out’ corridor, such as blinds for improved privacy and purchase of additional bedside tables to support patient nutrition and hydration needs.

Triage rooms in the walk in ED area did not have dual doors in line with best practice guidance such as Health Building Notes (HBNs). Dual doors enable staff to have a route of safe exit, should patients become violent. However, ED leaders had mitigated this by installing panic alarms in the room.

Children and young people were treated in the same areas as adult patients. This was due to the dated design of the ED. The walk in ED provided a shared waiting area with no separation between children and adults. ED leaders said a privacy screen had been considered, but this had not been implemented as patients were not expected to wait for triage longer than 15 minutes. This did not meet best practice guidelines from the Intercollegiate Committee for Standards for Children and Young People in Emergency Care which recommend that children and young people should be easily visible in the waiting area of all ED areas. Additionally, there should be audio-visual and secure physical separation between adult and paediatric patients. However, there was a separate waiting room for children and young people in the main ED and where possible, received care and treatment in more private high care rooms.

Staff were not always able to readily access and obtain specialist beds and adapted equipment when needed. Although there were systems and processes for accessing required adapted equipment, staff feedback and incident records showed this was not always readily obtained when needed. This included equipment such as hospital cots or foam barriers for bed rails to minimise risk of injury or entrapment. There was an incident with a baby in the ED, which resulted in no injury. The incident record showed leaders recognised patient trollies were more suitable for young children, but this was limited by the ED environment. Leaders considered identifying more dedicated paediatric spaces to address this. The new ED building due to be completed in 2027 was designed to include a separate paediatric ED. Additionally, to meet the needs of patients with learning disabilities or dementia, staff recalled using pillows to reduce the risk of bed rail entrapment. There had been no incidents of bed rail entrapment ‘Never Events’ in 2025. In response to our concerns, leaders indicated the new NHP paediatric ED will have a range of equipment according to Royal College of Paediatrics and Child Health (RCPCH) guidelines.

The ED service completed detailed environmental risk assessments monthly and took action to resolve identified concerns. There were a range of mitigations used to compensate for the poor infrastructure such as enhanced rounding of all patients and additional safety alarms.

The mental health suite consisted of 2 specially designed rooms and an observation suite, for patients with mental health concerns. These had been built and maintained in line with national standards such as Psychiatric Liaison Accreditation Network standards and RCEM estate standards. The risk of a patient using the fixtures and fittings as a ligature had been managed well and blind spots had been addressed. There were also low ligature risk hygiene facilities next to this suite with an anti-barricade door fitted. This was a significant improvement to the last inspection and meant patients and staff were protected from harm.

Medical devices were managed by the hospital clinical engineering team. Records showed a register of medical devices that reflected the equipment seen on the day of inspection.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have enough qualified, skilled and experienced staff. However, staff received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs.

There were not always enough consultant medical staff to safely staff the emergency department which could impact on safe patient care and sustainability of the service. The service employed 10.35 Whole Time Equivalent (WTE) consultant doctors. This was below the national guidelines set by RCEM 2023, who recommend a minimum of 12 WTE consultants for smaller emergency departments. The smaller size of this ED service, compared with larger ED services nationally, meant the services’ staff undertook more out of hours shifts and a greater frequency of weekend working. Between December 2025 and January 2026, some consultants worked weekend shifts as often as 1 in 3 weekends. This exceeded RCEM’s safe maximum recommendation of 1 in 8 weekends.

Emergency consultant staffing risk was initially escalated to senior leaders in September 2024, but the service had been unsuccessful in gaining approval to recruit to the requested 14 WTE consultants. Leaders said this was due to financial pressures. Additionally, 2 consultants routinely provided clinical cover to the linked air ambulance service. Although this was beneficial for service and skills development and enhanced shared learning between the services, this further impacted on consultant cover. As the service was due to expand between 2026 and 2027, there was already approval to recruit an additional paediatric emergency consultant. This was not enough to make up for the consultant deficit. We raised concerns about the sustainability of consultant cover with leaders who were aware of this issue and had planned to mitigate this risk by recruiting 4 additional middle grade doctors.

Following discussions with trust level senior leaders in February 2026, the service gained approval to recruit additional consultants, bringing the number of consultants above the 12 WTE minimum. Furthermore, leaders gained immediate approval to cover consultant shifts with locum arrangements to bridge the gap. The recruitment of the 4 additional middle grade doctors was deferred until consultant numbers were corrected. As part of mid to long term planning, leaders were undertaking a review of emergency department consultant job plans to support backfill of shifts that had been lost to air ambulance cover, with the intention to further increase consultant cover.

It was challenging for the service to cover gaps in the staff rota. Between October 2025 to December 2025 there were 335 vacant shifts advertised for temporary medical staff cover. The fill rate was 67.76% which meant approximately 100 medical staff shifts were not covered during this period. For the same period, 6.25% of registered nurse shifts and 26.3% of non-registered nursing staff shifts were unfilled.

The ED service did not always have enough registered nurses or healthcare assistants to safely staff the department. The service used the Safer Nursing Care Tool (SNCT) to calculate and monitor whether there were enough registered nurses and healthcare assistants for the increase in annual attendances and expected patient acuity and dependency. However, this did not consider the extra staff required to safely run the queue in and queue out corridor, or the 6 chairs added to the 7 space ED Admissions Unit (EDAU). This impacted on staff morale and wellbeing. For example, nurse coordinators would often not take a break during 12.5hour shifts to ensure the safe oversight of care. Although ED leaders gained approval from the trust to increase nursing staff levels in line with national bodies, this did not directly address the shortfalls in staff numbers due to regularly used additional patient spaces. The service was actively recruiting following the onsite inspection, with new nurse coordinators due to begin employment by the end of June 2026. This improvement was expected to ensure nursing coordinators were enabled to receive adequate rest breaks.

The service used a blended approach to staff the children and young people’s subspecialty of the ED service. The service rostered 1 registered children’s nurse per shift. This fell below the national standards set by RCEM and the Intercollegiate Committee for Standards for Children and Young People in Emergency Care, which states EDs must always have a minimum of 2 registered children's nurses on duty. This was partly due to the small pool of registered children’s nurses employed to work in the ED. However, the service had several mitigations for this area of risk including arrangements for ward registered children’s nurses to support ED when needed, escalation processes to transfer children and young people in the Paediatric Assessment Unit (PAU) on Kingfisher ward when the ED was under pressure and all registered adult’s nurses were trained in Paediatric Intermediate Life Support (PILS) and received additional inhouse paediatric training.

All consultant doctors held full Fellowship of the Royal College of Emergency Medicine (FRCEM) membership and 2 held Paediatric Emergency Medicine (PEM) qualifications. This met national standards for workforce expertise and training, such as the 2025 standards for children and young people in emergency care and training set by the Intercollegiate Committee for Standards for Children and Young People in Emergency Care.

Overall staff absence rates averaged 3.25%, which was lower than the national average which ranged between 4.7-5.7% in 2025.

The overall mandatory training compliance rate for all staff was 86% and fell below the trusts’ target of 90%. This was mainly due to inactive staff records for staff who no longer worked for the service, remaining on the electronic reporting system. The trust was working to remove reporting requirements for some staff who no longer needed specific pieces of training which was expected to bring the training rate up to the expected level by April 2026.

Staff received yearly appraisals. ED leaders had intentionally postponed some appraisals, to support the increase in patient attendances during the winter period. The service was on track to complete all appraisals by the end of April 2026.

We scored the service as 2. The evidence showed some shortfalls. The service assessed and managed the risk of infection. However, there were some areas such as hand hygiene and equipment cleaning which fell below the expected standard.

Staff did not always maintain high standards of hand hygiene and did not always clean equipment between patient use. During the onsite inspection, we observed all staff were bare below the elbows, but did not always use hand gel or wash hands before and after patient care and treatment. Also, we observed staff using equipment such as observations equipment without cleaning in between patient use.

Cleaning rotas for the FAB area in January 2026 were not always completed twice daily. This included equipment and restocking checks.

Approximately half of the chairs in the walk in ED waiting area were damaged, with tears making them difficult to clean properly. However, this had been noted in January environmental risk assessments and reported for repair. ED areas were otherwise visibly clean, had required wipe clean furnishings and appeared generally well-maintained.

However, leaders monitored and completed regular monthly audits for hand hygiene, peripheral venous cannula (PVC) and urinary catheter care compliance. There were mechanisms of clinical governance for the hospital infection prevention and control (IPC) team to review departmental performance and quality. The ED team had performed consistently well in some areas such as hand hygiene, where compliance was 99% in November 2025. There were no IPC outbreaks reported in the ED service in 2025.

IPC audits highlighted areas for improvement, such as peripheral vascular device compliance which achieved 70% between March 2025 and January 2026, where the ED was the worst performing area of the hospital. Also, the urinary catheter care audit in December 2025 showed staff were mostly good at documenting catheter insertion and proper placement of urine bag but were poor at documenting daily reviews and checks of the catheter in patient records. This was likely due to patients remaining in ED areas longer than expected, such as in the ‘queue out’ corridor. There was a risk that patients might be at an increased risk of infection if these invasive devices were not consistently managed well.

We scored the service as 2. The evidence showed some shortfalls. The service had safe systems for the appropriate and safe handling of medicines, however we saw that these were not always followed by staff.

Medicines such as antidotes, controlled drugs and medicines for use in an emergency were available in the main department and stored well. However, in areas where patients were being looked after in corridors, we saw that medicines were not stored well and staff told us they would have to go back to the main department to access antidotes and emergency medicines. Blank prescription stationary was not managed according to trust policy. Daily checks were not consistently taking place and staff responsible for this told us this was due to time pressures on their role.

Staff in the emergency department told us that pharmacy could be contacted with specific medicines queries. However, there was no formal clinical pharmacy support to the emergency department. Alongside the construction of the new emergency department the trust were in the process of reviewing the pharmacy service to the emergency department. However, the potential changes to the provision would fall short of recommendations in national guidance.

Doctors told us that as part of clerking a patient into the department they accessed information from the Dorset Care Record to confirm details of medicines prescribed by the patients GP. For patients visiting from outside Dorset, the Summary Care Record could be accessed. We saw examples of regular medicines being put on hold when contraindicated in periods of acute illness, for example we saw anticoagulants being held in patients admitted with bleeding.

A recent medicines related Never Event had occurred in the emergency department. A medicine had been administered via the wrong route. The prescribed route was oral and the medicine was administered intravenously. We saw that the trust were undertaking a thorough investigation of the incident and had already begun to make changes to practice to prevent this happening again.

An extensive and robust medicines safety programme was available at the trust. A medicines safety nurse was embedded in the pharmacy medicines safety team. Staff told us this improved their ability to engage with nursing staff across the trust and make improvements to medicines administration practices.

The medicines safety team investigated medicines incidents and undertook a wide-ranging program of medicines audits. We saw examples of how these led to changes in practice and improvements in patient safety.

The service had systems to ensure staff knew about medicines safety alerts and took action to ensure compliance with these alerts. The medicines safety team also revisited historical medicines safety alerts and audited the trusts ongoing compliance against these alerts.