Stephen is currently working as a senior matron - liver, endoscopy and GI services at The Royal Free NHS Foundation NHS Trust, this role has presented him with the opportunity to lead and improve endoscopy services to enhance the patient experience. Stephen has a keen interest in developing the endoscopy team, providing opportunities to assist them in achieving their full potential within the organization.

Prior to this appointment he was lead specialist practitioner at St. Mark’s Hospital and non-medical prescribing lead for the London North West Healthcare NHS Trust. These roles afforded Stephen the opportunity to undertake ward based care for tertiary patients who had undertaken complex colorectal surgical procedures, liaising extensively with the multi-disciplinary team.

Stephen has also contributed to a stoma care nursing book and other related topics, he has also written several articles on the Enhance Recovery Programme (ERP). As a member of the team which implemented ERP into St. Mark’s Hospital, Stephen has a wealth of knowledge relating to this topic.



Statement of the Problem: In 2009, the National Patient Safety Agency (NPSA) introduced the term “Never Events” into National Health Service practice (Moppett and Moppett, 2016). Never events are defined as a significant, fundamentally preventable patient safety incidents that could have been avoided if the healthcare provider had implemented suitable preventative measures (NPSA, 2009). Within the authors clinical area a never event occurred, following the insertion of the incorrect biliary stent.

This never event led to an evaluation of the existing nursing endoscopy documentation, which was noted to be unsatisfactory.

Methodology & Theoretical Orientation: Current literature regarding the incorporation of patient safety into endoscopy documentation was evaluated. Stakeholders with an interest in developing a new nursing care plan were approached and a new document was developed and completed within ten weeks. This new care plan contains Local Safety Standards for Invasive Procedures (LocSSIP’s) (NHS England, 2015; Tingle, 2016). An important element of the LocSSIP’s are the individual safety pauses which occur pre-procedure, during the procedure if any variances occur and finally, post-procedure, these replaced the currently used WHO checklist.  Prior to implementation of the nursing care plan into clinical practice the document underwent several PDSA cycles whilst being trialed by a group of endoscopy nurses caring for a small cohort of patients. Further training has been provided on the LocSSIP component of the document to enhance staffs understanding of this important patient safety improvement.

Conclusion & Significance: By implementing the new endoscopy nursing care plan with integrated LocSSIP and safety pauses an improvement in patient safety has been observed. Endoscopy staff have embraced the new documentation and no further never events have occurred since this document has been introduced.