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Inspection Summary

Overall summary & rating


Updated 24 March 2016

St Thomas' Hospital is part of the Guys and St Thomas' NHS Foundation Trust (GSTT) which provides acute services to the population in the London boroughs of Southwark and Lambeth generating over 2 million patient contacts per year. The hospital has 920 beds and also acts as a tertiary referral centre in a number of specialties across the south of England including cancer services, cardiothoracic services and orthopaedics. The hospital also includes the Evelina London Children's Hospital.

GSTT employs approximately 12,586 staff of which 5560 are employed at St Thomas' Hospital.

We carried out an unannounced inspection of St Thomas' Hospital between 7th and 10th September 2015. We also undertook unannounced visits to the hospital on 21st,22nd,23rd and 26th September.

Overall this hospital is rated as good. Urgent and emergency services and services for children and young persons were rated as outstanding. Medical care, surgery, end of life care,outpatients and imaging, critical care and maternity and gynaecology were rated as good.

The compassionate and supportive nature of the care provided was rated outstanding as was the quality of leadership provided. Services were rated as good in terms of effectiveness and responsiveness, however the overall provision of safe care requires improvement.

Our key findings were as follows:


  • There was an open and transparent approach to incident reporting that was supported by processes for reporting and the learning from incident investigations largely embedded.
  • Both nursing and medical staffing levels and skill mix supported the provision of safe care and was well supported by a programme of mandatory training. Staffing levels in maternity services were reviewed annually and although there had been an increase in the antenatal day assessment unit  staff found it hard to keep up with demand at times.
  • Their were effective arrangements in place to minimise the risks of infection to patients and staff.
  • Medicines and medical records were managed in an appropriately secure and monitored manner.
  • Access to equipment and the quality of the physical environment were good with the exception of parts of the critical care service which was cramped with beds close together.
  • Patient risk was well assessed across the trust, however the full five steps to safer surgery had not been fully embedded in operating theatre practice.


  • Staff had ready access to and followed policies and protocols driven by accepted national guidelines and best practice.
  • Multi-disciplinary teams were very well developed with a full range of health and social care professionals. In some areas, notably the urgent and emergency care department, the multi disciplinary teams were supplemented by further specialist teams including alcohol and toxicology support.
  • Staff received appropriate appraisal and supervision and worked within a competency framework. Learning and development opportunities were provided for and specialist roles well developed in nursing.
  • Patients were largely given timely pain relief following the application of appropriate pain scoring tools although we did identify some inconsistent documentation.
  • Meal times were protected and well supported to ensure nutrition of patients. Similarly fluid intake was monitored to protect patients from dehydration.
  • Consent processes and the documentation of mental capacity was largely good, however review of consent forms in surgery identified illegible recording.


  • Our observations and feedback from patients and carers indicated a kind, compassionate caring approach to the delivery of care. This was of particular note in children's services, critical care and end of life care where exceptional practice was identified.
  • Patients reported that they treated with dignity and felt fully involved in their treatment and care.
  • Services were well designed to provide emotional support to patients, carers and colleagues with access to counselling and spiritual support. Post bereavement support was of an exceptional standard in a number of services.


  • Services were well planned to meet the needs of the local population and co-ordinated with community and primary care services with the homeless team and the proactive older patients service examples of excellence.
  • Patients were largely treated in timely manner meeting national access targets. However the trust had not attained the 62 day cancer access target since 2013.
  • Services were designed to meet individual needs with the development of communication support for dementia and other complex patients very well developed. This was enhanced by the patient experience tale 'Barbara's story' which had clearly impacted on all staff and was extensively understood.
  • Patient flow was well managed leading to minimal movement of patients between wards and a low numbers of surgical cancellations. Proactive discharge planning was well supported by the hospital at home team.
  • The processes for the management of complaints and dissemination of learning from complaints were well developed although one surgical department had a significant number of complaints remaining unresolved.


  • The culture of organisation was highly positive, open and proud and was fully reflected in the high degree of engagement and empowerment of staff in service provision and improvement.
  • Leadership within the trust was visible, supportive and collegiate and this, along with the organisational culture, contributed to the stability of the workforce in terms of recruitment, retention and low sickness levels.
  • Robust governance arrangements were in place to monitor, evaluate and report performance and risk back to staff and upwards to the trust board.
  • The trust vision and strategy was well communicated and understood and as a consequence directorate plans were fully aligned.
  • The organisation encouraged and rewarded innovative practice and service development.

We saw several areas of outstanding practice including:

  • The use of 'Barbara's story' to engage with staff and enhance a compassionate approach to patient care. 
  • The specialist support units active within the urgent and emergency department including alcohol, toxicology, homeless, youth support and play therapy for children.
  • The role of the security team in the emergency department was embedded into the day to day working of the department. The team was multi-lingual and trained in effective de-escalation techniques and demonstrated outstanding empathy to patients.
  • The provision of 'reflection time' to staff within the urgent and emergency department.
  • The approach to communication with and support of dementia and complex needs patients via well designed communication boxes and a specialing team.
  • The ward environment and signage afforded dementia patients.
  • The Proactive Older Patient (POP) service.
  • The multidisciplinary team support for families attending the neonatal unit.
  • The paediatric cardiology service had introduced a home monitoring programme for infants following single ventricle palliation surgery (Norwood 1 operation or hybrid procedure). This allowed these patients to safely live at home with their families while they recovered and prepared for the second stage of their treatment.

  • Supportive practice of the mortuary and bereavement team.
  • The SPCT was effective and provided face to face support seven days per week up to 9pm, with calls taken until 11pm and a consultant providing out of hours cover.
  • The AMBER care bundle and a range of training courses for staff in end of life care such as the Sage and Thyme training model, simulation days and Schwartz rounds.
  • We saw staff in the bereavement office had sourced funding to provide family members with sympathetically designed cloth bags so they had a more discreet way of taking home personal belongings of a deceased patient, rather than use a plastic hospital property bag.
  • Staff in the emergency department had sourced funding and designed and produced a bereavement card that they sent to any families whose relative died in the department.

However, there were also areas where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure the quality and safety team coordinate and have oversight of all governance issues to improve learning and sharing across directorates.
  • Ensure that all women attending maternity department receive a venous thromboembolism risk assessment.
  • Ensure that appropriate levels of midwifery staffing are available in all areas so that women are cared for in the most appropriate environment.

In addition the trust should:

  • Review barrier nursing arrangements within HDU and ensure the environment meets infection prevention and control guidance
  • Ensure that the full 'five steps to safer surgery' are embedded in operating theatre practice.
  • Continue reviewing and improving cancer performance.
  • Ensure consent is clearly documented and patients are given documentation of the process. Implement the recommendations from the consent audit 2014.
  • Ensure all complaints are responded to in a timely manner.
  • Where appropriate utilise day surgery more to reduce the length of stay.
  • Address areas of the national fracture neck of femur audit where the trust is performing below the national average.
  • The hospital should ensure that staff are familiar with the mental capacity assessment process and that this is followed where appropriate.
  • Ensure all staff are aware of safeguarding principles and triggers for making a referral
  • Continue to increase consultant cover in maternity services.
  • Ensure that telephone advice given to women in maternity services is documented
  • Ensure there is a system in place to check that HSA4 notifications of termination of pregnancy for fetal abnormalities are submitted to the Department of Health.
  • The hospital should consider reviewing the tools staff use to assess pain and introduce a standard methodology that is consistently used and recorded.
  • The hospital should consider reviewing the process for completing DNACPR form, determine a specific location where they are kept and ensure staff are aware they can be used as an interim measure on discharge until the primary care team can complete a new one.
  • The hospital should consider reviewing the escalation process when delays occur with the completion of death certificates. 
  • Ensure all incidents in the outpatients department are investigated promptly and outcomes of the investigations recorded and shared with team to prevent recurrence.
  • In the outpatients and clinical imaging departments ensure all staff are appraised regularly as prescribed by trust’s policies related to staff training and development
  • The hospital should ensure staff are aware how to arrange for an interpreter.
  • ​The hospital should ensure that consultants review the results of local audits and implement strategies to ensure results continue to improve towards meeting CEM guidelines.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas


Requires improvement

Updated 24 March 2016



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Updated 24 March 2016

Checks on specific services

Critical care


Updated 24 March 2016

There was a proactive safety culture for reporting and learning from incidents. Critical care management were aware of on-going risks; these were recorded on the department risk register and largely reflected our inspection findings. Safety thermometer results and patient outcomes, particularly for patients receiving ECMO, were good. Patients were cared for by safe numbers of staff, using evidence-based interventions. Caring staff obtained consent prior to procedures and maintained patient privacy and dignity.

The critical care service was flexible to the needs of patients and successfully used a “never say no” admissions policy. Few patients were transferred out of hours and the proportion of delayed discharges from critical care was better than in other similar units. The critical care environment was cramped with little spacing between beds. However this issue was being addressed with a HDU rebuild and a new critical care unit. Staff and patients were engaged in developing plans for the new units and providing feedback about the service.

Substantial participation in national and international research projects was apparent and we saw evidence of many departmental contributions to journal articles, book chapters and clinical guidelines. New innovations in critical care including telemedicine were being trialled and plans for formal implementation were in place.

Staff knowledge of safeguarding and Deprivation of Liberty Safeguards (DoLS) was variable across the service despite a high uptake of training in this area and safe practice relating to this was not embedded. Staff appraisal rates were low and less than the recommended 50% of nursing staff had a post registration award in critical care nursing.

Outpatients and diagnostic imaging


Updated 24 March 2016

Outpatients and diagnostic imaging services provided at the hospital were safe, caring and well managed. However, they were not always responsive to patients' needs.

There were long term strategies developed for individual departments and staff were aware of them. Staff felt they could influence decisions made in relation to day to day running of their department and felt empowered by their management. The hospital had effective governance systems and healthy organisational culture of openness and transparency. Staff were happy working at the hospital and were provided with appropriate support to allow them to perform their work effectively.

Patients’ care was well organised, with individual patients being discussed during multidisciplinary team meetings. Patients told us they felt involved in their care and that they were treated with dignity and respect. They also felt involved in decisions about their care and treatment.

There was a sufficient number of nurses and medical and dental staff in post to run all of the scheduled clinics and extra evening and weekend clinics when required. Staff knew how to report incidents and raise a safeguarding alert, they were encouraged to report incidents and received direct feedback from their line managers. Staff told us they were able to share concerns openly. Staff were competent and had had appraisals within the past twelve months. They had access to information in order to support decision making and offer appropriate care and treatment.

The trust had met the national waiting time target of 18 weeks for non-admitted and incomplete pathways. The trust had also consistently performed in line with the England average in relation to the two week wait urgent referral performance target. The trust had systems which allowed gathering data, they were able to analyse it to identify risks and prioritise patients accordingly to clinical need.

However, we noted the services were not always responsive as the hospital did not meet national targets related to cancer treatment and had performed below the England average since April 2013.

Urgent and emergency services


Updated 24 March 2016

The vision and strategy of the team working within the department was one of striving for excellence, which was demonstrated through a continuous programme of clinical and professional development. This was delivered by a cohesive, highly enthusiastic team that worked in a culture of mutual respect and trust.

Our review of over 190 individual pieces of evidence and discussions with over 30 members of staff, revealed that the department was led by a team who embedded transparency and openness in the day-to-day working of the department. Staff were encouraged to report incidents and did so confident in the knowledge that learning would take place from them. Investigations into incidents and complaints were robust, impartial and emphasised service improvement.

Although the ED had not consistently met the government’s 95% target for admitting, transferring and discharging patients within four hours of arrival, staff had numerous procedures in place to mitigate the impact of this. The use of an effective streaming process for arriving patients had contributed to a very high performance in ambulance handover times, including no black breaches in the year leading to our inspection. Streaming and triage processes had been streamlined by a highly collaborative team that had conducted pilots and research to assess the safest and most efficient methods of registering and treating arriving patients. The drive and ability of staff to conduct on-going projects in order to improve the efficiency and quality of the service was evident in many other areas, including the flexible deployment of staff and a programme of specialist training that was highly regarded and facilitated by dedicated practice development nurses.

The clinical effectiveness of the department was sustained by a substantial number of audits that were overseen by consultants and senior nurses. Audits demonstrated that consultant sign-off in severe sepsis and the management of neutropenic sepsis patients had improved from 2014 to 2015. Junior staff were encouraged to conduct audits in areas of interest to them and each nurse acted as a link for an area such as infection control or dementia.

Most of the interactions we witnessed between staff and patients were positive and were based on compassion and respect. Where we saw that some individuals dealt with patients brusquely or without regard for their distress, senior staff had plans in place to address poor attitudes. We saw evidence that past approaches to dealing with such issues had been effective. Feedback we received from patients was mostly positive but some people did comment negatively on some of the unfriendly interactions we had seen. We considered such instances to be isolated and we found that the majority of patients held the ED in high regard, as evidenced from the frequent thank you letters and cards staff had received.

The ED was frequently presented with challenges to care and treatment based on the local population, including social care needs of homeless people and treatment needs for people who had overdosed on recreational drugs. Staff had led a number of innovative programmes to better support such patients and to improve their long-term health outcomes. Such approaches had led to substantive relationships with other local service providers, such as those who supported homeless people and those who experienced domestic violence. A well-established mental health liaison team was very highly regarded by the ED staff we spoke with and helped them to care for patients with psychosis and other mental health problems. We identified eight distinct projects that had been carried out by staff to help them care for people with complex needs whilst maintaining the overall clinical standards of the department. The projects served to enhance the scope of the service as well as to contribute to the feelings of achievement we found amongst staff.

The ED was undergoing a major rebuild that had changed the configuration and capacity of the current department. Plans and developments had been communicated to patients and staff had implemented a number of procedures to mitigate the impact of the building works. This had included a 24-hour streaming process and a 24-hour receptionist function in the majors unit. Staff had attended planning meetings with designers and architects to give their input into the new department design, particularly around the design of cubicles for patients with psychiatric needs.

Consideration had been given to the treatment of patients who had learning difficulties or who were not able to communicate verbally. In addition, a well trained and competent security team played a key role in the ED and enabled staff to treat patients with psychiatric needs safely. Staff had a good understanding of the Mental Capacity Act (2005), safeguarding procedures, dementia and their responsibilities for patients who had a Deprivation of Liberty Safeguards authorisation in place.

Maternity and gynaecology


Updated 24 March 2016

We rated the maternity and gynaecology service as good, but some aspects of maternity services require improvement.

Women’s services promoted innovation and encouraged their staff to provide responsive and woman-centred care and treatment. Staff were proud of working for the trust and felt they were able to contribute to improving services. Multidisciplinary teams of professionals with a range of knowledge and skills provided outstanding treatment and care for women with specialist needs, such as pregnant women with lupus, and women with endrometritis.

Staff gave women information and encouraged them to be involved in making choices about their care. Pregnant women were able to make choices about the birth they wanted.

The Antenatal Day Assessment Unit (ADAU) was often full to capacity and women sometimes had to wait a long time to be seen. Births that took place on the ADAU were not reported as incidents unless there were complications with the delivery.

We found there was some confusion among midwives about whether or not all women needed to have a venous thromboembolism (VTE) risk assessment. 

Staff told us management encouraged openness. Incident reporting had increased, and there were systems in place for reviewing, investigating and learning from these. There was evidence of changes to practice following incidents. There was a trigger list of maternity incidents, but we did not find a shared understanding of other incidents to be reported. For example, staff shortages were not always logged on the incident reporting system. Furthermore, we found that incidents were recorded as ‘low harm’ even when women or their babies were transferred for additional care.

Gynaecology services gathered evidence about their services to make business cases for improvements to safety and responsiveness. For example the trust had agreed to increase consultant presence at the emergency gynaecology unit. The maternity service, however, did not have the recommended levels of consultant cover, and although this had been on the risk register since 2010, there had been no increase in the number of consultants at the time of our inspection.

Policies and treatment protocols were informed by evidence based national guidance. Gynaecology and maternity services participated in a number of leading edge research projects and their practice was informed by research findings. Staff ran projects to test new ways of working, for example a project to give early warning of women liable to have a pre-term birth.

There was a programme of audits but the programme required further development.. Outcomes for women were and babies were generally in line with or exceeded national expectations. However, the rate of caesarean sections was worse than the national average and action to reduce this had not achieved sustained improvement. Gynaecology clinics met targets for referral to treatment times.

There was effective working with other specialties in the trust and with local commissioning groups and GPs. Staff of all disciplines reported good team support and learning and continuing professional development. Line managers supported nursing and midwifery staff, and the supervisors of midwives provided regular review and additional training. Junior doctors at all levels felt supported by the consultants and registrars

Medical care (including older people’s care)


Updated 24 March 2016

Overall we found medical care services at St Thomas’ were good.

The safety of medical care services was good. There was a positive culture of incident reporting; staff understood and fulfilled their responsibilities to raise concerns and report incidents. We found measures for the prevention and control of infection met national guidance and standards of hand washing and cleanliness were consistently high and regularly audited. We found there were sufficient doctors and registered nurses on duty; staffing levels were tracked four times a day across the hospital. Patients who were deteriorating received a speedy response and had their care reassessed.

We rated the effectiveness of medical care services as good. Staff were well supported with access to training, clinical supervision and development. Use of NICE guidance was used across a range of conditions. There was a programme of national and local audits regarding clinical practice in place. Patients were assessed by a dietician when screening suggested a risk of malnutrition.

Patients’ nutritional needs were assessed with


recorded and risks identified. Consultants covering acute medicine were available seven days per week. Patients were asked for verbal consent to be treated and we saw consent forms to treatment forms had been signed by the patients prior to medical procedures.

We rated the caring aspects of medical care services as good. Patients received compassionate care and were treated with dignity and respect. Patients and their relatives were positive about their experience of care and the kindness afforded them. Patients told us they were involved in decisions about their care and treatment and were given the right amount of information. The trust's performance in the Family and Friends test (FFT) was consistently higher had a higher than average response rate to the Friends and Family test (FFT) than the England average.

We rated the responsive aspects of medical services as outstanding. The admissions ward was overseen by multidisciplinary medical teams who undertook assessments and provided a rapid response to reduce

unavoidable admission and improve early discharge. The hospital proactively managed patients discharge. Where a patient's discharge was delayed this was escalated to the discharge team to progress. Most patients 79%, (21,405) experienced no ward move and were treated in the correct speciality bed for the entirety of their stay. Patients had their needs assessed and fundamental care rounds were undertaken at different times of the day. Formal complaints were managed through the Patient Advice and Liaison Service (PALS), they were investigated with learning points identified and fed back to staff.

We rated the well-led aspects of medical services as good. Staff were aware of the trust and acute medicine vision and incorporated this as part of their daily work. The culture within the division was one of openness and honesty. There was an appropriate system of clinical governance in medical services that identified quality and risk issues. Staff reported they were supported by their managers and department heads. We found staff and patients were engaged with the development of medical care services, and saw examples of innovative practice.



Updated 24 March 2016

There were clearly defined vision and strategies for each surgery service that included working with other directorates and other organisations to provide the best health outcomes for all. There was strong clinical leadership with visible presence and nurses were empowered.

There was a proactive approach to seeking out and embedding new and more sustainable models of care. Quality improvement was a part of all staffs daily roles and all staff were continuously striving to improve services.

Patients were supported, treated with dignity and respect and involved in their care and treatment. Patients told us that the care was kind, compassionate and they felt listened too. We observed a number of interactions where patients and their families were involved in their care and helped with their emotional needs. The average response rate to the friends and family test was 35% with respondents most commonly recommending the service.

There were sufficient numbers and mix of all staff to provide safe care. There was good retention of nursing staff and management of turnover. There was a very low use of bank and agency nurses. Staff were qualified and had the skills and expertise to carry out their roles effectively in line with best practice. Care was coordinated and staff were worked collaboratively to understand and meet the needs of patients.

There had been nine never events in 12 months and we found the World Health Organisation (WHO) safer surgery checklist needed to always be fully used. However, although we found an open culture of learning from incidents, learning was not shared across directorates.

Staff were knowledgeable on the needs of their local population and service users. Access and flow was well managed by the service by working with the whole hospital. Waiting times and cancellations were minimal.

Services for children & young people


Updated 24 March 2016

We rated the hospital services good for safety. There was a robust and open process for ensuring that clinical incidents were reported and investigated and that lessons learnt from them were fully shared with all staff. Robust safeguarding systems were in place. Patient risks were appropriately identified and acted upon with clear systems in place to identify and manage a baby, child or young person’s with a deteriorating medical condition.

We assessed the effectiveness of care provided as good. There was participation in audits and care and treatment was provided in line with professional guidance. The hospital was effective at coordinating its multi-disciplinary teams to ensure the best outcomes for patients. While not all services operated seven days a week, services were flexible to meet patients’ needs.

We rated the care provided as outstanding. We saw many examples in all areas of the hospital to demonstrate that the hospital was delivering compassionate care. Parent feedback unanimously supported this. Sensitive emotional support was offered to patients, parents and staff. Parents told us they had a good understanding of the care their baby or child was receiving and felt the hospital involved them in the care their children received. Friends and family test outcomes were also highly complimentary of the service. Children and their families were treated with compassion, dignity and respect.

We rated the responsiveness of the service to the needs of patients and their families as good overall, although there were some elements that were outstanding. We found many examples where the hospital and its staff had made special efforts to meet the needs of children, young people and their families. Examples of initiatives were a fasting reduction initiative for children having surgery, communication boxes on wards to help communicate with nonverbal children or those who did not speak much English, and clinics being timed so secondary school children would not miss too much school. Joint clinics were organised so that young people could meet their ongoing care team to help ease the transition to adult services. However, there were challenges in meeting referral to treatment times in some specialities, and dealing with year on year increases in demand with limited scope to increase capacity in the medium term.

Complaints and concerns were taken seriously. They were responded to promptly to achieve resolution. Feedback was actively sought from parents, children and young people about their current care experience, and where possible changes to improve the quality of care were introduced in response to suggestions.

We found leadership in ELCH to be outstanding. The vision to establish Evelina as a comprehensive specialist children’s hospital within a regional clinical network was well understood and supported by staff.

The hospital had a strong clinical governance structure, focused on reducing clinical risk, monitoring quality and improving patient outcomes. There was committed,supportive leadership at local, service and hospital levels, and clear reporting lines for escalating risk, disseminating information and monitoring standards, We found an open and transparent culture with motivated and compassionate staff who were well informed about the hospital’s priorities as well as those of the wider trust, and felt they had a genuine role in shaping the development of the hospital. Staff valued the democratic culture and were passionate about supporting children and their families through sickness,. There was an ethos of continuous improvement. Families and patients also felt involved in developing the hospital through consultation and effective communications.

End of life care


Updated 24 March 2016

Staff who worked in the specialist palliative care team (SPCT) demonstrated a multidisciplinary approach to caring for their patients.

They worked cohesively with generalist nurses and medical staff, respecting each other’s skills, experience and competencies in a professional manner that benefited the patients they cared for.

Staff at St Thomas’ Hospital provided skilled and compassionate end of life care to patients. The SPCT was effective and provided face to face support seven days per week including 24/7 community visiting. Due to staff shortage at the time of the visit on call was restricted to visits until 9pm and calls taken until 11pm. The Consultant rota remained unchanged during this period. 

There was good leadership of the SPCT, with staff commenting on how senior managers were visible, approachable and willing to help out. They also provided consistent and prompt guidance and support. We found many examples of innovative practice, including the AMBER care bundle and a range of training courses for staff in end of life care such as the Sage and Thyme training model, simulation days and Schwartz rounds. We saw staff in the bereavement office had sourced funding to provide family members with sympathetically designed cloth bags so they had a more discreet way of taking home personal belongings of a deceased patient, rather than use a plastic hospital property bag.

The hospital had a long term vision and strategy plan around end of life care. This was in its infancy and staff commented that it needed to be revised and made more achievable. Nevertheless staff spoke very positively of the multi-disciplinary team approach; the importance of quality outcomes for patients and the focus on providing care that was based on individual need. We saw, for example, that staff had arranged for the painting materials belonging to one patient nearing the end of life to be brought to the ward so they could continue with their art. The SPCT encompassed national guidance into its end of life care protocols and practice such as the NHS guidance – Priorities for the Care of the Dying Person and One Chance to get it Right - developed by the Leadership Alliance for the Care of Dying People (LACDP). It also referred to the NICE quality standards for end of life care.

Bereavement support was available from the SPCT social workers, chaplaincy and the bereavement office. We saw patients were cared for with dignity and respect. Medicines were provided in line with guidelines for end of life care. Staff facilitated rapid discharge of patients to their preferred place of death. Feedback from patients and relatives, both in person during the inspection and gathered by the hospital in its own bereaved carer survey, was overwhelmingly positive.

The hospital was in the process of moving to wholly electronic based records. We found that during this process staff needed to use three different software systems as well as paper records, which led to some confusion and uncertainty around where to find key information. This was particularly noticeable with regard to 'do not attempt cardiopulmonary resuscitation' (DNACPR) forms. We found that in some patients’ notes their condition indicated a mental capacity assessment would have been appropriate but staff had not carried one out. We were told there were sometimes delays in relatives being issued with a death certificate due to the unavailability of doctors to complete the paperwork.

From January to December 2014 there had been 971 deaths at the Trust.