Standard Operating Procedures

A selection of Trust Standard Operating Procedures are available via the links below, to request in alternative formats please contact the Information Governance team via email informationgovernancePHT@nhs.net or Telephone No. 01752 431547

Last Updated 23rd June 2025

Acute Paediatrics

• Paediatric Administration of Medication - Single Checking.pdf[pdf] 384KB

Cancer

• Clinical Harm Review.pdf [pdf] 266KB

• Daily Cancer Tracking.pdf[pdf] 283KB

• Management of Suspected Cancer Referrals.pdf [pdf] 260KB

Clinical

• Transfer of Adult Patients with Mental Health Need.pdf[pdf] 446KB

• Operation of the Pneumatic Air Tube Transport Systems.pdf [pdf] 319KB

• Venous Thromboembolism (VTE) Prevention SOP.pdf[pdf] 3MB

• Investigation and Management of Venous Thromboembolism (VTE) SOP.pdf[pdf] 568KB

• End of Life Care in Hospital.pdf [pdf] 2MB

• Specimen Transport SOP.pdf [pdf] 365KB

• Nursing Safer Staffing Escalation SOP.pdf [pdf] 185KB

• Disclosure of Invasive Cancer Reviews - NHS Cervical Screening Programme.pdf [pdf] 370KB

• Radiological confirmation of correct placement of nasogastric tubes in Adults, Children and neonates for feeding.pdf [pdf] 190KB

• Discharge Lounge SOP.pdf [pdf] 752KB

• Primary Spontaneous Pneumothorax Pathway.pdf [pdf] 216KB

• Issuing of fit notes by non-medical health care professionals.pdf[pdf] 371KB

• 16 - 17-year olds and correspondence from the Trust.pdf [pdf] 245KB

• The training and support of non-medics regarding the completion of Treatment Escalation Plans (TEPs)[pdf] 310KB

• Care of last days of life patients at Mount Gould Hospital.pdf [pdf] 583KB

Clinical Administration

• Clinic Cancellation Escalation SOP.pdf [pdf] 208KB

• Relet SOP.pdf[pdf] 190KB

• Delivery of Non-Face to Face Clinics.pdf [pdf] 295KB

Clinical Records Management

• Managing Health Records SOP.pdf [pdf] 259KB

Facilities & Estates

• Water Flushing SOP.pdf [pdf] 715KB

• Labelling, Allocation and Management of Global Location.pdf [pdf] 497KB

• Theatre Ceiling Void Access.pdf [pdf] 192KB

• Ward Moves.pdf[pdf] 394KB

• Drivers of Trust Vehicles.pdf [pdf] 459KB

Falls Prevention

• Baywatch Process.pdf [pdf] 290KB

• Baywatch Process Appendix 1 - Baywatch Process.pdf [pdf] 90KB

• Baywatch Process Appendix 2 - Baywatch Sign.pdf [pdf] 88KB

• Baywatch Process Appendix 3 - Baywatch Rota.pdf [pdf] 44KB

• Use of Yellow Wristbands.pdf [pdf] 290KB

Finance

• Losses and Special Payments.pdf [pdf] 253KB

• Labelling, Allocation and Management of Functional GLN.pdf [pdf] 615KB

Fire Safety

• Workplace Fire Safety Checklist.pdf [pdf] 554KB

• Trust Employees Working in Non Trust Buildings Workplace Fire Safety Checklist.pdf [pdf] 459KB

• Personal Emergency Evacuation Plan.pdf [pdf] 286KB

• DSEAR Risk Assessment.pdf [pdf] 357KB

• Fire Incident Response and Release of Persons from Lifts.pdf [pdf] 313KB

Health & Safety

• Preventing Workplace Slips Trips & Falls.pdf[pdf] 338KB

• COSHH Risk Assessment SOP.pdf [pdf] 803KB

• First Aid at Work SOP.pdf [pdf] 472KB

• Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR).pdf[pdf] 809KB

Healthcare Governance

• Managing Safety Incidents Within the NHS Cervical Screening.pdf [pdf] 209KB

Human Resources

• Dealing with Bullying and Harassment SOP.pdf [pdf] 343KB

• Verification of Registration of Clinical Staff.pdf pdf] 331KB

• Severe Weather SOP.pdf [pdf] 207KB

• Locum Consultant Appointment SOP.pdf [pdf] 155KB

• Substantive Consultant Appointment SOP.pdf [pdf] 285KB

• Supporting Our Transgender Colleagues.pdf [pdf] 283KB

• Appeals Procedure.pdf [pdf] 190KB

• Employee Leaving SOP.pdf [pdf] 213KB

Information Governance

• Data Protection Impact Assessment SOP.pdf [pdf] 216KB

• Disclosure of Person Identifiable Data by Post.pdf [pdf] 182KB

• Disclosure of Personal Data by Telephone SOP.pdf [pdf] 303KB

• Information Governance Incident Handling SOP.pdf [pdf] 643KB

• Management of Freedom of Information (FOI) Requests SOP.pdf [pdf] 352KB

• Disclosure of Personal Data by Email SOP.pdf [pdf] 512KB

• Disposal of Paper Confidential Waste SOP.pdf [pdf] 179KB

• Management of Records on IT Network Shares.pdf [pdf] 195KB

• Data Protection SOP.pdf [pdf] 255KB

• Confidential Information SOP.pdf [pdf] 207KB

• National Data Opt Out SOP.pdf [pdf] 287KB

• Data Sharing SOP.pdf [pdf] 289KB

• Document Protective Marking SOP.pdf[pdf] 216KB

Ionising Radiation Safety

• Managerial Responsibilities For Radiation Safety.pdf [pdf] 237KB

• SOP for Medical Exposures.pdf [pdf] 218KB

• Control of Radioactive Substances.pdf[pdf] 214KB

• SOP for Occupational and Environmental Monitoring.pdf [pdf] 212KB

• Incidents Involving Ionising Radiations.pdf [pdf] 361KB

• Responsibilities of Radiation Protection Supervisors.pdf [pdf] 304KB

• Management of Classified Persons under the Ionising Radiations Regulations 2017.pdf [pdf] 285KB

• Cooperation of Employers.pdf [pdf] 314KB

• SOP Concerning the Radiation Protection Assurance Audit Programme.pdf [pdf] 186KB

• SOP Outside Workers.pdf [pdf] 206KB

• Radiation Safety Training Procedure under the Ionising Radiations Regulations 2017 (IRR 2017)  .pdf [pdf] 219KB

• Radiation Safety Training Procedure under the Ionising Radiations Medical Exposures Regulations 2017   (IRMER 2017)    .pdf [pdf] 242KB

• The use of Clinical Imaging Board (CIB) Radiation Incident Coding Taxonomy in Datix.pdf [pdf] 659KB

Maternity

• Maternity Triage SOP.pdf [pdf] 255KB

• Placental Histology SOP.pdf [pdf] 179KB

• Elective Caesarean Section SOP.pdf [pdf] 253KB

• Maternity Theatre Recovery SOP.pdf [pdf] 232KB

• Labelling of Neonatal Screening Blood Spot Cards.pdf [pdf] 165KB

• Registration, Identification and Security of Newborn Infants SOP.pdf [pdf] 163KB

• Guideline Development within Maternity Services.pdf[pdf] 162KB

• Carriage and storage of Entonox by Midwives.pdf [pdf] 405KB

• Lodging Mothers on Transitional Care Ward SOP.pdf [pdf] 201KB

• Safe sleeping between parent and infant.pdf[pdf] 155KB

• Insertion of Cervical Ripening Balloons for induction of labour by midwifery staff.pdf [pdf] 498KB

• Responsibility of the Consultant.pdf [pdf] 162KB

• Daily Newborn Examination Failsafe Access.pdf [pdf] 349KB

• cffDNA Testing for Fetal Rhesus Status.pdf [pdf] 221KB

• Newborn Early Warning Trigger and Track (NEWTT) Observations Recording, Reporting and Escalation Process.pdf [pdf] 295KB

• Cord blood sampling.pdf [pdf] 174KB

• Providing midwifery care for a relative or friend.pdf [pdf] 185KB

• Booking and consent for post-mortems in Obstetrics and Gynaecology.pdf [pdf] 1MB

• Instrument and Swab Counts Pre and Post Birth.pdf [pdf] 191KB

• Neonatal Readmission SOP.pdf [pdf] 223KB

Manual Handling

• 02 Inanimate Load Handling.pdf [pdf] 609KB

• 03 Moving and Transporting a Bed or Trolley.pdf [pdf] 214KB

• 05 Sit to Stand Transfer with two using Key Points.pdf [pdf] 245KB

• 06 Sit to Stand Transfer with one using Key Points.pdf [pdf] 332KB

• 07 Insertion of a Hoist Sling Whilst Patient is in a Seated Position.pdf [pdf] 556KB

• 08 Lateral Transfer of Plus Size Patient Using Air Lifting Device System.pdf [pdf] 522KB

• 09 Turning the Plus Size patient using the Repo Sheet in conjunction with the  overhead gantry hoist system.pdf [pdf] 578KB

• 10 Lateral Transfer of Patients Using XL Slide Sheet and Transfer Board.pdf [pdf] 479KB

• 11 Turning Patient onto Side Using Slide Sheet.pdf [pdf] 927K

• 12 Moving a patient up the bed/ trolley/x-ray table etc. using an XL slide sheet.pdf [pdf] 239KB

• 13 Inserting the tubular slide sheet under the supine patient without rolling them pdf [pdf] 177KB

• 16 Lowering a Patient from Chair to Floor following a Cardiac Arrest.pdf [pdf] 469KB

• 17 Rota Stand Assisted Transfer from one Position to Another.pdf [pdf] 357KB

• Major Trauma clothes off sequence Emergency Department.pdf [pdf] 1MB

• 21 Emergency Evacuation From The Birthing Pool In The Event Of A Life Threatening Situation.pdf [pdf] 606KB

• 26 Arjo Huntleigh Sara Stedy assisted transfer from one seated position to another.pdf [pdf] 328KB

• 27 Use of the Pro Loop Patient Specific Sling in the amputee mode.pdf [pdf] 266KB

• 29 Retrieving the Patient from the floor using Evacuation Hover Jack/Lateral Transfer.pdf [pdf] 352KB

• 30 Turning an ICU Patient Prone.pdf [pdf] 485KB

• Changing ZX Oxygen Cylinder on a Lifeguard Patient Trolley.pdf [pdf] 745KB

• Handling of Gas Cylinders F; LF; VF; AV; HX and ZX.pdf [pdf] 612KB

• Handling of Gas Cylinders AK; J; and L.pdf [pdf] 703KB

• Repositioning Supine to prone with the Proturn.pdf [pdf] 842KB

• Non-clinical Mandatory update comptency.xls [xls] 114KB

• Mandatory Induction Inanimate Loads Competency Statement.xls [xls] 111KB

• Repositioning Supine to Prone utilising Controlled Patient Pronation technique.pdf [pdf] 2MB

Medical Devices

• Medical Devices Users Guide.pdf [pdf] 494KB

• Management and Use of Scott Duraflow Powered Air Purifying Respirator (PAPR) and Hood.pdf [pdf] 337KB

• Management and use of CleanAir Personal Respiratory Protection System(PRPS) with Disposable Hood.pdf [pdf] 1MB

Medicine Management

• Preparing and Administering Intravenous Medicines and Fluids SOP.pdf [pdf] 202KB

• Safe Handling and Administration of Injectable Cytotoxic Drugs.pdf [pdf] 232KB

• Managing Extravastion SOP.pdf [pdf] 947KB

• Setting up variable rate IV insulin infusion SOP.pdf [pdf] 144KB

• Management of Drug Errors.pdf [pdf] 735KB

• SOP for Clinical Service Continuity in the Event of ARIA e-Prescribing System Unavailability.pdf [pdf] 293KB

• Safe Storage of Refrigerated Medicines (including Temperature Monitoring).pdf [pdf] 481KB

• Steroid Emergency Cards.pdf [pdf] 443KB

• Prescribing Retinoids to women of childbearing potential.pdf [pdf] 450KB

• Safe handling of Potassium Permanganate to minimise the risk of inadvertent oral administration.pdf [pdf] 344KB

• Ranibizumab (Lucentis®) for Retinopathy of Prematurity (ROP).pdf [pdf] 232KB

• Programming Patients Own Drugs Locker.pdf [pdf] 290KB

Neurosurgery

• Electronic Referral system (Urgent and Emergency) in Neurosurgery.pdf [pdf] 841KB

Occupational Health

• Display Screen Equipment (DSE) SOP.pdf [pdf] 211KB

• Prevention and Management of Dermatitis Latex Allergy SOP.pdf [pdf] 426KB

• Management of Stress SOP.pdf [pdf] 293KB

• Contamination Incidents - Management of Contamination Incidents.pdf [pdf] 315KB

• Appendix A - Contamination Incident What to Do.pdf [pdf] 100KB

• Appendix B - Contamination Incident Assessment (CIA) Form.pdf [pdf] 238KB

• Appendix C - ED Management of a High-Risk Contamination Incident.pdf [pdf] 206KB

• Appendix D - PEP Patient Information Leaflet.pdf [pdf] 23KB

• Appendix E - Consent and Confidentiality Testing for BBV.pdf [pdf] 176KB

• Appendix F - Consent Form for Source Patient Blood Testing.pdf [pdf] 161KB

• Appendix G - Datix Severity Grading for Contamination Incidents.pdf [pdf] 120KB

• Prevention of Contamination Incidents.pdf [pdf] 307KB

• Appendix A - Preventing Inoculation Injuries Poster.pdf [pdf] 663KB

• Appendix B - Examples of and the order for putting on PPE.pdf [pdf] 632KB

• Appendix C - Assembling and Using a Sharps Bin Safely.pdf [pdf] 488KB

• Substance Misuse at Work SOP.pdf [pdf] 337KB

• Immunisation and Pre-placement Screening of Healthcare Workers SOP.pdf [pdf] 364KB

Operational Management

• Nurse in Charge - Rules and Responsibilities.pdf [pdf] 234KB

• Non-elective care of renal patients, and care of inpatients on Mayflower ward.pdf [pdf] 237KB

• Non-elective care of Haematology patients, and care of inpatients on Bracken Unit.pdf [pdf] 207KB

• Non-elective Care of Oncology Patients, and care of Inpatients on Brent Ward.pdf [pdf] 200KB

• Adult Ward to Ward Clinical Handover.pdf [pdf] 1MB

• Decision-making relating to moving patients between adult inpatient wards.pdf [pdf] 250KB

• SOP for Admission Assessment and Discharge of Patients referred to the Medical Assessment Unit .pdf [pdf] 351KB

• Non-elective care of Neurology patients, and care of inpatients on Merrivale ward.pdf [pdf] 481KB

• Transplant Ward Rounds.pdf [pdf] 114KB

• Full Capacity SOP.pdf [pdf] 202KB

Physical Intervention

• Safe Holding System Use in the Intensive care Unit .pdf [pdf] 719KB

• Restraint Techniques SOP.pdf [pdf] 930KB

Procurement

• Supply Chain Product Recalls and Returns (SC04).pdf [pdf] 289KB

• Supply Chain New Product Introduction.pdf [pdf] 270KB

• Supply Chain Product Ordering.pdf [pdf] 223KB

• Supply Chain Inventory Control.pdf [pdf] 215KB

• Supply Chain Product Receipting.pdf [pdf] 222KB

• Supply Chain Stock Issue.pdf [pdf] 200KB

• Supply Chain Cage Management.pdf [pdf] 207KB

• Supply Chain Fork Lift Truck Operation.pdf [pdf] 177KB

• Invoicing & Payments SOP.pdf [pdf] 3MB

• Requisitioning, Ordering, Receipting SOP.pdf [pdf] 2MB

• Master Data & Catalogue Management SOP.pdf [pdf] 2MB

• New Product Request Form (buyer only).pdf [pdf] 291KB

• New Product Request Form.pdf [pdf] 231KB

Risk Management

• Serious & Moderate risk review and approval procedure.pdf [pdf] 253KB

Safeguarding

• Unidentified Patients - Identification SOP.pdf [pdf] 496KB

• Management of Patients with Female Genital Mutilation (FGM).pdf [pdf] 459KB

• Bruising in Immobile babies and Children.pdf [pdf] 273KB

• Child Protection Information Service (CP-IS).pdf [pdf] 389KB

• Discharge Information Sharing when Children are being Discharged into Care due to Safeguarding Concerns .pdf [pdf] 275KB

• Left before clinical assessment.pdf [pdf] 276KB

• Child (16-17 years) admitted (or Pending Admission) to Adult or Paediatric Ward following deliberate Self Harm.pptx [pptx] 78KB

Security

• SOP for Individuals who are Violent or Aggressive.pdf [pdf] 621KB

• Appendix 1 - Acceptable Behaviour Agreement.pdf [pdf] 245KB

• SOP for Individuals who are Violent or Aggressive Form.pdf [pdf] 87KB

Theatres

• Management of patients with body piercing on peri-operative pathways SOP.pdf [pdf] 200KB

• Throat Pack Use in Theatre.pdf [pdf] 190KB

• Throat Pack Flow Chart.pdf [pdf] 83KB

• Theatre Scheduling SOP.pdf [pdf] 322KB

• Cath Lab and Pacing Theatre telephone pre-assessment process for screening MRSA & MSSA       .pdf [pdf] 198KB

• Electrosurgery SOP.pdf [pdf] 183KB

• Monitoring of patients undergoing procedures requiring Local anaesthesia.pdf [pdf] 238KB

• Safe storage, management and use of kidney perfusion fluid during kidney retrieval and transplantation .pdf [pdf] 159KB

• Main Recovery Clinical Management SOP.pdf [pdf] 961KB

• Main Recovery Operational Management.pdf [pdf] 390KB

• Supporting the team following sudden death or catastrophic event.pdf [pdf] 185KB

• Care of the Imminently Dying or Deceased Patient in the Perioperative Clinical Area.pdf [pdf] 229KB

• Sharps Handling during invasive procedures in the Operating Theatre or Procedure room.pdf [pdf] 222KB

• SOP for Management and Verification of Implants during Invasive Procedures.pdf [pdf] 214KB

• Accessing Help During an Anaesthetic Emergency.pdf [pdf] 317KB

• Recommendations for Surgical Procedures on Patient’s with CIEDs.pdf [pdf] 762KB

• Preoperative Checklist for Cardiac Implantable Electronic Devices (CIED).pdf [pdf] 76KB

• Management of the Use of Formalin within Theatres.pdf [pdf] 348KB