Impact Projects

Showcasing our contributions to health and care service providers.

Independant Investigations

A Mental Health Trust commissioned an independent investigation following the unexpected death of a patient with serious mental illness and multiple comorbidities, who died within 48 hours of admission with presumed pneumonia. A Structured Judgement Review (SJR), using the Royal College of Physicians’ methodology, was carried out by a multidisciplinary team with expertise in mental and physical health.

The review identified delays in recognising deterioration: early signs of sepsis were missed, NEWS2 scores were not escalated, and no senior medical review occurred within 12 hours. These findings reflected national challenges in mental health settings, where diagnostic bias can delay recognition of serious physical illness.

In response, the Trust implemented sepsis huddles for high-risk patients, delivered ‘recognise and rescue’ training, and introduced enhanced digital alerts for deteriorating physical health. The patient’s family were engaged throughout, and their insights shaped wider safety communications.

The initiative aimed to improve staff confidence, reduce diagnostic bias that delays physical health recognition, and ensure timely escalation—aligning with national priorities for safe, integrated care. Within six months, sepsis bundle compliance improved by 23%, and staff confidence in recognising and escalating physical concerns significantly increased, demonstrating measurable and cost-effective improvement in patient safety.

A Clinical Harm Review (CHR) for non-obstetric ultrasound services was initiated following concerns raised by a secondary care provider about the accuracy of diagnostic reports. An initial review identified inconsistencies in imaging quality and measurement accuracy, triggering a comprehensive investigation into underlying systemic factors.

Key issues included staff qualifications, inconsistent use of equipment and software, unclear referral criteria, and variability in reporting templates. In response, a series of corrective actions were introduced, including workforce training aligned with national standards, mandatory continuous professional development, and standardisation of equipment and reporting processes across sites.

A clinical audit system was implemented to monitor diagnostic accuracy, support learning, and inform future improvement. Ongoing actions include targeted sample audits, strengthened inter-provider communication, and a compliance framework to monitor impact on quality and safety.

The CHR aligns with the NHS Patient Safety Incident Response Framework (PSIRF), promoting a system-based, learning-focused approach. The review also highlighted the influence of human factors, such as environment, workload, and decision-making, on diagnostic quality. Behaviour change, supported by education, feedback, and peer review, is now embedded in practice to promote a culture of safety, reduce unwarranted variation, and drive continuous quality improvement.

Leadership Support

Amid sustained system pressures across emergency departments (EDs) within the Integrated Care System (ICS), operational leads identified significant variation in how emergency pathways were commissioned across providers. This inconsistency led to clusters of high-acuity patients being conveyed by ambulance into already constrained EDs, intensifying pressure on frontline teams. Over six months, staff sickness, particularly related to stress and anxiety, increased, and concerns were raised about inconsistent patient oversight and poor flow into hospital beds, resulting in delayed care and rising clinical risk. Despite multiple operational meetings, the challenges persisted without resolution, signalling the need for a coordinated, clinically led system response.

In response, the Chief Nurse and Medical Director co-led a Clinical Leadership Collaborative, bringing together senior clinicians from acute and ambulance trusts. Grounded in collective leadership principles and the NHS’s Being Fair approach, the initiative fostered transparency, shared accountability, and system learning.

Key actions included a joint operational dashboard, real-time peer reviews, and strengthened escalation and handover protocols. A thematic review of patient journeys revealed gaps in joint decision-making, prompting the introduction of a shared clinical lead role and weekly multidisciplinary reflection sessions.

Within eight weeks, high-acuity handover delays fell by 22%, and staff confidence improved. The programme has since evolved into a permanent system leadership forum.

Service Improvement

Clinical Harm

The Integrated Care Board (ICB) identified rising delays in Emergency Department (ED) assessment for frail older adults across the system, contributing to unnecessary admissions, deconditioning, and poor patient experience. In response, the ICB led a coordinated improvement programme focused on early intervention, same-day emergency care, and integrated discharge planning.

Using NHS England’s SDEC guidance and quality improvement methodology, the ICB supported acute and community partners to co-design Frailty Assessment Units (FAUs) embedded within EDs. These units introduced frailty screening at triage using the Clinical Frailty Scale to fast-track patients to early therapy, senior review, and discharge planning.

The initiative was driven by the real-life case of a patient who waited over 14 hours in ED before admission. This prompted stronger collaboration between clinicians, therapy leads, discharge teams, and social care to redesign the frailty pathway.

Within six months, admissions in patients aged 80+ were reduced by 30%, median assessment times improved from 11 to 3 hours, and patient satisfaction increased. The ICB is now supporting wider adoption of the model across its footprint to embed consistent, person-centred care for older people.

Transforming Care

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