Welcome to the seventh edition of our Penrose Health newsletter – The Penrose Scroll. If you have any suggestions for the next edition, please let us know here! 👈

Latest News

DNAs - How’s My Function?

DNAs are not good for anyone - they waste clinicians’ valuable time and resources. So far, we’ve been looking at them by surgery, but we thought we might try something new - observing how each function fared.

Above are the stats by function for Q2 2025. As you can see, GPs ended June with the lowest DNA rate, beating Paramedics by a whisker (0.4%) - go team GP! However, HCAs are up there with a whopping 12.3%, way above our company Q2 total average of 8.6%. But wait…clutch those pearls tightly…HCAs also saw the second biggest overall decrease of DNAs over the three month period (1.9 percentage points), being beaten by the Care Coordinators, with a decrease of 2.1 percentage points (okay, you can breath now).

The real take-home message here is that, in all departments, the trend is downward, so well done teams and let’s keep tanking these numbers! Remember, the national average is around 7%…shoot for the stars (or, in this case, the depths of the sea!).

New Appointment Appropriateness Feedback Form

Keeping Up To Date on CPD

One of the Significant Events that occurred recently highlights the importance of staying in touch with new developments in treatment regimes and monitoring.

In this particular case, a patient was prescribed Azithromycin by an external consultant, for continuation of prescription and monitoring in primary care, without mentioning the need for blood tests and an ECG. Unfortunately, not everyone is as communicative as we may need them to be, so it is really important to stay in the know through CPD webinars, etc.

For this particular case, new SEL COPD guidelines were published in February 2025, advising that specialists provide the initial prescription, with primary care handling ongoing prescriptions. The specialist team are responsible for treatment monitoring.

However, there are likely to be more situations like this, so keep up to date with CPD and remember, if there are external trainings that you feel apply to your role here at Penrose, feel free to submit a 🎓 Training Requests form found on the homepage of the Portal.

Learning & Development Updates

Blue Stream Academy

Wow, well done team! Soon we’ll run out of room for improvement…

Upcoming training events

Past events & online learning

And finally, you can check out these past training events and online learning modules whenever you have the time…

What’s new in the Penrose Portal?

Ask Aunty Portal…

Significant Events Heads Up

“It’s good to learn from your mistakes. It’s better to learn from other people’s mistakes.” — Warren Buffet

1️⃣ The Emergency Trolley

Event: There have been multiple recent SEs regarding the Emergency Trolley:

1. Daily Checks not done.

2. Missing items: one adult medium concentration mask missing as well as 10 Loratadine tablets, with no SEA to support the use of these items. Trolley seals were also voided on most of the drawers indicating someone had opened them.

3. Adrenaline taken from Trolley because normal stocks were expired.

4. Trolley tamper seals open and 2x paracetamol missing.

2️⃣ Error on Morphine prescription

Event: A 200mg dose of Morphine was mistakenly prescribed instead of 20mg. The medication was dispensed by the pharmacy, but the patient noticed the error and did not take it. This serious error could have caused significant harm or death.

3️⃣ Check labels thoroughly…

Event: Three incidents occurred recently regarding labelling of samples:

1. The laboratory reported that the cervical screening sample could not be processed due to a mismatch between the patient details on the form and those on the vial - the vial was labelled with another patient's name. As a result, the sample was deemed inadequate and was not processed by the laboratory.

2. A cervical screening result for a patient was returned with multiple discrepancies in the patient identifiers. Although the name on the sample vial matched the intended recipient, both the date of birth and NHS number corresponded to a different individual. The sample was deemed inadequate, not processed and the patient will have to repeat it in three months. In this situation, the label was misaligned during printing, resulting in cut-off details, so the clinician manually wrote the label, which led to the incorrect information being recorded.

3. A sample was left in a room with a note requesting someone else print the form. The sample was not found until it was too old to process. It was left here because the printer in the room was not functioning.

4️⃣ Safeguarding coding error for unborn child with CPP

Event: Mum had Child Protection Plan for her unborn child and then temporarily registered out of area. When she moved back in the area with the baby, the child was not coded for Child Protection or any safeguarding (SG) concern raised.

5️⃣ Inappropriate processing of London Ambulance Service Call patient by reception

Event: A paramedic from the London Ambulance Service (LAS) visited a patient early in the morning and was concerned that the patient was unwell but refusing hospital admission. The paramedic phoned the surgery to express concerns and was told by reception to email this to the surgery. The email was not picked up until 17:20 that day. This was not appropriate and the duty doctor that morning should have been alerted straight away.

Beyond First Impressions

From HK to KF via Wuxiaworld…

Thanks so much for sharing, Hang. Agreed - peace is inspirational, having those rare moments to take stock is so valuable. Also agreed - nothing beats escaping into a book, especially for this fan of fantasy fiction…we’re grateful for the introduction to Wuxiaworld. Interior design, you say? Good at CAD draughting? Have you spoken to Esther Blenke? I sense a kindred spirit here (see edition 5 of The Scroll)!

The Shout Out 📢 

We think all of our employees are invaluable, but if you think a member of your team deserves a shout-out for something special they’ve done or achieved, let us know here.

We’re recruiting…