Isle of Wight NHS Trust provides all acute health services to a population of approximately 140,000 people living on the Island. There is a significant increase in population during holiday and festival seasons. St Mary’s Hospital in Newport is the trust’s main base for delivering acute services for the island’s population.

We carried out an unannounced focused inspection of the emergency department at St. Mary’s Hospital on 21 January 2019. The purpose of the inspection was to review the safety of the emergency department as part of a focused winter inspection programme. At the time of our inspection the department was under adverse operational pressure.

We did not inspect any other core service or wards at this hospital or any other locations provided by Isle of Wight NHS Trust. We did visit the urgent care centre, the ambulatory emergency care unit and the acute medical unit. During this inspection we inspected using our focussed inspection methodology. We did not cover all key lines of enquiry. We did not rate this service at this inspection.

The trust has one emergency department (ED), located at St Mary’s Hospital in Newport. It provides a 24-hour, seven day a week service. It is a designated trauma unit but patients with multiple trauma are usually flown directly to the major trauma centre in Southampton.

The ED consists of a major treatment area with 10 cubicles, a minor treatment area with three cubicles, resuscitation room with three trolley bays and a new rapid assessment and treatment area. Children have a separate waiting room and are treated in three rooms adjacent to the major treatment area. There are separate rooms for mental health assessment, eye examinations and application of plaster casts. Adjacent to the emergency department is a newly formed urgent care centre for the treatment of patients with minor illnesses and injuries.

Our key findings were as follows,

• Despite recent recruitment of additional band seven nurses there remained a significant shortage of qualified nurses. In the month prior to our inspection there was heavy reliance on agency nurses. Although agency nurses are fully qualified they do not always have the specialist experience needed in ED and have sometimes not worked in the department before.

• Staffing information displayed in the department during our inspection showed that eight nurses were expected to be on duty but only six were present. As a result, the nurse in charge was having to assess newly arrived ambulance patients, look after patients requiring care in the corridor, assist in the resuscitation room, take over from nurses on meal breaks as well as co-ordinate the care of all the patients in the department. It was not possible for one nurse to do all of this and we found several aspects of patient care had not been completed.

• There were periods of time during the evening when there were no nurses in the major treatment area, the minor treatment area or the rapid assessment area.

• Although a formal review of nursing levels was undertaken in September 2018, it was not clear whether the increase in nursing numbers would be implemented.

• Initial assessment (triage) of ambulance patients did not take place according to guidance produced by the Royal College of Emergency Medicine and the Royal College of Nursing. Although a handover generally took place within 15 minutes of arrival, there was no face-to-face assessment of these patients by an experienced nurse. Subsequent observations and assessments were often undertaken by a healthcare assistant.

• The department was crowded throughout our inspection with patients receiving care and treatment (such as intravenous infusions) in corridors.When we arrived, one patient had been in the department for 15 hours. The patient had been nursed in the corridor for three hours.

• During the evening there was no nurse in the rapid assessment and treatment area for 30 minutes. This meant that newly arrived ambulance patients (up to four at any one time) were being assessed by a healthcare assistant.

• During a review of the records of patients in the major treatment area we found that four out of six patient safety checklists were incomplete.

However,

• Almost all staff spoke positively about working in the emergency department.
• There had been improvements in patient flow since new processes for GP referred patients had been implemented.
• All critically ill patients were seen quickly by a senior emergency department doctor and were treated according to national guidance.
• Junior doctors felt well supported and were positive about the training they received in the emergency department.
• The new role of patient flow co-ordinator helped to ensure that patients waiting for specialist assessment or to be admitted to a ward were not forgotten.

Professor Edward Baker

Chief Inspector of Hospitals

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We did not rate acute services overall at last inspection in November 2016, as not all services were inspected.

At this inspection, our overall rating of acute services went down since inspection in 2014. There was minimal improvement and areas of deterioration across the three services inspected November 2016. We rated acute services as inadequate because:

• There were significant concerns about safety across acute services and particularly emergency and urgent care, medicine, surgery and end of life care services, where we rated safe as inadequate. Safety systems, staffing and learning from when things go wrong also needed to improve across most other services including maternity, children and young people services and diagnostic imaging.
• The effectiveness of medicine and end of life care service was inadequate with improvements also needed in emergency and urgent care, surgery and diagnostic imaging.
• Emergency and urgent care, medicine, surgery, critical care and end of life care services were not sufficiently responsive to the needs of patients.
• Leadership, management and governance needed significant improvement across acute services as not sufficient to delivery high quality care and the improvement. Well led was rated inadequate in emergency and urgent care, medicine and end of life care services. This also required improvement across most other services including surgery, maternity, children and young people services, outpatients, and diagnostic imaging.

However:

• Overall, staff cared for patients with compassion, provided emotional support. They involved them and those close to them in decisions about their care and treatment
• Critical care and outpatient services were rated good overall.