Derriford Hospital

On this page

• 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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment the rating remains 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 people could be harmed.

Although the service had made many improvements since our last visit, the volume of patients visiting the department meant treatment and care was not always provided in a safe way. Patients did not always have timely access to assessment or treatment. There were long waits for some patients in corridors and across the department and long waits for medical reviews. The service was previously in breach of legal regulation in relation to safe care and treatment. At this assessment the service remained in breach of this regulation.

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.

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.

Trust policies and procedures provided staff with guidance for reporting, managing, investigating, and learning from incidents. The trust’s incident reporting and management policy was in line with the requirements of the National Patient Safety Incident Response Framework (PSIRF) and focused on learning from incidents to provide safer care. The trust’s patient safety incident response plan identified safety priorities.

Staff said there was a good culture for reporting incidents, they knew what incidents to report and how to report them. Staff were debriefed and received support following serious incidents. Managers were responsible for investigating incidents and leaders shared learning, themes and trends with staff at daily meetings. We observed staff raising questions and concerns at meetings. Some staff said they received emails detailing learning from incidents they raised.

Review of incident investigation reports showed areas for learning and improvement were identified and action plans written. Audits were discussed at clinical governance meetings and learning was shared. The September 2025 paediatric clinical governance meeting addressed risk, incidents and concerns. Lessons learned were discussed with actions identified such as feedback that the department was difficult to access from the general waiting area. Leaders planned to address this in coordination with the youth patient council.

There was evidence changes had been made because of patient feedback such as offering eye masks and ear defenders to help patients sleep in the main treatment area.

The trust had a duty of candour (DoC) and being open policy in line with legislation. Staff understood duty of candour and were open and transparent, giving patients and families full explanations if things went wrong.

All deaths in the emergency department were recorded, details of mortality reviews completed (following a mortality screening tool) and outcomes reviewed. The trust’s mortality review policy provided guidance. Morbidity and mortality (M&M) meetings were used to identify learning from deaths and implement actions to improve practice. Staff told us mortality reviews were discussed at monthly governance meetings and recommendations were implemented when required.

The service did not always work well with people and health system partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

On arrival to the emergency department, patients who self-attended were booked into the department by a receptionist who passed the details to a senior nurse for review and allocated patients to the most appropriate area. Patients were triaged by trained staff using the Manchester Triage System (MTS).

There were improvements in streaming and flow since our last visit. There were policies and escalation plans to manage increased pressures on the service and improve the patient pathway to transfer patients to a point of care as quickly and safely as possible. Nursing clinical educators in the department taught staff about triage and streaming patients to appropriate pathways. However, the service continued to struggle with demand resulting in crowding and faced challenges which meant they could not always ensure patients received timely triage or treatment.

Accessibility to services demonstrated some improvement for walk-in patients. Data showed wait for triage (initial assessment) had improved with an average wait time of 15 to 26 minutes (October 2024 to September 2025). However, during our visit we observed patients waiting from between 16 minutes to 1.5 hours. This continued to be outside of the NHS England guidance for emergency departments initial assessment of within 15 minutes of arrival. Echocardiograms (ECGs) were not always performed and reviewed by clinicians within 15 minutes of identifying chest pain due to long waits for triage. The wait to see a clinician in the ambulatory waiting area was up to 3.57 hours. The percentage of patients treated, transferred or discharged within 4 hours remained below the regional standard (78%) and national emergency access standard (EAS, aiming for 95%). UEC ranged from 47% to 54% between June and October 2025.

We found some patients were queued within the corridor to the majors area while waiting for admission. Staff told us this was to keep the ambulance handover time of 30 to 45 minutes. We observed between 6 and 8 patients waiting on trolleys in corridors. This was a recognised situation in hospitals across the country. Within majors, we observed patients were seen by emergency department staff within a timely fashion. However, some patients remained within the emergency department for long periods before being seen by the medical team. Patients in the resuscitation area were still being routinely seen by medical consultants.

Leaders told us they were working on ways to improve flow as a high priority by conducting hourly risk assessments and increasing the number of beds on 3 wards. These strategies were helping.

Staff told us a significant factor impacting good flow was decision to admit (DTA) when patients were ready to clinically proceed but had not been reviewed by medical doctors. This impacted patients’ length of stay. During our visit the longest wait for medical review was up to 20 hours due to the volume of patients and availability of medical doctors.

Data showed fewer patients were streamed to same day emergency care units (SDECs). There was an improvement in the medical SDEC which no longer accommodated patients overnight and had relocated to a larger location. On this visit we observed the frailty SDEC regularly had frailty patients overnight and other patients from the emergency department if there was a shortage of beds. Staff told us keeping patients overnight had a negative impact as it limited their ability to utilise their specialist skill set. Patients were in mixed sexed bays and sometimes moved overnight if a bed on a ward became available which disturbed sleeping patients. However, frailty SDEC planned to be relocated (March 2026) to the medical SDEC area to increase capacity with additional recliner chairs. Leaders told us there would be no trolleys and overnight accommodation of patients would cease.

To help improve flow, the GP gateway hub signposted patients to services such as GPs, SDECs, urgent treatment centre (UTC) and medical receiving unit (MRU). Triage and streaming staff routinely assessed patients’ suitability to be transferred to a chair to wait for treatment (“fit to sit”). Clinically stable patients who were referred by a GP were sent to surgical or medical assessment units more consistently.

Some patients were referred to the recently opened Dartmoor UTC which saw an average of 100 patients a day with capacity to increase this number. The UTC’s time to triage and time to treatment was good and patients could be referred to a speciality SDEC or direct to other specialities in the hospital.

There were marked improvements regarding ambulance handovers. The hospital ambulance liaison officer (HALO) reception desk was now staffed by the hospital. Good systems and processes aimed to transfer patients from ambulances into the department within 30 to 45 minutes of arrival which was an improvement and meant ambulances were free to pick up other urgent cases in the community. The number of ambulances with patients onboard waiting outside the department had reduced. We observed between up to 6 ambulances during our visit. Staff liaised with crews regarding parking to ensure incoming time-critical patients were transported smoothly. HALOs used an on-line chat called positive patient placement (PPP) with ambulance crews and reviewed patient notes prior to arrival to stream patients to other areas within the trust and out of hospital pathways. They liaised with other departments such as the medical assessment unit (MAU) and SDECs to make arrangements prior to a patient’s arrival.

Fewer patients returned to ambulances to wait but staff said it could sometimes happen. Nurses supported patients in ambulances with medicines, food and drink. There was no evidence showing patients spent the night in ambulances or waited on ambulances for transport home following discharge. However, we were told the improved ambulance drop off timeframe had resulted in some patients waiting in corridors when the department was full.

The mental health pathway for children was challenged. During our visit there were 3 children in the paediatric emergency department who breached the 12 hour limit and 1 child was in the department for 24 hours. There were delays in children being assessed by system partners and this was under review by the trust’s paediatric clinical governance team and listed on the risk register.

The children’s emergency department was able to transfer ill children to the assessment unit or escalate a child’s care to their high dependency unit (HDU). There was a team (separate organisation) to transfer critically ill children, either by helicopter or road ambulance, to another NHS trust which specialised in the care of critically ill children. Children were sent home with discharge information and the electronic system generated letters to GPs which included discharge information.

There was an end-of-life team who worked with the emergency department staff to transfer patients who were at the end of life to their preferred place of dying including transfer to home, hospice or another NHS hospital which could manage their care needs with dedicated end-of-life beds.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The trust’s safeguarding policy referenced national guidance about the actions staff needed to take if they were concerned a patient had been subject to abuse. Safeguarding referrals were sent to the local authority, and monthly meetings were held with the local council and other stakeholders to track referrals and discuss trends.

Safeguarding training for all staff working with people at risk was aligned to national guidance and monitored through the trust’s performance framework. Staff said they received training, knew how to escalate concerns and access support from safeguarding leads when appropriate. Bank staff told us they maintained their safeguarding training to be eligible to work for the trust. Staff were 100% compliant for Level 2. However, not all emergency department staff were up to date with Level 1 safeguarding adults training (77.50%) and Level 3 (29.55%). Leaders told us they were working to support staff to ensure compliance with training, and this was on the risk register.

Emergency department paediatric staff were 90.48% compliant with Level 3 safeguarding children training in October 2025. However, general emergency department staff were not compliant with levels 1, 2 or 3 training (Level 3 was 29.21% in October 2025). There was an action plan of training booked to address this shortfall for all levels.

Staff followed safe procedures for children visiting the service. Children’s nurses spoke of checking the trust system for safeguarding alerts and how they were confident to contact their matron or safeguarding team if they had concerns.

There were policies to guide staff about the use of restraint and restriction to ensure they were not used inappropriately. The use of restraint was understood and monitored, and less restrictive options are used where possible. The security team told us they worked through preventative methods before using restraint.

We reviewed a selection of completed recruitment files. There was a process to check all staff had an up-to-date enhanced disclosure and barring service (DBS) check and, where applicable, had kept their professional registration up to date.

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, supportive and enabled people to do the things that mattered to them.

We observed staff communicating with patients so they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. We saw staff had access to a full range of interpretation services and were able to support people with visual or hearing impairments. However, some patients said they were not always kept informed of what was happening.

Patient risks were still not always identified in the waiting room and the visual monitoring of patients was not effective as the layout of the room made it difficult for staff to safely observe patients. However, we observed an improvement in the monitoring of patients and checking of routine observations following triage which was carried out by health care assistants (HCAs). Building work to improve the layout and monitoring of patients was planned to start in November 2025 which would resolve this.

Initial assessment included infection prevention and control screening and identification of critically ill patients. Staff completed risk assessments for new patients, including falls risks. Staff tried to mitigate against patient falls by using falls stickers to identify those at risk backed up on the electronic patient record system. We observed comprehensive triage of patients; analgesia was offered and next steps explained. Initial assessments of patients included mental health triage including risk of self-harm, suicide or absconding.

Staff used the National Early Warning Score (NEWS2) (a nationally recognised tool to identify deteriorating patients and escalated them appropriately). There was an escalation process if a patient showed signs of deterioration. However, national guidance directed how quickly patients should receive treatment for sepsis based on their presentation. A consultant told us staff monitored patients for signs of sepsis which would be escalated to senior staff immediately when required. However, risk of sepsis was not always identified and addressed in a timely manner as evidenced in sepsis audits with scores decreasing from 80.95% in May 2025 to 54.29% in August 2025. Patients were not always appropriately screened for sepsis and antibiotics were not always given within one hour of the patient presenting with symptoms. The trust was taking action including discussion of sepsis paperwork completion in handovers, educators were asked to support staff to complete paperwork, and staff were encouraged to escalate sepsis.

We found not all patients received a venous thromboembolism (VTE) risk assessment to identify risk of blood clots and determine appropriate preventative treatment. This should have been performed by a doctor or qualified nurse using a standard tool based on NICE guidelines. Staff told us if patients presented with a high risk of a deep vein thrombosis (DVT) or pulmonary embolism (PE) they would be assessed as a priority. Patients should not be in the emergency department for more than 4 hours but there were long waits for medical doctor reviews therefore patients were often in the department for longer periods. VTE risk assessments were required after 12 hours and would therefore only apply to the longest waiting patients. The service aimed to introduce consistent VTE checks for patients who had been in the ED for 12 hours and over. This did not apply to patients who had been in the ED for less than 12 hours. This was raised with leaders during our visit.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The emergency department was difficult to access because there was no patient drop-off area. Signage to the department was difficult to navigate. Within the department there were crowded corridors due to relocated supplies because building work was about to start.

The layout of the seats in the main ambulatory waiting room, facing away from reception, was a risk to patient safety. However, imminent building work to reconfigure the area would improve visibility and the ability for staff to monitor patients. The waiting room was furnished with a television, had wi-fi access and refreshment machines. Triage and waiting times were displayed electronically. There was a relatives’ room which could be used for bereaved relatives and a dedicated psychiatric assessment room designed for patient safety.

The ambulatory and majors treatment areas were crowded during our visit. We observed there was not enough space and some patients were waiting on trolleys in corridors which was not appropriate for safe care and treatment. Staff told us there was not enough space in the majors treatment cubicles and the resuscitation area was cluttered which made it difficult to navigate around patients and set up equipment. However, leaders and staff were continually risk reviewing the situation as part of the improved flow strategies.

The majors treatment area appeared clean with lots of hand wash basins and there were sufficient supplies of personal protective equipment (PPE) available for staff. There were fire evacuation plans displayed on the walls and fire risk assessments were carried out.

We observed all rooms and equipment checks were good. Spreadsheets identified when equipment required testing and electrical appliance checks were due. Generators were tested weekly. The departmental engineer monitored faulty equipment. Decontaminated equipment was collected by porters. Environmental checks included weekly water flushing by the housekeepers. General environment audits were carried out monthly by matrons including computers and oxygen cylinders (oxygen cylinder storage audit showed 100% compliance in September 2025).

We observed the paediatric resuscitation area had a window which could be seen through from a main public corridor. However, this was addressed at the time with a temporary cover and a permanent solution was being arranged.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Not all staff were up to date with mandatory training. Leaders said the department found it a challenge to ensure staff kept up to date with training compliance due to staffing roster needs and length of training demands. However, the leadership team was working to support staff to ensure compliance with mandatory training. This was on the risk register and discussed in the September 2025 governance meeting when actions were identified to address the low compliance including giving staff dedicated training time, supported by the education team.

Data showed 79.58% of emergency nursing staff and 62.14% of emergency department staff had completed resuscitation training (October 2025). This was short of the trust’s 90% target. The department was taking action to address this with additional training sessions.

The vacancy rate for emergency department additional clinical services remained high over the past 12 months at between 35.83% and 42.99%. However, the vacancy rate for nursing (and midwifery) registered staff decreased from 9.54% in August to 5.01% in September 2025 and medical staff decreased from 2.62% in August to 1.60% in September 2025.

There was good staff culture and morale. Staff said they were supportive of one another and many had worked in the department for many years. We observed good 24-hour consultant staffing cover in the main treatment area. Some staff said there was good cover and an adequate mix of staff, while others said there were sometimes gaps in staffing overnight. Clinicians told us there was very good multidisciplinary working within the department and good relationships with colleagues across the trust. Emergency department doctors staffed the urgent treatment centre (UTC) 7 days a week and GPs staffed the UTC 5 days a week, Monday to Friday.

There were 4 clinical practice educators (nurses) who taught staff triage training and streaming to the correct pathways for nurses. New starters were monitored to ensure they received support and training. Staff were trained on streaming to ensure patients were relocated to suitable places such as the UTC.

The service did not always assess or manage the risk of infection. The trust had policies and procedures but staff did not always follow guidance.

The trust’s infection, prevention and management (IPC) policy guided staff to minimise the risk of infection to patients, staff and visitors. Infection control precautions were available for staff on the trust’s intranet. However, staff did not always follow good IPC processes.

We observed staff not always following good hand hygiene principles. Also, we saw staff not always cleaning equipment or changing gloves between patients. Clinical governance meeting minutes showed the primary area for improvement was decontaminating hands before and after contact with patients. Staff identified actions for improvement including increased education for nurses around hand washing and highlighting this at handover meetings.

The department’s cleanliness audits for the year showed monthly compliance in line with the national standards of healthcare cleanliness. Hand hygiene audits monitored staff compliance with national guidance and trust policy for handwashing. Data provided showed mostly high monthly compliance. In September 2025, 7 audits were carried out which showed 100% of staff applied gel correctly and gel was washed off correctly at second attempt. However, only 43 % washed gel off correctly at first attempt.

Emergency department staff had not always completed the required mandatory training in IPC. Only 63.11% of staff had completed Level 2 training. Data showed 81.08% of staff were up-to-date with Level 1 training. These were below the trust’s target of 90%.

Staff followed the national uniforms and workwear guidance. We saw hair tied back and staff were bare below the elbows. However, the ambulatory waiting area did not appear to be clean. Volunteers were observed wiping down chairs with wipes. Many chairs were ripped. We found departmental cleaning forms for nursing staff were not always completed.

There was not always safe management of sharps (disposable needles). Sharps bins were not always safely closed when not in use and were not always labelled correctly in line with guidance.

We found some hand sanitizers were empty. This was drawn to the attention of staff and they responded by refilling them.

Clinical and healthcare waste bins were labelled with appropriate stickers and we observed staff using them correctly.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

There were processes to improve people’s access to medicines and expedite discharge to improve patient flow within the department.

The emergency department was supported by pharmacy staff to assist with the safe use of medicines. Staff prioritised medicine reconciliation (the process of accurately listing a person’s current medicines) for patients with time-critical or high-risk medicines identified on the electronic prescribing and medicines administration system. However, the level of pharmacy support was not in line with national guidance. Leaders told us pharmacy support to the emergency department was currently under review.

The service had safe systems for the appropriate and safe handling of medicines. However, we saw these were not always followed by staff. We found expired medicines including antidotes and antibiotics in the adult emergency department. Staff took action to remove these medicines and replace them during our visit.

Accurate records of medicines checks were not always kept by staff according to trust policy. For example, checks of trolleys containing emergency medicines and fridges containing medicines were not consistently recorded. This meant there was a risk these medicines might not be suitable for use when needed. Kits containing medicines for specific medical emergencies such as hypoglycaemia and anaphylaxis were available. However, these kits were not covered by a policy or procedure. Regular, systematic checks of the kits were not taking place to ensure they were suitable for use when needed.

The service had systems to ensure staff knew about safety alerts and incidents. We saw reported incidents were monitored, reviewed and where required changes to practice were implemented by leaders.