The team have a dedicated email addresss manned daily:

National and Trust high priority clinical audit leads are:

Lisa Patterson - Clinical Audit Lead    

Kerry Dainton - Clinical Audit Facilitator 

Jayne Shelmerdine - Clinical Auditor 

Divisional Clinical audit local clinical leads are:

Joanne Henson - Clinical Audit Lead  

Kirsty Bramhill - Clinical Audit Facilitator 

Jennifer Dooley - Clinical Auditor


Clinical Audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change”

This definition is endorsed by the National Institute of Health and Clinical Excellence (NICE)


The clinical audit team are responsible for:

  • The development and delivery of the Trust Annual Clinical Audit Plan (National and Trust high priority activity)
  • Supporting divisions to develop and deliver divisional Clinical Audit Plans (Local priority activity)
  • Supports divisions in the development of monitoring tools utilising the Trust audit management system (AMaT).

If you would like to undertake a clinical audit or develop a monitoring tool the audit team are here to support you throughout the process with:

  • Registration
  • Planning and methodology design
  • Development of audit tool
  • Provide templates
  • Advice of analysis
  • Action planning development
  • Supporting the use of the Trust Audit and Management Tracking System (AMaT).

Clinical Audit Templates

Upon registration of your clinical audit project you will receive a prepopulated clinical audit report/presentation template and a compliance calculator

Link to clinical audit registration form

Link to monitoring tool registration form

Resources library

How to differentiate between clinical audit, research and service evaluation.

Link to HQIP guidance

Link to Trust prioritisation model

Link to Process for undertaking a divisional clinical audit  

AMaT guidance

Basic AMaT guidance (currently being updated)

Monitoring tools guidance (Ward, Area and Service Projects)

Link to AMaT Academy Ward and Area Audits

Action Plan Guidance (to be developed and will be shared shortly)

AMaT platform


The team provide:

  • Basic AMaT training
  • Advanced AMaT training
  • Junior doctor training 
  • For ad hoc clinical audit training please contact the clinical audit team

Clinical Audit Groups

The Trust oversight group for clinical audit is the Clinical Audit Assurance and Monitoring Group. The main function of the group is to implement robust governance arrangements that monitor, review and report on the systems in place to deliver the Trusts Clinical Audit Plan and support the Divisions to deliver the Divisional Clinical Audit Plans. The group is chaired by the Medical Lead for Clinical Audit and Quality Improvement and deputy chair is the Deputy Director of Improvement and Innovation.  Membership consists of the Divisional Clinical Audit Leads, Clinical Audit Team, Co-opted specialist leads and the Pharmacy Clinical Audit Lead. The purpose of the group is to:-

  • Provide oversight for all matters that relate to clinical audit
  • Review & monitor the Trusts Clinical Audit Plan
  • Review and approve all completed priority 1 and 2 Trust high level clinical audits and action plans
  • Receive National Clinical Audit progress updates
  • Approve any priority 2 clinical audits off plan 
  • Review the National Clinical Audit Patient Outcome (NCAPOP) list for mandated national audit

Divisional Audit Leads information to follow shortly.

Clinical Audit Forum

The Clinical Audit Forum (CAF), takes place quarterly as part of the Junior Doctors Medical Education Programme.  The invite is included in the Communications newsletter and the forum is open to all staff members as well as doctors and consultants of all levels. The CAF is the Trust’s forum for the presentation and dissemination of clinical audit findings, where we aim to promote discussions, encourage shared learning, and inform action planning. Feedback is sought on each presentation and presented back anonymously, alongside a register being taken and provided to the Medical Education Team.