Great Ormond Street 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

The surgical service had a strong culture of learning and patient safety, with staff feeling empowered to raise concerns and report incidents. Training and professional development were well supported, with staff receiving protected training time per year and access to career progression opportunities.

Incident reporting was well established, with clear processes to learn from safety events.

The service maintained safe systems for patient pathways and transitions, ensuring continuity of care from admission to discharge. Staff communicated information gathered during pre-operative assessments, which were thorough, and were able to identify patient risks to ensure patient safety during surgery.

Staff understood safeguarding processes, with clear documentation and training completion among staff.

The hospital maintained high environmental and infection control standards, with clean, well-maintained theatres and compliance with relevant guidelines. Staff managed equipment safety and maintenance well.

Staff stored medicines securely, and electronic prescribing systems supported safe administration. Parents were actively involved in medicine management, and discharge processes ensured continuity of care.

Staffing was a key challenge for both medical and nursing staff. The trust had undertaken a recruitment drive, but issues remained in some services such as.

• Staffing shortages, particularly in registrar cover and tracheostomy-trained nurses.
• Recurrent theatre maintenance issues, including a power outage during spinal surgery and ventilation failures.
• Governance challenges, with concerns around surgical accountability and oversight
• Lack of online safeguarding reporting, potentially impacting efficiency.

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 surgical service at Great Ormond Street Hospital (GOSH) demonstrated a commitment to patient safety through a culture of openness, transparency, and continuous learning. Staff across different surgical disciplines understood the importance of raising concerns and reporting safety incidents, with structures in place to ensure that lessons were learned and improvements implemented.

Staff reported that the service provided 60 hours of training per year, with individual mandatory training monitored by line managers to ensure completion. Within this allocated training time, staff had the opportunity to choose from a range of courses to enhance their skills. The trust also offered scholarships and funding for career progression, supporting long-term staff development.

A Freedom to Speak Up (FTSU) culture was embedded within the service, with posters displayed across the site, ensuring staff knew how to report safety issues. Staff consistently stated that they felt valued and supported by their line managers and senior leaders and were confident that concerns raised would be listened to and addressed appropriately.

The service maintained a regular programme of mortality and morbidity (MM)meetings across all surgical specialities, reflecting an established culture of learning and clinical governance. Each department held speciality-specific meetings with bespoke structures and documentation tailored to the needs of their patients. Across the period reviewed, MM documentation was thorough and clearly structured, detailing morbidity cases, contributing factors, and outcomes, with standardised classification used to assess the severity of complications. Themes emerging from the reviews included post-operative complications such as bleeding, infections, respiratory deterioration, and recurrence following complex repairs, all of which were managed appropriately. The orthopaedic service had revised its MM process in line with Royal College of Surgeons’ guidance, with a formal structure for documentation and learning, and there were ongoing efforts to share this standardised approach across other departments to support consistency and quality improvement.

There was evidence of effective learning from incidents. One example involved an unauthorised caller attempting to access patient information within the pre-operative assessment unit. Staff identified the risk, managed the situation correctly, documented the event, and shared the learning across the team to reinforce best practices in patient confidentiality and safeguarding.

Another example of proactive safety awareness was provided by a nurse, who had a surgical procedure after identifying a rash on a patient, believed to beat reaction to a preoperative medication. The surgical team reviewed the case, agreed with the nurse’s concerns, and postponed the procedure, ensuring patient safety. This demonstrated that staff at all levels, including students, felt empowered to raise concerns and that senior clinical staff responded appropriately to safety alerts.

The service had efficient mechanisms for incident reporting and learning from safety events. Staff confirmed that incidents and complaints were investigated appropriately, with findings shared through safety huddles, team meetings, and governance reviews. However, some concerns were noted regarding governance oversight, particularly in relation to the surgical governance framework and accountability structures, as highlighted in the Royal College of Surgeons (RCS) report.

A key area of risk identified was the safe staffing levels within surgical services. For example, there were concerns regarding the availability of tracheostomy-trained nurses, with incidents where only one trained nurse was present during shifts, limiting safe break coverage. In response to concerns around staffing, the trust implemented a recruitment drive, with new nurses in training and temporary staff cover arranged where required. However, at the time of the assessment, gaps remained in some key areas, particularly within ENT and Urology services.

The service had a proactive approach to ensuring patient safety and continuity of care throughout the patient journey, including referrals, admissions, intraoperative care, and discharge.

The service worked collaboratively with patients, staff, and healthcare partners to maintain safe systems of care. Staff consistently reported strong relationships with colleagues across different departments and external healthcare providers, supporting effective communication and multidisciplinary working.

A structured escalation process was in place, which helped mitigate potential delays and ensured that risks were proactively managed. Staff stated that patient flow was rarely affected by bed shortages, and there were systems to manage capacity efficiently.

Observations of three patients' journeys from pre-operative assessment through to surgery and recovery demonstrated that safety protocols were consistently followed. The World Health Organisation (WHO) safety checklist was used before and after surgery to reduce risks and ensure procedural safety.

During patient transfers from theatres to the recovery ward, staff followed handover procedures in line with the Association of Anaesthetists of Great Britain and Ireland (AAGBI) recommendations. This ensured that critical information was accurately communicated between teams, supporting post-operative care and early identification of potential complications.

Patients and families were actively involved in discussions about surgical risks and anaesthesia-related concerns. We observed a pre-operative assessment where a parent was fully informed about the risks associated with general anaesthesia, ensuring informed decision-making.

A robust electronic system was in use, providing links to other healthcare services and improving information sharing. Staff reported that this system was beginning to integrate with GP records, further enhancing continuity of care post-discharge.

Cardiac and Lung surgical teams held outreach clinics in person and online, ensuring that patients in non-London areas received ongoing specialist care. In some cases, when patients were too unwell to travel, procedures were performed locally, demonstrating flexibility and patient-centred care. Staff reported that these partnerships with local teams worked well, with ongoing clinical advice and support provided remotely.

The surgical service worked closely with patients, families, and healthcare partners to ensure children and young people were protected from harm, neglect, abuse, and discrimination.

Staff had a clear understanding of safeguarding responsibilities and were able to describe how they would take appropriate action when concerns were raised. They were supported by accessible safeguarding policies, which were available to all staff via the intranet.

All staff spoken with during the assessment were able to explain what safeguarding was and how they would report concerns. Safeguarding concerns were documented appropriately in patient records, with a flag placed on the electronic system to highlight individual safeguarding risks. A review of 10 sets of patient notes confirmed that safeguarding issues were clearly recorded.

Staff were observed discussing safeguarding concerns during handovers, demonstrating a proactive and embedded approach to safeguarding within the service.

Staff reported receiving recent safeguarding training, with all those interviewed stating they had completed training within the last two weeks. Additionally, staff knew how to access the safeguarding team for advice and support, and leaders described how safeguarding staff worked within the department to review pathways for children with mental health concerns or those at risk of harm.

The service had a dedicated safeguarding reporting system, and staff were aware of their responsibilities and how to raise concerns. Staff reported that referrals were typically made via a phone call to the safeguarding team, however, they were less familiar with the use of the electronic patient record system for submitting in-patient consults or out-patient referrals. Although the trust stated that this method was covered in induction and statutory training and displayed in clinical areas, some staff indicated that they were not fully confident with the electronic process. This suggested there may have been inconsistencies in awareness or application of available safeguarding referral options.

Staff highlighted examples of families experiencing stress that they had flagged this as a safeguarding concern. This reflected an awareness of the wider factors affecting child safety and wellbeing, and a commitment to identifying risks beyond direct clinical concerns.

The service demonstrated a proactive approach to managing and mitigating risk while supporting children and families in understanding and navigating potential concerns. The introduction of the premedication hub reflected a commitment to improving patient experience, and the structured approach to risk communication ensured that families were actively involved in decision-making. However, the concerns raised regarding staffing capacity indicated the need for further consideration of workforce planning as new initiatives were introduced.

Staff told us they had received specific training on how to communicate risks effectively with patients and families. This included guidance on speaking clearly, ensuring information was understood, and adapting communication methods based on the needs of the child and their parents or carers. The service had systems in place to ensure that all patients and families were fully informed about the risks associated with surgery and anaesthesia. These risks were explained both verbally and in writing, allowing parents and carers to make informed decisions about their child’s treatment. The approach was designed to be accessible, ensuring that discussions were not overly clinical but instead focused on clear, understandable language that addressed patient concerns.

Pre-operative assessments were carried out by appropriately trained staff, with nurses and Operating Department Practitioners (ODPs) conducting standard assessments, while more complex cases were reviewed by anaesthetists. This tiered approach allowed for a proportionate and individualised risk assessment process, ensuring that children with additional medical needs or complex conditions were reviewed by senior clinicians. Staff reported that this system worked well and allowed for a streamlined pre-operative assessment pathway.

To support patients experiencing significant anxiety before surgery, the trust had introduced a premedication hub within the theatre department. This space, staffed by recovery ward personnel, provided a quiet and calming environment where children could prepare for surgery with access to sensory equipment, toys, and other resources designed to reduce anxiety. Staff reported that this initiative had been well received by families and had contributed to a more positive experience for children undergoing surgery. Plans were in place to expand the criteria for the use of this facility so that more patients could benefit.

However, staff expressed concerns about the increasing demand on existing resources. They reported that while the premedication hub was a valuable addition, its expansion was being introduced without an increase in staffing levels. Some staff highlighted that the additional responsibilities were being absorbed into existing roles, which could create workload pressures and potentially impact their ability to provide one-to-one support for all children who required it. Staff acknowledged the benefits of the initiative but stressed the need for sufficient workforce planning to ensure its sustainability.

The service maintained a clean, well-designed, and compliant care environment that supported the safe and effective delivery of patient care. The physical environment across theatres, recovery areas, and wards was in most cases suitable for the needs of the patient population, with appropriate infection control measures, equipment storage, and waste management systems in place.

During observations in theatres, the environment was visibly clean and well-maintained. Staff followed infection control protocols, and the flooring, including edging and skirting, was compliant with Health Building Notes (HBN) 00/10, which enabled effective cleaning. Theatres also met HBN 00/09 standards, ensuring that the facilities were designed in accordance with best practice for surgical environments. Controlled drugs were stored correctly, with documentation completed accurately.

The service had processes in place for equipment safety and maintenance. All equipment observed had undergone Portable Appliance Testing (PAT) and was in-date at the time of assessment. Resuscitation trolleys were purpose-built and checked daily, including the automatic external defibrillator (AED). However, minor issues were noted in relation to the disposal of sharp items, as some sharp waste was incorrectly placed in bins designated for "controlled drugs only", which was not in line with local guidance.

Waste management across the service followed Health Technical Memoranda (HTM07/01) standards, with appropriate segregation and safe disposal of offensive waste. Clinical areas, including recovery bays and theatres, were well stocked with necessary equipment, ensuring staff had immediate access to resources to support patient care. Personal Protective Equipment (PPE) was stored in wall-mounted, easy-access containers, and all basins and taps observed were sensor-controlled to enhance infection prevention. Hand gel stations were present at all patient area entrances, though staff reported occasional instances where dispensers had run empty.

The service demonstrated an awareness of psychological safety as well as physical safety, particularly for children with sensory needs or anxiety before surgery. A pre-medication hub had been introduced in theatres, providing a quiet space with sensory equipment such as toys, LED lighting, and noise-cancelling headphones to help children feel more at ease before their procedures. Staff were also seen engaging with children using toys to create a more supportive and reassuring atmosphere within clinical areas.

Leaders within the estates and infection prevention and control (IPC) teams worked closely together to maintain environmental safety and cleanliness. Regular infrastructure testing and assessments were conducted, including assessments of power outages, fire safety, and water hygiene. At the time of assessment, two sites had tested positive for legionella and had been taken out of use. Staff explained that copper-silver ionisation and point-of-use filters were in place as control measures to prevent bacterial contamination due to the low water temperature of the estate.

In most areas, the hospital’s layout was intuitive and allowed staff to work efficiently and safely. Fire escape routes were clearly marked, and there was sufficient space for staff to care for patients without obstruction. However, in areas where units had been relocated, staff reported that the layout was not always ideal. For example, the Pre-Operative Assessment Unit reception desk was not positioned near the entrance, which had led to confusion among new patients and their families when arriving for assessments.

A day unit for post-operative and post-anaesthetic recovery, was well designed, allowing for clear visibility and staff oversight. A central coordinator was positioned with a full view of recovery patients, and each child was allocated one nurse and one assistant following surgery. Staff positioned themselves strategically to ensure a panoramic view of cubicles and corridors, ensuring continuous monitoring of patients during recovery. Parents and carers were permitted to stay with children, which provided additional emotional support post-surgery.

While most facilities were designed effectively, some areas required modernisation. For example, an outpatient area within the Sight and Sound building was noted to be crowded and in need of refurbishment, which staff felt did not provide an optimal waiting environment for children and families.The trust told us that this space was rented and, as such, it has limited control over the layout of the area.

During the assessment, concerns were raised about the maintenance of operating theatres and equipment safety. A recent power outage during a spinal surgery procedure required staff to use mobile phone torches to complete wound closure. This incident, alongside reports of water leaks affecting electrical systems and theatre closures due to filtration failures, indicated ongoing issues with estates and facilities management. The trust had taken corrective actions, including replacing relay switches, conducting electrical testing, and implementing daily ventilation reports to improve communication regarding facilities issues. However, recurrent theatre maintenance failures had resulted in delayed or cancelled surgical procedures, impacting patient safety and access to timely care.

The service had processes in place to ensure safe staffing levels and skill mix, although challenges remained due to workforce retention and the high cost of living in London. Leaders and staff demonstrated commitment to maintaining safe care, with flexible staffing models and recruitment initiatives to address shortages.

Staff within Cardiac and Lung services described a flexible approach to staffing, with personnel moved between three Intensive Care Units (ICUs) to ensure that patients received appropriate care from staff with the relevant skill set. This flexible deployment of staff helped mitigate shortages and ensured patients had access to clinicians with the expertise needed for their condition.

Across all areas, staff reported pride in working for the trust and a strong sense of job satisfaction. However, many staff highlighted that the high cost of living and commuting in London affected retention, particularly when their personal circumstances changed.

The data provided showed that some surgical areas at the hospital faced challenges with staffing levels, especially in key clinical roles such as nurses and operating theatre staff. For example, Panther Ward had significant staffing gaps, with nearly half of its Band 5 and Band 6 nursing posts vacant in December 2024.Across the wider surgical service, most vacancies were concentrated within these key bands, which are essential to the day-to-day care of children undergoing surgery. While a few areas had stable staffing or were slightly over their planned numbers, the overall picture suggested that vacancies were putting pressure on some parts of the surgical service. The data showed a clear need to keep focusing on recruiting and retaining the right staff to ensure children continue to receive safe, high-quality care.

Managers were aware of these recruitment and retention challenges and reported active efforts to mitigate staffing shortages. The trust had recruited from overseas and over-recruited in some areas to account for natural turnover. Despite this, staffing gaps remained in key areas, particularly within the Pre-Operative Assessment team, where vacancies had impacted the ability to support families and arrange appointments. However, managers reported that two fresh staff were due to start imminently, which was expected to improve service capacity.

Staff across the surgical service reported having access to appropriate training and professional development. The trust provided training aligned with staff roles and specialisms, enhancing clinical skills and expertise. Most staff felt they had received adequate support and supervision to carry out their duties safely.

Within surgical services at GOSH, compliance with statutory and mandatory training demonstrated a strong organisational focus on staff competence and patient safety. Nursing staff across surgical areas achieved a training compliance rate of 94%, which aligned with the overall trust average and indicated that training was prioritised and well-supported in these teams. Medical and dental staff in surgical services had a slightly lower completion rate of 88%. The trust did not provide sufficiently detailed breakdowns of training compliance by individual division, specialty, or ward, which limited the ability to assess whether standards were being consistently met across all surgical areas.

Domestic staff had recently been given the opportunity to work directly for the trust, which managers described as beneficial both for staff and for service delivery.

Managers and staff reported that agency staff were not used, with bank staff fulfilling shortfalls when required. This approach helped maintain continuity of care and ensured that all staff were familiar with trust policies and procedures.

The service supported staff through supervision, appraisals, and development opportunities. Professional revalidation processes were in place where required, and staff at all levels had opportunities to learn and advance their careers. Additionally, deficient performance was managed appropriately, ensuring that standards of care remained high.

The surgical service had effective systems in place to assess, manage, and minimise the risk of infection, in line with national guidance. The Infection Prevention and Control (IPC) team worked closely with the estates team to identify and mitigate infection risks, ensuring that premises, equipment, and procedures supported high standards of hygiene and cleanliness.

Theatres, wards, and recovery wards were observed to be visibly clean, and staff had access to personal protective equipment (PPE), which was used appropriately. The theatres were compliant with Health Technical Memoranda (HTM) guidelines, with staff adhering to relevant IPC policies and procedures. There was a structured review of IPC practices, with leaders actively working alongside theatre staff to evaluate and implement new strategies to reduce infection risk. At the time of assessment, a review was underway regarding pre-surgical hair removal on the ward, aimed at reducing the risk of infection in theatre.

The trust had specific IPC measures in place for international patients, recognising the need to screen for viral illnesses and antimicrobial-resistant infections. All overseas patients were screened upon admission, and IPC leaders received daily updates on results. The IPC team also attended regular antimicrobial meetings, ensuring that the service remained proactive in monitoring and responding to emerging infection risks.

Enhanced stool screening was implemented and contributed to improved detection of carbapenemase-producing organisms, aiding in the prevention of cross-transmission (type of bacteria that have developed resistance to antibiotics often used as a last resort to treat serious infections). Surgical site infection surveillance was sustained in neurosurgery, cardiac, and spinal surgery, with generally low infection rates reported. Audit compliance for line care bundles remained below target, hindered by documentation challenges within the electronic patient record system.

Domestic staff received joint training with the Infection Prevention and Control (IPC) team, focusing on key areas such as PPE use. Additionally, joint audits were conducted between domestic supervisors and ward staff to monitor environmental cleanliness. A rapid response team was available to manage emergency cleaning requirements, and clinical site practitioners prioritised cleaning based on patient needs. A new cleaning standards framework, implemented in line with national guidelines, had been adopted by the trust and the domestic team. This approach scaled the intensity of cleaning based on identified infection risks, ensuring that higher-risk areas received enhanced environmental cleaning interventions. Staff reported that this system improved infection control measures and targeted resources effectively.

Overall, staff demonstrated compliance with hand hygiene protocols, including handwashing, the use of alcohol gel, and appropriate use of gloves and aprons. However, during observations, some porters and healthcare staff were seen in the theatre environment without adhering to the "bare below the elbows" policy, which could compromise infection control standards. This indicated that while IPC protocols were followed, reinforcement of best practice among all staff groups was required. Trust’s audits suggested that hygiene compliance remained stable overall, though variations were noted across wards, and improvement efforts continued through education and audit initiatives.

The service had systems for the safe storage, administration, and management of medicines, ensuring compliance with relevant legislation and best practice guidelines. Medicines were stored securely, with controlled drugs (CDs) locked away with restricted access. CD checks were undertaken and documented ensuring that medicines remained in date and stock balances were accurate.

Patients and families were actively involved in medicine-related decisions, supporting informed consent and adherence to treatment plans. One parent told us that they were included in discussions about their child’s medication, describing staff as kind and thorough in explaining treatment plans. The hospital also had a self-administration policy, allowing parents to administer medicines to their child where appropriate. While this was not widely used, we spoke to one parent who was administering multiple medicines, having signed a consent document recorded in the child’s medicine administration records.

The hospital had an electronic prescribing and medicines administration system (EPMA), which was embedded and integrated within an enterprise-wide electronic patient record,in place since April 2019. Staff described the system as helpful and supportive in ensuring accurate documentation of medicines given, missed doses, or changes in prescriptions. Communication between healthcare professionals was well documented within the EPMA system, with clinical pharmacy notes providing prescribers with additional information and links to prescribing guidelines. This approach helped ensure medicines were dosed accurately, particularly in paediatric patients requiring weight-based calculations. We reviewed six medicine administration records, all of which included clear documentation of administration routes, times, and reasons for omissions where applicable.

Emergency medicines, including those required for resuscitation, were managed in line with Resuscitation Council (UK) guidance. Safety checks were recorded daily, ensuring that medicines and equipment remained ready for use in an emergency.

The hospital had electronic monitoring systems for medicines storage, including temperature-controlled environments for refrigerated drugs. The pharmacy team received automatic alerts if temperatures exceeded safe limits, allowing prompt intervention. We reviewed an example where a refrigerator failed to maintain temperature, triggering an alert to pharmacy staff. In response, medicines were transferred to another unit, and a replacement refrigerator was ordered, demonstrating a proactive approach to maintaining medicines safety.

Intravenous (IV) fluids were stored securely, but staff highlighted that the central storage location was not ideal for some theatres, potentially causing delays in access. A secondary storage location had been identified, which was expected to improve accessibility.

The pharmacy team was well-integrated into the service, with two dedicated theatre pharmacy technicians who were visible and responsive to staff needs. A new clinical pharmacist had recently joined the team and was set to attend risk action group meetings to provide expertise on medicines safety and incidents. Staff reported feeling confident in accessing pharmacy advice, and clear processes were in place for the supply and replenishment of medicines. Individual wards had also assigned pharmacists who supported teams with safe medicines management.

The service had processes to ensure medicines reconciliation on admission, with clinical pharmacists and pharmacy technicians reviewing patient medication records to prevent missed doses or discrepancies. We observed pharmacy staff engaging with parents to verify medicine histories, ensuring that prescribed medicines were accurate and up to date.

There was a clear process for reviewing and documenting antibiotic prescriptions, ensuring appropriate use and review dates for ongoing treatment. Pharmacists monitored antibiotics requiring close observation and liaised with the microbiology team to address any concerns.

A structured approach to learning from medicines incidents was evident. Errors or concerns were discussed during daily morning huddles and at monthly risk meetings, ensuring shared learning and continuous improvement. Staff were able to describe the reporting and investigation process for medicine-related incidents and provided an example where a medicine error had led to a review of practice and implementation of additional safety measures.

Additionally, a new discharge process ensured that families were provided with clear medicine information upon leaving the hospital. Since 2024, a discharge letter had been sent to community pharmacies with details of prescribed medicines and pharmacy contact information, ensuring continuity of care and ongoing medicine support.